Prior Lake Spine - New Patient Intake

New Patient Intake
Date

MonthDayYear
Date
Name*

First NameLast Name
Social Security #
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Age*
Birth Date*

MonthDayYear
Date
Race*
Marital Status*
Occupation*
Employer*
How many children?*
Names & Ages of Children*
Emergency Contact*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
How were you referred to our office?*
Family Medical Doctor*
When doctors work together it benefits you. May we have your premission to update your medical doctor regarding your care at this office?*

Major MedicalWorker's CompensationMedicaidMedicareAuto AccidentMedical Savings Account & Flex PlansOther
Name of Primary Insurance Company*
Name of Secondary Insurance Company (if any)*
AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.
The following person(s) have my permission to receive my personal health information:*
Patient's Signature*

Clear
Date

MonthDayYear
Date
Guardian's Signature Authorizing Care*

Clear
If this does not apply simply write N/A in text box.
Date

MonthDayYear
Date

Informed Consent
I hereby request and consent to the performance of chiropractic adjustments, acupuncture and/or other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed below or any other office or clinic.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) f)or which I seek treatment.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Rows	Now	Previously
Headaches
Neck Pain
Stiff Neck
Sleeping Problems
Back Pain
Nervousness
Tension
Irritability
Chest Pains/Tightness
Dizziness
Shoulder/Arm Pain
Numbness in Fingers
Numbness in Toes
High Blood Pressure
Difficulty Urinating
Weakness in Extremities
Breathing Problems
Fatigue
Lights Bother Eyes
Ears Ring
Broken Bones/Fractures
Rheumatoid Arthritis
Excessive Bleeding
Osteoarthritis
Pacemaker
Stroke
Ruptures
Eating Disorder
Drug Addiction
Gall Bladder Problems
Ulcers
Loss of Balance
Fainting
Loss of Smell
Loss of Taste
Unusual Bowel Patterns
Feet Cold
Hands Cold
Arthritis
Muscle Spasms
Frequent Colds
Fever
Sinus Problems
Diabetes
Indigestion Problems
Joint Pain/Swelling
Menstrual Difficulties
Weight Loss/Gain
Depression
Loss of Memory
Buzzing in Ears
Circulation Problems
Seizures/Epilepsy
Low Blood Pressure
Osteoporosis
Heart Disease
Cancer
Coughing Blood
Alcoholism
HIV Positive

Rows	Often	Sometimes	Never
Vigorous Exercise
Moderate Exercise
Alcohol Use
Drug Use
Tobacco Use
Caffeine
High Stress Activity
Family Pressures
Financial Pressures
Other Mental Stresses

Rows	Father	Mother	Spouse	Brothers	Sisters	Children
Arthritis
Asthma-Hay Fever
Back Trouble
Bursitis
Cancer
Constipation
Diabetes
Disc Problem
Emphysema
Epilepsy
Headaches
Heart Trouble
High Blood Pressure
Insomnia
Kidney Trouble
Liver Trouble
Migraine
Nervousness
Neuritis
Neuralgia
Pinched Nerve
Scoliosis
Sinus Trouble
Stomach Trouble

New Patient Intake

HISTORY OF PRESENT AND PAST ILLNESS

Functional Rating Index

SOCIAL HISTORY

Informed Consent