PATIENT INTAKE FORM

PATIENT INTAKE FORM

18+
Child and Family Chiropractic Center
8120 Penn Ave S., Suite 245 Bloomington, MN 55431
Name
Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Age
Occupation
Employer
Emergency Contact
Phone Number
Family Medical Doctor and Clinic
How were you referred to our office?
Patient Health History

18+
8120 Penn Ave S., Suite 245 Bloomington, MN 55431 (612) 590-5881
Patient Name
Date

MonthDayYear
Date
What condition are you being seen for?
Please describe your symptoms:
Less than one week agoBetween 1 week and 3 months agoMore than 3 months agoUnknownOther
Date of onset (if known)

MonthDayYear
Date
Constantly: 76%-100% of the dayFrequently: 26%-50% of the dayIntermittently: 0%-25% of the day
DullAchingSharpSharpNumbnessRegionalShooting
What changes your symptoms? Please indicate if the following make it BETTER, WORSE or it stays the SAME.
Ice
Better, worse, or same?
Heat
Better, worse, or same?
Sitting
Better, worse, or same?
Standing
Better, worse, or same?
Walking
Better, worse, or same?
Position changes
Better, worse, or same?
Rising from sitting
Better, worse, or same?
Lying down
Better, worse, or same?
Coughing or sneezing
Better, worse, or same?
In the morning
Better, worse, or same?
At mid-day
Better, worse, or same?
At night
Better, worse, or same?
With activity
Better, worse, or same?
After activity
Better, worse, or same?
At rest
Better, worse, or same?
Sleeping
Better, worse, or same?
ChiropractorPhysical TherapyHome CareMedicationsInjectionsSurgeryOther
Please describe which treatments, if any, have been the most helpful:
6. Have you had any special tests for this condition? a. Noneb. X-ray f. Other
NoneX-rayCT ScamMRIEMG
Have you had this condition before?
If yes, when?
EmployedUnemployedStudentRetiredHomemaker/SAHM/SAHDDisabledOther
What is your occupation?
If yes, when?
Working in your normal job WITHOUT restrictionsWorking in your normal job WITH restrictionsWorking in an alternate jobOther
Prolonged sittingProlonged standingLiftingDrivingOperating equipment or machineryRepetitive tasks: typing, writing, assembly, phoneOther
NoneHigh blood pressureAsthmaOsteoporosisKidney diseaseTuberculosisHepatitisChemical dependencyCancerMenopausalArthritisMental illnessEmphysemaStrokeDiabetesMultiple sclerosisDepressionSmokerSeizuresIncontinenceUnexplained weight lossThyroid diseaseHeart problemsHistory of fractures
Please list any surgeries you have had, and when they occurred:
NoneCardiac medicationsAnti-InflammatoryHormone Replacement TherapyPain MedicationAnti-Seizure MedicationMuscle RelaxantsThyroid HormonesSteroidsHeparin/CoumadinAntidepressantsMeds to Increase Bone DensityHigh Blood Pressure MedicationsOther
Date of last physical examination

MonthDayYear
Date
NoneLightModerateStrenuous
What is your height?
(Feet and inches)
What is your weight?
lbs.
Patient Signature

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Date

MonthDayYear
Date
WOMEN ONLY

PLEASE DO NOT SKIP THIS SECTION
YesNoUncertain
If pregnant, # of weeks?
How many live births?
Thank you for taking the time to fill out this very important paperwork.

Child and Family Chiropractic Center, LLC 8120 Penn Ave S., Suite 245 Bloomington, MN 55431 (612)590-5881
Child and Family Chiropractic Center
8120 Penn Ave S., Suite 245 Bloomington, MN 55431
(Please Print)
Date of Birth

MonthDayYear
Date
I, the patient above, or guardian for the patient, voluntarily consent to such care encompassing diagnostic procedures and medical treatment provided by the chiropractic physician as is necessary in his/her professional judgment. I understand that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as the result of examination or treatment in this facility.

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I hereby authorize Child and Family Chiropractic Center to release medical information regarding myself and my current condition to my insurance company for purposes of payment and /or quality reviews; and to referring, consulting treating physicians, or other medical providers as necessary to support continuation of care.

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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.

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I understand and agree to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. I understand that if I want a more detailed account of how my Patient Health Information is going to be used in this office and my rights concerning those records, I can request and obtain a copy of the HIPAA NOTICE that is available at the front desk. I understand that if there is anyone that I do not want to receive my medical records, I will inform the office.

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I have read this form and understand its contents at this date and time.
PATIENT OR LEGAL REPRESENTATIVE
LEGAL RELATIONSHIP
DATE

MonthDayYear
Date
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PATIENT INTAKE FORM

Patient Health History

WOMEN ONLY