Clone of NPIH

New Patient Intake and History Form

Thank you for taking the time to fill out this form. Your time is important and your health is more important. This form only takes about 10 minutes to complete. However, it will guide us to find underlying causes, not just symptoms. This approach helps us to recommend the care best suited for you.
Office and Appointment
Which office will you be visiting?*
What service(s) are you seeking?*

ChiropracticNeuropathyDecompressionShockwaveWeight Loss / Gut HealthCar Accident CareOther
Have you already set up an appointment with us?*

YesNo
What days and times work best for you (choose all that apply; we'll confirm)*

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AM
Patient Information
Are you filling this form out for yourself or for someone else?*

For myself (I am 18 or older)Someone else
Information regarding the person filling out this form for the patient (below)
My Name: My Phone: My Email: My Relationship to Patient: Other:
For the rest of this form, enter
information about the PATIENT.
Patient's First Name*
Enter this and the rest of the form about THE PATIENT
Middle Initial
Last Name*
Called Name (Nickname)
Date of Birth*
Age*
If under 3 years old, use a decimal (For example, 1.75 for 1 year, 9 months).
Biologic Sex*

MaleFemale
Social Security Number*
This is safeguarded. This form is HIPAA-compliant.
E-Mail*
Mobile Phone*
Home Phone
Work Phone
Your Street Address (Include Apt # if necessary)*
City & State*
Zip*
Emergency Contact Information
Recommended but optional. Name, relationship, phone number, etc.
Marital Status*

SingleMarriedDivorcedWidowedOther
Spouse's Name
If Applicable
Employment Status*

EmployedUnemployedRetiredStudent
Employer / Company Name*
Employer / Company - City and State*
Employer / Company Phone Number
Your Position
Physical Nature of your Job
How did you hear about us? *
What is the referral source?
What is the name of the person who referred you?
If applicable (including your doctor's name if he/she referred you)
Information about your Doctor(s)
Physician's Name*
(Please provide first and last names if known. Type ''None'' if none.)
Your primary doctor's Phone Number
Type "N/A" if not applicable.
Your primary doctor's physical Address
Type "N/A" if not applicable
It is customary for our office to update your doctor. Do we have your permission in doing so?

YesNo
Have you seen a chiropractor before?

YesNo
Who was your last chiropractor?
If applicable
When was your last adjustment and what were you treated for?
If applicable
Review of Systems

For each condition, use "N/A" to mean that you have never had the condition, "Had" if you have ever had the condition, and "Have" if you currently have the condition.

Musculoskeletal System*

	N/A	Had	Have
Neck pain
Back pain
Shoulder pain
Elbow pain
Arm pain
Hand, wrist, finger pain
Pelvic pain
Hip pain
Knee pain
Leg pain
Foot, ankle, toe pain
Arthritis
Osteoporosis
Scoliosis
Numbness
Jaw pain

Neurological*

	N/A	Had	Have
Headaches
Anxiety
Depression
Dizziness
Pins and Needles
Numbness

Cardiovascular*

	N/A	Had	Have
High blood pressure
Low blood pressure
High cholesterol
Poor circulation
Chest pain
Excessive bleeding

Sexual Health

The following question(s) are asked based on your reported age and biologic sex. This section may not have questions if there are none relevant for the patient's age and biological sex.
Date of Last Menstrual Period (females)*
Type [NA] if not applicable
Do you experience erectile dysfunction?

YesNo
Living with erectile dysfunction can be challenging and impact many aspects of your life. While ED is more common than you might realize, we understand it’s a sensitive topic to discuss. To make things easier and more comfortable for you, we’d like to offer you a private and discreet virtual consultation (via phone or video).

Normally, this consultation is $97, but as part of your overall new patient package, we’re offering it to you at no additional cost. During this consultation, we’ll discuss proven, drug-free and surgery-free treatment options that have helped many men regain confidence and improve their quality of life.
Would you like to schedule your free consultation today? We will email you our virtual consultation schedule.

YesNo
Metabolic, Gut, Chemical, and Hormonal
Sub-Clinical Symptoms including:*

HeadachesMigrainesN/A
Hormone Imbalance Including:*

PMSEmotional ImbalanceN/A
Gastrointestinal Issues Including:*

Bloating, cramps, or painful gasIrritable Bowel SyndromeUlcerative ColitisCrohn's Disease and other intestinal disordersN/A
Respiratory Conditions Including:*

Chronic SinusitisAsthmaAllergiesN/A
Joint Conditions Including:*

Knee, Shoulder, or SpineN/A
Autoimmune Conditions Including:*

Diabetes MellitusLupusRheumatoid ArthritisFibromyalgiaChronic FatigueN/A
Thyroid Conditions Including:*

Hashimoto'sHypothyroidismHyperthyroidismN/A
Developmental and Social Concerns Including:*

Autism / Asperger'sADD / ADHDN/A
Skin Conditions Including:*

EczemaSkin RashesHivesN/A
Do you suffer with any of the following? Circle the number that most closely fits.
Constipation and/or Diarrhea*

0

1

2

3

0 is None, 3 is Severe
Abdominal Pain or Bloating*

0

1

2

3

0 is None, 3 is Severe
Mucous or Blood in Stool*

0

1

2

3

0 is None, 3 is Severe
Joint Pain or Swelling, Arthritis*

0

1

2

3

0 is None, 3 is Severe
Chronic or Frequent Fatigue or Tiredness*

0

1

2

3

0 is None, 3 is Severe
Food Allergies, Sensitivities, or Intolerances*

0

1

2

3

0 is None, 3 is Severe
Sinus or Nasal Congestion*

0

1

2

3

0 is None, 3 is Severe
Chronic or Frequent Inflammations*

0

1

2

3

0 is None, 3 is Severe
Eczema, Skin Rashes, or Hives (Urticaria)*

0

1

2

3

0 is None, 3 is Severe
Asthma, Hay Fever, or Airborne Allergies*

0

1

2

3

0 is None, 3 is Severe
Confusion, Poor Memory, or Mood Swings*

0

1

2

3

0 is None, 3 is Severe
Use of NSAIDS (Aspirin, Tylenol, Motrin)*

0

1

2

3

0 is None, 3 is Severe
History of Antibiotic Use*

0

1

2

3

0 is None, 3 is Severe
Alcohol Consumptions Makes You Feel Sick*

0

1

2

3

0 is None, 3 is Severe
Gluten Sensitivity or Celiac Disease*

0

1

2

3

0 is None, 3 is Severe
Nausea*

0

1

2

3

0 is None, 3 is Severe
Weight Issues*

0

1

2

3

0 is None, 3 is Severe
Your Total (don't edit this)
Medical History

Tell us a bit about your medical history
List all Surgeries and Procedures with Dates
List all major illnesses, injuries and accidents
List All Hospitalizations (Cause, Dates)
List Pregnancy Data
List any Medication and/or Supplements
Do you drink? If so, how much?*
IE: 1 beer per week or 0-10 drinks per mo.
Do you smoke, chew or vape (nicotine or tobacco)? If so, quantity and method:*
IE: 1/2 pack cigarettes per day.
Do you consume caffeine? If so, how much?*
IE: 2 cu. coffee and 1 cu. tea per day.
Please list your children including name, age and any condition(s).
Do your family suffer from any of the following?

Neck PainBack PainHeadachesMigrainesPinched NerveDisc IssuesArthritisNeuritisScoliosisOther
Explain who suffers from the condition(s) above.
Maternal History. Please indicate if your mother is alive. If not, cause of death. List ALL conditions on her side of family and who suffered. If you cannot provide this, just put "N/A"*
NOTE: The purpose of this is to determine your potential risk for genetic disease/condition. If you were adopted and cannot fill this out, please just type ''Adopted. Do not know mother.''
Paternal History. Please indicate if your father is alive. If not, cause of death. List ALL conditions on his side of family and who suffered. If you cannot provide this, just put "N/A"*
NOTE: The purpose of this is to determine your potential risk for genetic disease/condition. If you were adopted and cannot fill this out, please just type ''Adopted. Do not know father.''
Were you injured because of an accident or workplace injury?*

Car Accident (less than 2 years ago)Car Accident (more than 2 years ago)Workplace AccidentNone of the aboveOther
Chief Complaint

Tell us about your main complaint (reason for your appointment)
What is troubling you and where?*
How long has it been bothering you?*
Has this ever happened before? Explain.
Did you have an injury or illness that may have caused this?
What makes it feel better?*
What makes it feel worse?*
How would you describe the pain?

DullAchySharpStabbingBurningElectricPins/NeedlesTinglingNumbnessRadiating or shooting painOther
Describe the radiating or shooting pain
What is the intensity NOW? (0-10)*
What is the intensity On AVERAGE? (0-10)*
What is the intensity At WORST? (0-10)*
What is affected?

SleepingFocusEatingHygieneUrinationDefecationSittingStandingWalkingWorkingSocial LifeParentingHouskeepingOther
What is the timing pattern for this complaint?

Constant (unceasing)Intermittent (comes and goes)Other
If intermittent, how frequently does the pain come and go?
Is there any pattern to the pain?
IE: Worse in the morning. Worse in the winter.
List anything else we may need to know here.
IMPORTANT: Do you suffer from any of the following in your legs, feet, toes, arms, hands, and/or fingers?*

PainNumbnessTinglingPins / NeedlesWeaknessSensitivityLoss of ReflexBurning/AchingDifficulty SleepingSores/Ulcers or InfectionsNone of the above
Neuropathy Quotient (10 max)
Submitting Form

Just a few steps remaining
How do you want us to bill your visits?*
NOTE: If this is due to an accident, select ''UNSURE.''
Insurance Information (From Card)
Company: Provider Relations Ph#: Member Name: Member DOB: Member ID: Group#: Relationship to Member: If you have a secondary insurance, type the same information below: Also see back of card. Fill out what you can!
Submission Agreement: The information I have entered is authentic and true to the best of my knowledge. I authorize payment of insurance benefits directly to Shiloh Chiropractic or ChiroPro. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers, services and payers and to secure the payment of benefits. I understand that I am ultimately responsible for all costs of care incurred at Shiloh Chiropractic as determined by my treating doctor; any fees for professional services will be immediately due and payable. I agree to pay a $50 "no call no show fee" if I do not keep my appointment or cancel within 24 hours of the appointment time. I understand and agree to allow Shiloh Chiropractic and ChiroPro to use information in this form for the purpose of the diagnosis, treatment, payment, healthcare operations and coordination of care. I am aware that this patient health information is going to be used in Shiloh Chiropractic and ChiroPro and my rights concerning the privacy of said information is safeguarded. I understand that Shiloh Chiropractic and ChiroPro has a published HIPAA policy at its office and that I can request to view that in its entirety at any time. By submitting this form, you acknowledge and understand that the data is being submitted electronically. You can abstain from sending any filed by simply typing "abstain" in that field. If you are not comfortable submitting your data electronically, you may opt to fill out an alternative paper form in the office or you can download it on our website ChiroPro.com or ShilohChiro.com. If you opt to fill it out in office, simply make arrangements to get to the office 20-30 minutes prior to your scheduled appointment. If you have questions, please call our office.
Full Name of person filling out this form.*
Date

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Signature*

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New Patient Intake and History Form

Office and Appointment

Patient Information

Information about your Doctor(s)

Review of Systems

Sexual Health

Metabolic, Gut, Chemical, and Hormonal

Medical History

Chief Complaint

Submitting Form