germantownchiro.com - NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM
Date:

MonthDayYear
Date
Name

First NameMiddle NameLast Name
DOB

MonthDayYear
Date
MaleFemale
Height:
Weight:
SingleMarriedWidowedDivorced
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone NumberCell Phone Number
YesNo
YesNo
Email Address:
example@example.com
YesNo
HomeWorkCellEmail
Emergency Contact:
Contact Name:
Relationship to Patient:
Contact Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone :
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Info:
Name of Insured
Insured DOB
Insurance Company
Group #
ID #
Primary Insurance Phone Number
Secondary Insurance Phone Number
Other Insurance:
Name of Insured
Insured DOB
Insurance Company
Group #
ID #
Primary Insurance Phone Number
Secondary Insurance Phone Number
Motor Vehicle Accident⁫Work related Accident⁫ Neither/Other
YesNo
If yes, when and where?
YesNo
If yes, when and where?
How did you hear about us?
What is your complaint? (Why are you seeing the doctor today?)
How/When did your complaint start?
Constant (76-100% of the time)Frequent (51-75% of the time)Intermittent (26-50% of the time)Occasional (0-25% of the time)
What makes it worse?
What makes it better?
AchyDullStiffSharpBurningThrobbingPinchingStabbingShootingNumbTinglingOther
What would you rate your pain on a scale of 0-10 with 0 being no pain and 10 being the worst imaginable pain?

1

2

3

4

5

6

7

8

9

10

1 is Np Pain, 10 is Worst Imaginable Pain
Numbness/TinglingWeakness
If so, where?
What activity/activities is/are difficult or that you cannot do now? Please list below and then write a number describing your ability to perform this activity on a scale of 0-10, with 0 being completely unable to perform and10 being able to perform without any limitation at all.
Is there anything else that the doctor needs to know?
HEALTH HISTORY
Please read through the list and check the box next to each condition that applies to you.

Musculoskeletal - General

Rows	Now	Past
Degenerative arthritis
Rheumatoid arthritis/ Gout
Compression fracture
Osteoporosis
Disc injury
Scoliosis
Ankylosing spondylitis
Hip or sacroiliac pain
Leg, Knee, ankle, foot pain
Shoulder pain
Arm, elbow, hand pain
Rib or chest pain

GI/GU/Endocrine

Rows	Now	Past
Diabetes
Abdominal pain
Constipation/Diarrhea
Uncontrolled Bladder/Bowel
Menstrual problems
Menopause symptoms

Nervous System

Rows	Now	Past
Headaches or migraines
Tingling or numbness of arms, legs, hands or feet
Pinched nerve or sciatica
Poor balance
Depression or Anxiety
Dizziness or vertigo
Seizures/Epilepsy
Numbness of inner thighs/groin

Cardio-Pulmonary

Rows	Now	Past
Pacemaker/implanted device
Breathing trouble or Asthma
High blood pressure
History of stroke or aneurysm

EENT

Rows	Now	Past
Jaw or TMJ problem
Ear problems, infections or ringing
Chronic sinus problems
Face pain

Injuries and General

Rows	Now	Past
Car crash/whiplash injuries
Work injuries
Sports injuries
Psoriasis or psoriatic arthritis
Unexplained weight loss
Fibromyalgia / Chronic fatigue
Tuberculosis, Hepatitis or HIV
Cancer or Tumor
Recent fever over 102°F

YesNo
Past/Social/Family History
Surgeries/Procedures:
Family History:

Select all that apply

Rows	Mother	Father	Sister	Brother
Rheumatoid Arthritis
Cancer
Diabetes
Stroke

Social History:
Selecy all that apply to you
OccasionalOftenNever
OccasionalOftenNever
OccasionalOftenNever
> 1 Pack/day⁫< 1 Pack/day ⁫Never
Daily1 x/ week2 x /week3 x /weekNever
> 1 hour< 1 hour> 30 minutes< 30 minutes
How do you exercise?
Appointment Policy:

If you are more than 5 minutes late for an appointment, you may be asked to reschedule or wait until there is an opening in the schedule. You will be charged a $25 missed appointment fee if you do not cancel within 24 hours of your appointment. You will only be charged this amount on your 3rd offense to allow for uncontrollable circumstances. If you have an insurance policy that does not allow missed appointment fees, you may be dismissed as a patient or only allowed to schedule same day appointments in the future. I have read, understand, and accept the appointment policies as outlined above.
INITIAL
HIPAA Privacy Practices
YESNO
I acknowledge that I have received and /or have been given the opportunity to review this Chiropractic Office’s Notice of HIPAA Privacy Practices for protected health information.
INITIAL
List of People who may have access to your medical records:
I certify that I’m the patient or legal guardian listed above. I have read/understand all included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I am responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
Patient Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

NEW PATIENT INTAKE FORM

Emergency Contact:

Insurance Info:

Other Insurance:

HEALTH HISTORY

Past/Social/Family History

Family History:

Social History:

HIPAA Privacy Practices