Clone of Patient intake forms

Date

MonthDayYear
Date
Age
Date of Birth

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
preferred phone contact

HomeWorkCell
Home
Work
Cell
Email
example@example.com
Sex

MFOther
SSN
Marital/Partner Status:

SMWDSep
Partnerspouse
Emergency/Guardian Contact
Name
Relationship
Cell Phone
Home Phone
Employment Status

EmployedUnemployedRetiredStudentOther
Employer
Occupation
PCP
Address
Phone
Date of latest exam visit

MonthDayYear
Date
Other Physicians
Permission to send a health update to your PCP

Yes, ok to send.No, please do not send.
Does your present condition involve a claim for

Work injuryCar AccidentSlip/fall
Date of injury

MonthDayYear
Date
Date reported

MonthDayYear
Date
Date of treatment/exam:

MonthDayYear
Date
Do you have insurance coverage?

YesNo
Do you have a co-pay

YesNo
Do you have a deductible?

YesNo
Insurance Company
May we contact you at home and leave messages?

YesNo
How Did You Hear About Us
Date

MonthDayYear
Date
What brings you to our office
Rate your pain on a scale of 1-10, with 10 being the worst:

12345678910
Type of pain?

N= NumbnessB= BurningSH=ShootingS= StabbingT=TinglingA=Dull AcheI= Intense AcheSP=Spasm
Describe your symptoms in order of severity
1
2
3
4
5
When did symptoms begin?

MonthDayYear
Date
Getting:

BetterWorseComes & goesNot improving
Result of

Motor Vehicle AccidentWork RelatedOther:
Other information about your condition
Does your condition keep you awake at night?
Can you get relief by changing your position?
Have you received prior treatment? If so when and where?
Have you had an Xray or MRI If so when and where?
Past Medical History
NAME
DOB

MonthDayYear
Date
PCP
Past Medical History: Please mark with a check any of the following which you currently have or have been treated for in the past.

AllergiesAnxietyBlood ClotCancerConcussionDepressionDiabetesHeart AttackHeart DiseaseHepatitisHerniated DiscHigh Blood PressureHigh CholesterolHIVIrritable Bowel Disease ( Crohn's Disease, Ulcerative Colitis)Kidney DiseaseLyme DiseaseMigraine HeadachesMultiple SclerosisNeuropathyOsteoporosis or OsteopeniaPacemakerParkinson's DiseaseRheumatoid ArthritisScoliosisSeizuresStrokeThyroid DysfunctionTremorUlcerVertigoOther
Any history of spinal/rib fractures or other broken bones?
Please list any prior SURGERIES and HOSPITALIZATIONS:
YEAR
REASON
Hospital
Please list all MEDICATIONS you are presently taking (if you have a list please give it to the receptionist):
Medication
Reason
Family History: Please list any immediate family member (parents, siblings, children) who has the following

Alzheimer'sCancerDiabetesHigh Blood PressureHeart DiseaseStorkeOther
Social Habits
Smoking status?

Current SmokerPrevious SmokerNon smoker
Do you consume alcohol

YesNo
Frequency?
Do you exercise regularly?

YesNo
DATE

MonthDayYear
Date
Payment acknowledgement for services rendered

Today's health insurance climate is challenging. We understand and acknowledge that it can be difficult to pre- determine what your insurance will cover before or at the time of your visit. We ask that you, the patient, contact your insurance plan to determine your individual coverage. We will assist you in this venture as best we can, but often find the specifics of your coverage are most often determined after your claim has been submitted and an EOB (explanation of benefits) has been sent to us by your insurance company. This coverage may be different from the pre-determined coverage provided on your insurance card or over the phone. We will work with you to make sure that your out of pocket expenses are reasonable and try as best we can to inform you of any possible costs associated with your treatment upfront.
I understand that my health insurance coverage may be limited and may only cover a portion of my therapy (there is a chance it might not cover any of my therapy)
I understand that I am responsible for payment at the time of service for any co-pays, deductibles, and previously determined non-covered services.
I also acknowledge that I am responsible for payment of services that have been denied or deemed noncovered services by my Health Insurance Company after a claim has been submitted
I ultimately understand that I am responsible for payment of health care services provided at the office of Dr. Jeffrey C. Smith.
Date

MonthDayYear
Date
PRIVACY NOTICE ACKNOWLEDGEMENT

We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy policies and procedures. We encourage you to read this document fully, as it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use of your health information, we would be happy to address them. I acknowledge that I have received a copy of Jeffrey C. Smith, DC's notice of Privacy Practices for Personal Health Information.
Name print
Date

MonthDayYear
Date
Informed Consent to Chiropractic Treatment

The nature of chiropractic treatment: The doctor will use his/her hands in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint. Various ancillary procedures (such as hot or cold packs, therapeutic ultrasound, electric stim) or myofascial techniques may also be used.

Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered "rare".

Other treatment options which could be considered may include the following:
- Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.
- Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.
- Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.
- Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.
Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and herby give my full consent to treatment.
Name print
Date

MonthDayYear
Date
Should be Empty:

Emergency/Guardian Contact

Describe your symptoms in order of severity

Past Medical History

Please list any prior SURGERIES and HOSPITALIZATIONS:

Please list all MEDICATIONS you are presently taking (if you have a list please give it to the receptionist):

Social Habits