Kasandra Ruettiger New Patient Intake Form

1

Name

First Name

Last Name

2

Birth Date

Date

3

Gender

4

Today's Date

Date

5

Home Address

6

City

7

State

8

Zip

9

Home Phone

10

Cell Phone

11

SSN #

12

Email

example@example.com

13

Employer

14

Occupation

15

Hours/ week

16

How long at this position?

17

Married?

YESNO

18

Name of Spouse

19

Spouse's Date of Birth

Date

20

Name and ages of your children:

21

How did you hear about us?

22

Person responsible for this account:

23

Primary Medical Insurance

24

Do you consent to receive automated communication?

YESNO

25

Please identify the reason/ complaint(s), injury, or illness that brought you to this office:

26

When did this problem(s) begin?

27

Is your problem the result of ANY accident?

YESNO

28

Date of Accident

Date

29

If yes, identify type:

Auto

Work

Home

Other

30

If others (please explain)

31

Have you suffered from the same or similar problem(s) in the past?

YESNO

32

If yes, when?

Date

33

Who provided the treatment?

34

Please state what they said or recommended:

35

What were the results?

Favorable

Unfavorable

36

Is this condition progressively getting worse?

YESNO

37

What % of the day do you experience your symptoms?

Constants

Frequent

Intermittent

38

Are your symptoms worse in the:

AM

PM

Consistent all day no change

39

Does it interfere with your:

Work

Sleep

Daily Routine

Recreation

41

Describe your activities at work.

42

Have you ever had a chiropractic care?

YESNO

43

If yes, name of chiropractor:

44

How long were you under his care?

45

What were the results?

46

Are you taking mediation(s)? for complaint(s): Muscle relaxers/ Pain killers/ Over-the-counter?

47

I certify that the above information is correct to the best of my knowledge. I will not hold the doctors or staff responsible for any errors or omissions that I may have made in this form.

56

Choose any symptoms you have or have had in the past:Men Only

Breast Lump

Erection Difficulties

Lump in Testicles

Cancer

58

Date of last menstrual period:

Date

59

Date of last mammogram:

Date

60

Other Complaints

61

Choose any symptoms you have or have had in the past:Genitourinary

Blood in Urine

Frequent Urination

Lack of Bladder Control

Painful Urination

85

On scale of 1-10, 10 being the highest, rate your commitment to getting rid of the problem:

86

Please list any concerns that might interfere with your commitment (transportation, time, finances, Other, etc):

87

List all medications

88

List all Vitamins/ Supplements/ Herbs

89

Any Allergies?

90

Smoking: cigars pipe cigarettesChoose One

Daily

Weekends

Occasionally

Never

91

Alcoholic Beverage ConsumptionChoose One

Daily

Weekends

Occasionally

Never

92

Recreational Drug UseChoose One

Daily

Weekends

Occasionally

Never

93

Soda/Pop ConsumptionChoose One

Daily

Weekends

Occasionally

Never

94

Does anyone in your family suffer with the same condition(s) you have?

YESNO

96

Have they ever been treated for their condition?

YESNO

97

List other hereditary conditions the doctor should be aware of:

98

Patient Signature

99

Notice of HIPPAA Privacy Practice

100

PERMITTED DISCLOSURES:

101

YOUR RIGHTS:

102

COMPLAINTS

103

Charleston Chiropractic Studio Office Policies

104

Medicare Policy

105

I give Charleston Chiropractic Studio permission to use my name, my photo, and my personal chiropractic testimonial for marketing purposes, office branding, and on social media including but not limited to: Facebook, Twitter, Pinterest, Instagram, YouTube, etc. Charleston Chiropractic Studio can also use my name and/or photo and/or testimonial for marketing or social proof purposes in the office on the referral board, testimonial book, etc. I give ongoing consent to the aforementioned requests until I request that my name and/or testimonial be no longer available to the public.