Abundant Health New Patient Intake Form

New Patient Application For Care

Our mission is to empower individuals to regain control of their health and lives.
Patient Demographics
Patient Name *

First Name Middle Name Last Name
Birthdate *

Month Day Year
Date
Age *
Age
Sex *
Choose One
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *
Work Phone *
Mobile Phone *
Email *
example@example.com
Marital Status *
Employer *
Occupation *
Spouse's Name

First Name Last Name
Spouse's Employer
Number of Children
Emergency Contact *

First Name Last Name
Relationship *
Emergency Contact Phone Number *
How did you hear about our practice? *
If you were referred to our practice by a current/former patient, who can we thank for referring you?

First Name Last Name

	Health Concern
Primary
Secondary
Third
Fourth

Insurance Information
Primary Insurance

You can upload pictures of your primary insurance card below or complete the form.
Upload Front of Insurance Card

Cancel of
Upload Back of Insurance Card

Cancel of
Insurance Company
Copay
GROUP #
SUBSCRIBER #
Insured Name

First Name Middle Name Last Name
SOCIAL SECURITY #
Subscriber Date of Birth

Month Day Year
Date
RELATION TO PATIENT:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Secondary Insurance

You can upload pictures of your secondary insurance card below or complete the form.
Upload Front of Insurance Card

Cancel of
Upload Back of Insurance Card

Cancel of
Insurance Company
Copay
GROUP #
SUBSCRIBER #
Insured Name

First Name Middle Name Last Name
SOCIAL SECURITY #
Subscriber Date of Birth

Month Day Year
Date
RELATION TO PATIENT:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Social History
Do you use or do you have history of using tobacco? *

Yes No
Do you use or do you have history of using illegal drugs? *

Yes No
How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never

X-Rays/Imaging Studies

FEMALES ONLY: Please read carefully, check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our front desk staff for further explanation.
The first day of my last menstrual cycle was on:

Month Day Year
Date
I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant.
By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
Signature

Clear

Informed Consent
Abundant Health Physical Medicine - Informed Consent: REGARDING: Medical Services, Chiropractic Adjustments, Modalities, Functional Medicine, Regenerative Medicine, Extracorporeral Shockwave Therapy, Aesthetic Procedures and Therapeutic Procedures: A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often minimal, complications such as sprain/strain injuries, irritation of a disc condition, dislocations of joints, and although very rare, fractures, and possible stroke (estimated to be related in one in one million to one in two million cervical adjustments), have been associated with chiropractic adjustments. Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Abundant Health Physical Medicine have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. I have reviewed and accepted informed consent.
Please sign below: *

Clear

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW TO ACCESS THIS INFORMATION. Please Review Carefully

Acknowledgement of Receipt of Notice of Privacy Practices
I acknowledge that I have reviewed the Notice of Privacy Practices of Abundant Health Physical Medicine.
(PLEASE INITIAL ONE OF THE FOLLOWING OPTIONS AND SIGN BELOW.) *

YES, I wish to receive an electronic coy of Privacy Notice NO, I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office.
If YES, Please enter the email address to where you'd like the Privacy Notice sent to.
example@example.com
Please check the button below: *

I acknowledge that it is the policy of Abundant Health Physical Medicine to leave reminder messages on my answering machine, text messages or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing.
Please check the button below: *

I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Front Desk about my concerns to be forwarded to the appropriate department.
Signature *

Clear
Should be Empty:

	P for in the Past	C for Currently Have	N for Never have had
Broken Bone
Dislocations
Tumor(s)
Rheumatoid Arthritis
Disability
Cancer
Heart Attack
Osteo Arthritis
Diabetes

	How Long Ago	Type of Care	Provided By Whom
Injuries
Surgeries
Childhood Diseases
Adult Disease

	No Effect	Painful (can do)	Painful (limits)	Unable to Perform
Carry Children/Groceries
Sit to Stand
Climb Stairs
Pet Care
Extended Computer Use
Read/Concentrate
Getting Dressed
Shaving
Sexual Activities
Sleep
Static Sitting
Static Standing
Yard Work
Walking
Washing/Bathing
Sweeping/Vacuuming
Dishes
Laundry
Garbage
Driving

New Patient Application For Care

Patient Demographics

History of Complaint

On a scale of 0 to 10 with ten being the worst pain and zero being no pain, rate your above complaints by selecting the appropriate number below

Insurance Information

Primary Insurance

Secondary Insurance

Past Health History

Family History

Review Of Systems

Social History

Quadruple Visual Analogue Scale

Provider will calculate your score

X-Rays/Imaging Studies

Informed Consent

HIPAA Personal Health Information Release

Notice of Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices