EMAIL 1 New Hatlen Family Chiropractic Patient Intake Form

HEALTH PROFILE
Healthy Posture = Relaxed Healthy Brain and Nervous System
Bad Posture = Stressed Unhealthy Brain and Nervous System
Make sure to click on the SUBMIT button on the last page.
Today's Date

MonthDayYear
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Age
Height
Current weight
Ideal healthy weight
Gender
Address

Street Address

Street Address 2

CityState

Zip Code
Phone Number
E-Mail
Social Security Number (For insurance)
Marital Status
Spouse's/Partner's Name
Children
As part of my Pediatric Poor Posture Prevention Program, all of your children under 18 years old receive a complimentary computerized posture analysis. Would you like to have your children checked for abnormal posture?
Occupation
Employer
Contact in case of Emergency
Emergency Contact Phone #
Whom may we thank for referring you to my office?
Name of your Health Insurance Company: (We will get a copy of your card in the office)

Other
If you are here because you were recently involved in an auto accident or work-related injury, please select the date of injury below:
Date of Injury:

MonthDayYear
#1 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #1 health issue?
If your #1 health issue is not listed above then describe below:
Location: Which side(s) is your #1 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #1 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #1 health issue? (How many hours, days, weeks, months or years?)
Onset: Did your #1 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #1 health issue?
Timing: When is your #1 health issue the worst? (Check all that apply)

Other
Quality: Describe the sensation(s) of your #1 health issue. (Check all that apply)

Other
Aggravates: What makes your #1 health issue worse? (Check all that apply)

Other
Relieves: What makes your #1 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #1 health issue prior to todays visit)

Other
Life Effect: How is your #1 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#2 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #2 health issue?
If your #2 health issue is not listed above then describe below:
Location: Where is your #2 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #2 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #2 health issue? (How many hours, days, weeks, months or years?)
Onset: What do you believe caused or is causing your #2 health issue?
Onset: Did your #2 health issue come on gradually or suddenly?
Timing: When is your #2 health issue the worst? (Check all that apply)

Other
Quality: Describe the sensation(s) of your #2 health issue. (Check all that apply)

Other
Aggravates: What makes your #2 health issue worse? (Check all that apply)

Other
Relieves: What makes your #2 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #2 health issue prior to todays visit)

Other
Life Effect: How is your #2 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#3 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #3 health issue?
If your #3 health issue is not listed above then describe below:
Location: Where is your #3 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #3 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #3 health issue? (How many hours, days, weeks, months or years?)
Onset: Did your #3 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #3 health issue?
Timing: When is your #3 health issue the worst? (Check all that apply)

Other
Quality: Describe the sensation(s) of your #3 health issue. (Check all that apply)

Other
Aggravates: What makes your #3 health issue worse? (Check all that apply)

Other
Relieves: What makes your #3 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #3 health issue prior to todays visit)

Other
Life Effect: How is your #3 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#4 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #4 health issue?
If your #4 health issue is not listed above then describe below:
Location: Where is your #4 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #4 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #4 health issue? (How many hours, days, weeks, months or years?)
Onset: What do you believe caused or is causing your #4 health issue?
Did your #4 health issue come on gradually or suddenly?
Timing: When is your #4 health issue the worst? (Check all that apply)

Other
Quality: Describe the sensation(s) of your #4 health issue. (Check all that apply)

Other
Aggravates: What makes your #4 health issue worse? (Check all that apply)

Other
Relieves: What makes your #4 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #4 health issue prior to todays visit)

Other
Life Effect: How is your #4 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#5 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #5 health issue?
If your #5 health issue is not listed above then describe below:
Location: Where is your #5 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #5 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #5 health issue? (How many hours, days, weeks, months or years?)
Did your #5 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #5 health issue?
Timing: When is your #5 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #5 health issue. (Check all that apply)

Other
Aggravates: What makes your #5 health issue worse? (Check all that apply)

Other
Relieves: What makes your #5 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #5 health issue prior to todays visit)

Other
Life Effect: How is your #5 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#6 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #6 health issue?
If your #6 health issue is not listed above then describe below:
Location: Where is your #6 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #6 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #6 health issue? (How many hours, days, weeks, months or years?)
Did your #6 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #6 health issue?
Timing: When is your #6 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #6 health issue. (Check all that apply)

Other
Aggravates: What makes your #6 health issue worse? (Check all that apply)

Other
Relieves: What makes your #6 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #6 health issue prior to todays visit)

Other
Life Effect: How is your #6 health issue negatively effecting your every day life?
#7 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #7 health issue?
If your #7 health issue is not listed above then describe below:
Location: Where is your #7 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #7 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #7 health issue? (How many hours, days, weeks, months or years?)
Did your #7 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #7 health issue?
Timing: When is your #7 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #7health issue. (Check all that apply)

Other
Aggravates: What makes your #7 health issue worse? (Check all that apply)

Other
Relieves: What makes your #7 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #7 health issue prior to todays visit)

Other
Life Effect: How is your #7 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#8 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #8 health issue?
If your #8 health issue is not listed above then describe below:
Location: Where is your #8 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #8 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #8 health issue? (How many hours, days, weeks, months or years?)
Did your #8 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #8 health issue?
Timing: When is your #8 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #8 health issue. (Check all that apply)

Other
Aggravates: What makes your #8 health issue worse? (Check all that apply)

Other
Relieves: What makes your #8 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #8 health issue prior to todays visit)

Other
Life Effect: How is your #8 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#9 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #9 health issue?
If your #9 health issue is not listed above then describe below:
Location: Where is your #9 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #9 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #9 health issue? (How many hours, days, weeks, months or years?)
Did your #9 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #9 health issue?
Timing: When is your #9 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #9 health issue. (Check all that apply)

Other
Aggravates: What makes your #9 health issue worse? (Check all that apply)

Other
Relieves: What makes your #9 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #9 health issue prior to todays visit)

Other
Life Effect: How is your #9 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#10 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #10 health issue?
If your #10 health issue is not listed above then describe below:
Location: Where is your #10 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #10 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #10 health issue? (How many hours, days, weeks, months or years?)
Did your #10 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #10 health issue?
Timing: When is your #10 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #10 health issue. (Check all that apply)

Other
Aggravates: What makes your #10 health issue worse? (Check all that apply)

Other
Relieves: What makes your #10 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #10 health issue prior to todays visit)

Other
Life Effect: How is your #10 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#11 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #11 health issue?
If your #11 health issue is not listed above then describe below:
Location: Where is your #11 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #11 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #11 health issue? (How many hours, days, weeks, months or years?)
Did your #11 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #11 health issue?
Timing: When is your #11 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #11 health issue. (Check all that apply)

Other
Aggravates: What makes your #11 health issue worse? (Check all that apply)

Other
Relieves: What makes your #11 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #11 health issue prior to todays visit)

Other
Life Effect: How is your #11 health issue negatively effecting your every day life?
IF YOU HAVE NO ADDITIONAL HEALTH ISSUES, SCROLL TO THE BOTTOM, SIGN AND SUBMIT. THANK YOU.
#12 HEALTH ISSUE

(PLEASE NOTE: If you have Medicare, insurance or if you have been involved in an auto or work related injury it is important to document all health issues)
What is your #12 health issue?
If your #12 health issue is not listed above then describe below:
Location: Where is your #12 health issue located?

Other
Severity: On a scale of 1-10, with 10 being the worst, how would you rate the severity or intensity of your #12 health issue?
Frequency: What percentage of your day do you experience your #1 health issue? (Drop down list)
Duration: How long have you experienced your #12 health issue? (How many hours, days, weeks, months or years?)
Did your #12 health issue come on gradually or suddenly?
Onset: What do you believe caused or is causing your #12 health issue?
Timing: When is your #12 health issue the worst? (check all that apply)

Other
Quality: Describe the sensation(s) of your #12 health issue. (Check all that apply)

Other
Aggravates: What makes your #12 health issue worse? (Check all that apply)

Other
Relieves: What makes your #12 health issue better? (Check all that apply)

Other
Treatment: (Check all the treatments you have received for your #12 health issue prior to todays visit)

Other
Life Effect: How is your #12 health issue negatively effecting your every day life?
On your desktop computer, hold down the left mouse button as you move the mouse to sign your name inside the box below. On your phone you can sign using your fingernail or stylus.
Patient or Authorized Person's Electronic Signature
Should be Empty:

HEALTH PROFILE

Healthy Posture = Relaxed Healthy Brain and Nervous System

Bad Posture = Stressed Unhealthy Brain and Nervous System

#1 HEALTH ISSUE

#2 HEALTH ISSUE

#3 HEALTH ISSUE

#4 HEALTH ISSUE

#5 HEALTH ISSUE

#6 HEALTH ISSUE

#7 HEALTH ISSUE

#8 HEALTH ISSUE

#9 HEALTH ISSUE

#10 HEALTH ISSUE

#11 HEALTH ISSUE

#12 HEALTH ISSUE

On your desktop computer, hold down the left mouse button as you move the mouse to sign your name inside the box below. On your phone you can sign using your fingernail or stylus.