New Patient Intake
Welcome to The Posture Lounge!
Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to askone of our qualified Chiropractic Assistants. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care.
Patient Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Gender
Male
Female
Other
Date of Birth
-
Month
-
Day
Year
Date
Employer
Occupation
Marital Status
Single
Married
Widowed
Partner
Separated
Divorced
Other
Number of Children
Reason for visit
Is the purpose of this appointment related to: (check all that apply)
acute injury
chronic discomfort
sports injury
work related injury
auto related injury
fall
Other
If job related, have you mde a report of your accident to your employer?
yes
no
Other
When did this condition begin?
Has this condition:
gotten worse
stayed constant
come and go
Other
Name of Primary Physician
City of your Primary Physician
Place an X on the image below, where you feel pain, numbness or tingling:
Experience with Chiropractic
Who referred you to this office?
Have you been adjusted by a chiropractor before?
yes
no
Other
Reason for previous chiropractic care:
Name of previous Chiropractor & approximate date of last treatment
Initial Consultation Form
The rating scale below is designed to measure the degree to which several aspects of your life are presently disrupted by your health condition (pain and/orsymptoms you may be experiencing). In other words, we would like to know how much your health condition (pain and/or symptoms you may be experiencing) ispreventing you from doing what you would normally do, or from doing it as well as you normally would. Respond to each category by indicating the overallimpact of pain in your life, not just when the pain is at its worst.For each of the 6 categories of daily life, PLEASE INDICATE THE NUMBERWHICH BEST DESCRIBED YOUR TYPICAL LEVEL OF ACTIVITIES. 0 means no disability at all, and a score of 10 means that all of the activities in which youwould normally be involved have been totally disrupted or prevented by yourhealth conditions(pain and/or symptoms you may be experiencing).
FAMILY/HOME RESPONSIBILITIES:activities related to the home or familyincluding chores duties performedaround the house (yard work, doingdishes, errands, favors for other familymembers, driving children to schooletc.) (Enter 0 - 10)
no pain
1
2
3
4
5
6
7
8
9
worst pain
10
1 is no pain, 10 is worst pain
RECRATION: hobbies, sports, andother similar leisure time activities. (Enter 0 - 10)
no pain
1
2
3
4
5
6
7
8
9
worst pain
10
1 is no pain, 10 is worst pain
SOCIAL ACTIVITIES: activities which involve participation with friends and acquaintances other than family members including parties, theater, concerts, dining out, and other social functions. (Enter 0 - 10)
no pain
1
2
3
4
5
6
7
8
9
worst pain
10
1 is no pain, 10 is worst pain
OCCUPATION: activities that are a partof or directly related to one's jobincluding nonpaying jobs as well, suchas that of homemaker or volunteerworker. (Enter 0 - 10)
no pain
1
2
3
4
5
6
7
8
9
worst pain
10
1 is no pain, 10 is worst pain
SELF CARE: activities which involve personal maintenance and independent daily living (taking a shower, driving, getting dresses, etc.) (Enter 0 - 10)
no pain
1
2
3
4
5
6
7
8
9
worst pain
10
1 is no pain, 10 is worst pain
LIFE SUPPORT ACTIVITIES: basic life supporting behaviors such as eating, sleeping, and breathing. (Enter 0 - 10)
no pain
1
2
3
4
5
6
7
8
9
worst pain
10
1 is no pain, 10 is worst pain
Any secondary complaints that we should know about?
Ownership of X-ray Films
It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office. If you require a copy of your films, we would be happy to provide that to you at an additional copy fee.
Authorization for Care
I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.
I consent that all information provided is true and correct and I have read and agree with all the above statements.
SUBMIT
SUBMIT
Should be Empty: