Intake Form

Thank you for choosing our office for your chiropractic care. We at Columbia County Chiropractic Center, LLC strive to provide excellent care to all of our patients, and SO in that endeavor, we ask that you be prompt for your appointment. If you are more than 15 minutes late, we may find it necessary to reschedule your appointment, again in consideration for all of our patients. It is our goal to spend quality time with each of you.

Please bring the completed forms with you to your appointment, and if you have any questions regarding the forms, please call us at 386-752-4313. We look forward to meeting you.
Columbia County Chiropractic Center, LLC

279 SW Main Blvd, Lake City, FL 32025

Darrel T. Mathis, D.C., F.A.C.O.
Today's date

MonthDayYear
Date
Patient's Name
Nickname
Street Address
City
State
Zip
Email
example@example.com
Phone (hm)
Phone (wk)
Phone (cell)
I would like to receive appointment reminders by text

YesNo
My cell phone carrier is (Verizon, AT&T, etc.)
Social Security #
Date of Birth

MonthDayYear
Date
Age
Sex
Employer
Occupation
If student, name of school
Marital Status

singlemarriedwidoweddivorcedseparatedother
Spouse's Name
In case of emergency, contact
phone #
Relation to you
Who may we thank for referring you?
Other referral sources

YellowbookYP ATTInsurance CompanyGoogle (or) search enginePhysicianBrochurewebsiteOther
PAYMENT IS REQUIRED AT THE TIME OF SERVICE
Method of payment

cashcheckcredit/debit card
INSURANCE ASSIGNMENT AND RECORDS AUTHORIZATION
I hereby authorize Columbia County Chiropractic to furnish information to insurance carriers, attorneys, or adjusters, concerning myillness and treatments, and I hereby assign to the physician(s) all payments for medical services rendered to me or my dependents. I understand that I am responsible for any amount not covered by my insurance.
Signature

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Date

MonthDayYear
Date
Parent/Guardian signature (if patient is a minor)

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For Medicare Patients Only
AUTHORIZATION FOR MEDICARE BILLING PURPOSES

LIFETIME FILE (Medicare Patients Only)

I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or its intermediaries or carriers, any information needed for this or any related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services, Signature to the physician if he so desires to accept.
Signature

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Date

MonthDayYear
Date
FINANCIAL POLICY

Revised 2/2/11
As your family chiropractor, we are committed to providing you with the best possible chiropractic care. In order to achieve this goal, we need your assistance and understanding of our financial policy. We will gladly discuss your proposed treatment and do our best to answer any questions relating to your insurance. However, you must realize:
1. Your insurance is a contract between you, your employer, and your insurance company. We are not a party to that
2. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will cover.
We must emphasize that, as your chiropractic provider, our relationship and concern is with you and your health, not your insurance company. While filing your insurance claim is a courtesy that we extend to our patients, all charges not covered by your insurance are your responsibility from the date the services are rendered.

Any balance on your account after 60 days, will be turned over for collection. Delinquent charges and costs of the collection process will be added to the outstanding balance. We realize that emergencies do arise and may affect timely payment on your account. If such extreme cases do occur, please contact us promptly for assistance in the management of

We accept cash, personal checks and credit/debit cards. Returned checks are subject to a $25.00 service fee.
- PPC/PPO/HMO Insurance coverage: Copayment must be paid at the time of service, unless prior arrangements have been made.
- Medicare insurance coverage: Medicare has a deductible and then pays 80% of the manipulation only; please see additional paperwork.
- Worker's compensation: We must have authorization from either your employer or the insurance carrier prior to your first appointment.
- Auto accidents: Until coverage is verified, payment is due at the time of service even if you have an attorney and/or the accident was not your fault. Once coverage has been verified, then your deductible and/or copayment will be due at the time of service.
If you have any questions about the above information, please do not hesitate to ask us. We are here to help you.

My signature below states that I have read and understand the guidelines of the financial policy.
Patient, Parent/Guardian Signature

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Date

MonthDayYear
Date
ACKNOWLEDGMENTOF NOTICE OF PRIVACY PRACTICES
I acknowledge that I am provided the opportunity to review a copy of the Notice of Privacy Practices, found on our website, www.columbiachiro.com, and that I have read it or declined the opportunity to read it, but do understand that Columbia County Chiropractic is bound by the Notice of Privacy Practices regarding my medical records.

I understand that this form will be placed in my patient chart and maintained for six years.
Date

MonthDayYear
Date
Patient name (please print)
Patient signature

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Parent/Guardian (if patient is a minor)

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*** If you would like a copy of the Notice of Privacy Practices for your own records, *** please let us know at the front desk and we will provide one for you.
Name
Date

MonthDayYear
Date
Age
Race
Gender
Height
Weight
Review of systems

*Be sure to list all conditions or symptoms, BOTH past and present.

