Chiropractic Intake

Chiropractic Intake

Female
About You
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Birth Date:*
Birth Gender:

MaleFemale
Height:
Weight:
Occupation:
Marital Status:

SingleMarriedSeparatedDivorced
Spouse's Name:
How did you hear about us? *
Emergency Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relation to you?
HIPPA Release
This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization. I give Eastern Iowa Health and Wellness Center/Family and Sport Chiropractic/Iowa Wellness Center permission to disclose medical information concerning:

AppointmentsMedical InformationBoth
This information can be released to the following people: (please include full name and phone number for each person)
Signature

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I authorize Eastern Iowa Health and Wellness Center/Family and Sport Chiropractic to send updates on my treatment/condition to my primary care physician.

YesNo
Primary Care Physician Name:

First NameLast Name
PCP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
When were you last seen there?
Insurance
Will you be using insurance?*

YesNo
If yes, please provide the insurance information below:

Insurance NameInsurance ID Number
Insured's NameInsured's Birth Date
I understand that I am responsible for payment of all deductibles and copayments related to my care. I am responsible for my deductible and any portion that my insurance does not cover. If my insurance company payment is not received within 75 days after the date of service, I am responsible for the entire balance due. I understand that if I have a balance for medical services not paid, I will make a minimum payment of $50.00 each month or 20% of the outstanding balance by Autodebit Payment whichever is greater. If my balance is not paid in a timely and monthly fashion, I promise to pay any and all collection, court, and attorney fees in the collection of my account. A finance charge of 1.5% per month is applied on all unpaid account balances after 30 days. I further understand that if my treatment is associated with a personal injury or accident claim, all medical bills will be paid at 100% of the above fee schedule regardless of the outcome of my case. I understand that if a check is returned for insufficient funds, I will be charged a $30.00 service charge. I further understand that if my insurance company declines payment, I authorize Dr. Karim to file small claims court on my behalf against my insurance company as a method of collection. I further understand that I will be present at the court date if needed. I have read and fully understand the above financial terms and prices.
Signature*

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History
Please select the following that pertain to your present health / past medical history:*

AnemiaAsthmaArthritisAllergies/SensitivitiesArtificial JointAtherosclerosisBruise EasilyCancerCarpal Tunnel SyndromeContagious Skin ConditionMononucleosisFrequent Colds & FluDeep Vein Thrombosis/Blood ClotsDiabetesEpilepsyHeadaches/MigrainesHeart ConditionMumpsRheumatoid ArthritisOpen Sores/WoundsNervous DisordersPhlebitisShortness of BreathPregnancyHigh/Low Blood PressureHepatitisFractureHigh CholesterolKidney DiseaseSwollen GlandsSprains/StrainsThyroid ProblemsSyphilisTuberculosisGonorrheaHigh FeversPneumoniaStrokeJaundiceMental IllnessAlcoholismTennis ElbowTMJRheumatic FeverVein ProblemsChicken PoxPolioNervous DisordersHIVSkin RashesInsomniaMultiple SclerosisObesityMeningitisOsteoporosisFibromyalgiaBronchitisNone of the aboveOther
If other is checked, please explain:
If Diabetes is checked above, how many years?
Are you a smoker? If yes, what is the frequency?
Do you consume alcohol? If yes, what is the frequency?
Do you consume caffeine? If yes, what is the frequency?
Do you have a pacemaker or defibrillator?
Please check any of the following that have occured in your family (blood relative):*

Heart DiseaseDiabetesOsteoporosisAlzheimer's DiseaseCancerHigh Blood PressureAllergiesAlcoholismAnemiaAsthmaBleeding TendenciesKidney DiseaseMental IllnessObesityStrokeThyroid ProblemsTuberculosisOtherNone Apply
If other is checked, please explain:
Please list any Disease/Illnesses/Surgeries with dates:
Please list any Allergies and Reactions or reply none: *
Women's Health
Are you pregnant?*

YesNo
Are you nursing?*

YesNo
Are you taking birth control?*

YesNo
Do you experience painful periods?*

YesNo
Do you have irregular cycles?*

YesNo
Do you have breast implants?*

YesNo
Do you perform a regular self-breast examination?*

YesNo
Do you take hormone replacement therapy (HRT)?*

YesNo
Do you take oral contraceptives?*

YesNoOther
When was your last PAP/pelvic exam?*

Within the past yearBetween 1-4 yearsGreater than 5 yearsNever had a PAP or pelvic examPrefer not to answer or don't know
What was the date of your last menstrual period? (only answer if still menstruating)*

Within the past month or currentlyWithin the past 1-3 monthsGreater than 3 monthsPostmenopausalHave not yet begun menstruationPrefer not to answer or don't know
Reason for Appointment
Please enter the number(s) corresponding to any problem area(s): *
Ex: 15, 25, 43
How long have you had this complaint?*

Less than 5 days (acute)Between 5-30 days (sub acute)More than 30 days (chronic)
What caused this condition? *
Is there a certain date this condition began? *
Please describe your discomfort: *
On a scale of 1 to 10, with 0 being none and 10 being severe, how do you rate your discomfort?*

012345678910
How often do you feel this discomfort?*

ConstantFrequentOccasionalIntermittent
How has this complaint changed since the onset?*

WorsenedRemained the sameImproved
Does the pain radiate?

YesNo
What activity is most significantly affected by this discomfort? (Explain)*
What treatments, if any, have you received since the injury?*
What aggravates this condition?*
What improves this condition or gives you relief? *
Have other health care provider(s) performed tests related to this condition?*
Have you ever had any previous episodes of this condition?*
Other Symptoms
Fatigue:*

NeverMildModerateSevere
Mood Changes (irritability, anxiety/nervousness, depression):*

NeverMildModerateSevere
Decreased Mental Ability (memory loss, confusion, loss of focus):*

NeverMildModerateSevere
Hot Flashes / Night Sweats:*

NeverMildModerateSevere
Weight Gain (bloating, excessive belly fat, inability to lose weight):*

NeverMildModerateSevere
Decreased Sex Drive (vaginal dryness):*

NeverMildModerateSevere
Sleep Problems (can't stay asleep, can't fall asleep):*

NeverMildModerateSevere
Cold Hands & Feet / Always Cold:*

NeverMildModerateSevere
Hair Loss / Breakage:*

NeverMildModerateSevere
Dry Wrinkled Skin:*

NeverMildModerateSevere
What are you interested in getting help with?*

Acne/RosaceaAesthetics (Skin Care)Anti-AgingBio-Identical HormonesBody SculptingBotoxCellulite ReductionDiastasis RectiDetoxificationEmsculpt NeoFood SensitivitiesHair RegenerationHelp with SleepLaser Hair RemovalLaser Tattoo RemovalLaser Nail Fungus RemovalLight TherapyWeight Loss/Weight ManagementMicro-NeedlingNutritionPain ManagementSexual EnhancementSkin TighteningStem CellsWrinkle ReductionUrinary IncontinenceLeaking of UrineFrequent UrinationNone of the Above
Please bring an up to date medication list with you to your appointment. Do not bring your actual medications to the clinic, just a list please.
Should be Empty: