General / Adult Intake

HIPAA Notice & Acknowledgment
Yor Privacy Rights
We are committed to protecting your health information. Your information may be used for treatment, payment, and healthcare operations as required by law. A copy of our Notice of Privacy Practices is available at the front desk and upon request.
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Informed Consent to Chiropractic Care
Chiropractic care focuses on supporting the nervous system and musculoskeletal system so the body can function, adapt, and heal as efficiently as possible. Care is gentle, individualized, and appropriate for each person's age, size, and health history. I understand that chiropractic care does not diagnose or treat disease, that results may vary, and that no guarantees have been made regarding outcomes
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Financial Policy & Insurance
Payment is due at the time of service unless prior arrangements are made. Belleair Bluffs Chiropractic accepts some insurance plans. Insurance benefits are verified as a courtesy and are not a guarantee of payment. Patients are responsible for any balance not covered by insurance
Insurance Plan
leave blank if uninsured
Method of Payment for First Visit
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Communication & Media Consent
Appointment Reminders & Communication
Photo / Video Consent
From time to time, photos or videos may be taken for clinical documentation, education, or marketing purposes. No identifying information will be shared without your explicit permission. Participation is completely voluntary and will not affect your care
Photo/Video Permission
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Previous Care
Prior Chiropractor
Last Appointment with Prior Chiropractor

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Prior Chiropractor Address
Prior Chiropractor Phone
Please enter a valid phone number.Format: (000) 000-0000.
General Practitioner
GP Phone
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May we send a report of findings to your GP?

Reason for Visit
Health Reason 1
Health Reason 2
Health Reason 3
Health Reason 4
In the past week, how much has pain interfered with daily activities? (0-10 being the most)

Case History

Fill this Out for your Main Complaint
Onset: Nerve pressure can occur suddenly or gradually, how did the problem start? How long ago did the problem start?
Subluxations may be more aggravated by certain activities or relieved by certain behaviors or actions.
Palliative: What makes the pain better? Ice/ Heat/ Medication (how much/how often?)
Provocative: What makes the pain worse? Walking up stairs/ Washing dishes/Vacuuming/ Driving/ Bending over/etc.
Quality: Depending upon which fibers of a nerve are pinched, subluxations can result in different feelings. How would you describe your pain?
(Dull/Achy/ Knifelike/ Sharp/ Shooting/ Stabbing/ Electrical/Hot/Cold/Numb/ Tingling)
/10 Ave
/10 Wrs
Radiation: The more severe the nerves end up being pinched, the further from the source of the problem the pain can radiate, do you notice the pain sometimes travels to other areas? (legs/arms/around your sides)
Timing: Sometimes Subluxations can be more aggravated over time, while others respond better once you start moving. Is the problem worse in the morning or evening vs. before use or after activities?
Additional Notes:
When this current problem is at its absolute worst, in what ways does it interfere with your daily activities
If this problem was left unattended for another five years, how do you think it would affect you?

Chiropractic Knowledge
What have you heard about chiropractic?
Do you know what a subluxation is?
Insurance & Payment
Do you have insurance?
Insurance Plan
Method of payment for first visit
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The above information is true and accurate to the best of my knowledge. My reason for consultation is for evaluation of my physical health and the potential for improvement.
Patient or Guardian Signature
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Adult Intake Form