If you answer Yes, please Explain

	NO	YES	if Yes. Explain
Do you have skin, hair or nail problems?
Do you have mouth and/or throat problems?
Do you have nose and/or sinus problems?
Do you have ear problems?
Do you have eye problems?
Do you have chest or lung (breathing) problems?
Do you have heart and/or blood vessel problems?
Do you have blood or lymph node problems?
Do you have digestive problems?
Do you have genital problems (e.g. prostate, testicular, vaginal)?
Do you have urinary (including kidney or bladder) problems?
Do you have any nervous system diseases and/or mental health problems?
Do you have any gland and/or hormone problems?
Do you have allergy or immunity problems?
Do you have any muscle, tendon or ligament problems?
Do you have any bone or joint diseases (examples: bone=osteoporosis, joint= arthritis?

Females

If you answer Yes, please Explain

	NO	YES	if Yes. Explain
Have you had menstrual problems?
Have you ever taken birth control pills?
Is there any chance that you are currently pregnant?
Do you have any breast problems?

Additional Questions

If you answer Yes, please Explain

	NO	YES	if Yes. Explain
Do you have problems with recurring headaches?
Are you losing weight without trying?
Does your pain wake you up at night?
Have you had a change in bowel or bladder habits?
Have you had a sore that doesn’t heal?
Have you recently had any unusual bleeding or discharge?
Do you have a thickening/lump in the breast or elsewhere?
Do you have indigestion or difficulty swallowing?
Have you had an obvious change in a wart or mole?
Do you have a nagging cough or hoarseness?

In the space below, please explain or give additional details regarding the information you have given above. Also, if there is any information about your health history, which was not requested, please fill it in below.
List any diseases which you have had in the past, including childhood diseases
Tell us if you have ever been diagnosed as having a particular condition such as diabetes, cancer, AIDS, etc.

If you answer Yes, please Explain

	NO	YES	if Yes. Explain
Have you suffered any physical injuries such as falls or blows, automobile accidents, whiplash, concussion or head injury, lacerations, sprains, strains, dislocations, broken or cracked bones? Please include dates

List any surgeries you have had (don't forget appendix, tonsils, ear tubes, wisdom teeth, C-section etc
Surgery 1
Date

MonthDayYear
Date
Surgery 2
Date

MonthDayYear
Date
Surgery 3
Date

MonthDayYear
Date
Surgery 4
Date

MonthDayYear
Date
Signature*

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Date

MonthDayYear
Date
Medications: Please list below all medications (prescription & non-prescription) that you are currently taking or take on an occasional basis:
Date started

MonthDayYear
Date
Medication name
Strength
Dosage
Frequency
Prescribing doctor
Strength
Date started

MonthDayYear
Date
Medication name
Dosage
Frequency
Prescribing doctor
Any allergies or allergic reactions?

NOYES
If Yes, explain
Type of allergy:

MedicationFoodEnvironmental
Reaction
Your diet is

BalancedFairPoorExcessiveRestricted
Family History
Disease in family: (arthritis, heart disease, cancer, diabetes, multiple sclerosis, etc Living or deceased
Father
deceased (age)
Cause
Mother
deceased (age)
Cause
Brother(s)
deceased (age)
Cause
Sister(s)
deceased (age)
Cause
Grandmother (P)
deceased (age)
Cause
Grandfather (P)
deceased (age)
Cause
Grandmother (M)
deceased (age)
Cause
Grandfather (M)
deceased (age)
Cause
Hospitalizations/Major Illness/Injury
Any hospitalizations?

NOYES
Date

MonthDayYear
Date
Reason for Hospitalization
Hospital name
List (recent) immunizations/vaccinations:
Date

MonthDayYear
Date
Vaccine
Date

MonthDayYear
Date
Vaccine
43. When was your last tetanus shot
Flu shot
Social History
In what position do you usually sleep?
How many hours?

46810
other
Do you exercise on a regular basis?

NOYES
If Yes, Explain
What hobbies do you have, with your free time?
Do you use

CaffeineNicotine (gum, dip vapor)Recreational DrugsAlcohol
How often do you use Caffeine day/week
cup(s)
How often do you use Nicotine day/week
amount
How often do you use Recreational drugs day/week
amount
How often do you use Alcohol day/week
drink(s)
Smoking Status
Never Smoked
If current everyday (how much?)
If current occasional smoker (how much, how often?)
Former smoker how long did you smoke?
51. Please describe your work.

ProfessionalPhysical LaborDriverClericalFactoryHomemakerStudentOther
Physical Demands

HeavyModerateMildSedentary
How would you rate your stress levels?

HighMediumLow
Please describe your current complaint; in other words, what brought you to see us?
What are your expectations for today's visit?
Who's your Primary Doctor?
Other Specialists
OB/GYN
Dentist
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

PAYMENT IS REQUIRED AT THE TIME OF SERVICE

INSURANCE ASSIGNMENT AND RECORDS AUTHORIZATION

For Medicare Patients Only

FINANCIAL POLICY

ACKNOWLEDGMENTOF NOTICE OF PRIVACY PRACTICES

Review of systems

Females

Additional Questions

Family History

Social History

Smoking Status