Practice Member Intake Form
Connecting the Disconnected Since 2008
How did you hear about Core Health?
*
Please Select
Friend or Family
Google
Facebook
Instagram
Pride of Dakota
Community Event
Other
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
Male
Female
Marital Status
Single
Married
Divorced
Widowed
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Spouse's Name
Number of Children
Primary Complaint:
*
How long ago did the initial symptoms begin?
*
Was there a specific incident that caused your symptoms to begin?
*
What aspects of your life do you find most difficult, bothersome, painful and/or cannot do without being compromised, due to your primary complaint?
*
Choose a frequency you experience pain, symptoms, dysfunction and/or discomfort from this condition:
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Always
Hourly
Daily
Occasionally
Other
Please describe your pain, symptoms, dysfunction &/or discomfort:
*
Pain Level rating when worst
Best
0
1
2
3
4
5
6
7
8
9
Worst
10
0 is Best, 10 is Worst
Pain Level rating when best
Best
0
1
2
3
4
5
6
7
8
9
Worst
10
0 is Best, 10 is Worst
Has this condition affected your sleep?
Yes
No
Please select any therapy you have received (choose all that apply).
PEMF
Chiropractic
Red light therapy
Hot/cold therapy
Shockwave therapy
Decompression/traction
Neurophysiological care
Accupuncture
Massage
Other
For each treatment/therapy you selected above please provide your last treatment date, how many total treatments you have had and how effective the treatment was.
*
Additional History &/or Health Concerns related to and/or not related to your primary complaint
*
Broken Bones
Major Strain/Sprain
Eating Disorder
Been Hospitalized
Had Surgery
Auto Accident
Been Struck Unconscious
Had A Stroke &/or Heart Issue
Other
Did you check a box above? Please explain here:
(Female Only) Are you pregnant, or have you had signs of pregnancy?
Yes
No
(Female Only) Are you planning to get pregnant in the next 12 months?
Yes
No
Medications:
Medication List Upload
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Family Health History:
Family Health History:
By signing below:
I certify that I'm the patient or legal guardian listed above. I have read/understand the 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 of chiropractic.
I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctors to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me.
I understand and agree that all services rendered to me will be charged to me, and I'm responsible for a timely payment of such services.
I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.
Signature
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