New Patient Intake Form

Appointment

Title

Mr. Mrs. Ms. Miss Dr. Other

If other, please specify.

First Name

Last Name

Date of Birth

Sex

Male Female

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Home Cell Work Don’t leave messages

Home Phone

Cell Phone

Work Phone

Email address

Social Security Number

Home Address

City

State

Zip Code

Primary Care Physician

Phone

Emergency Contact

Relationship

Home Phone

Cell Phone

Employment Status

Employed Unemployed FT Student PT Student Other

If other, please specify.

Employer Name

Your Occupation

Occupational Activities: (Check one that best describes your job)

If other, please specify.

Spouse

First Name

Last Name

Home Phone

Work Phone

Spouse Date of Birth

If screening, please specify.

If other, please specify.

Please indicate where you are experiencing the following symptoms:

Numbness
Burning
Sharp
Tingling
Dull Ache

Average Pain Intensity:

How are your symptoms changing?

Getting better Not changing Getting worse

Does anything improve your pain?

No Yes

Please provide details.

Are your symptoms a result of

Motor Vehicle Accident

Work-related Accident

Other

If other, please specify.

When did your symptoms begin?

How did your symptoms begin?

How often do you experience your symptoms?

Constantly

(76-100% of the day)

Frequently

(51-75% of the day)

Occasionally

(26-50% of the day)

Intermittently

(0-25% of the day)

What describes the nature of your symptoms?

Sharp

Ache

Numb

Shooting

Burning

Tingling

Throbbing

Other

If other, please specify.

Are You Pregnant?

Yes No

Date of last menstrual cycle

Medical Conditions: (Check all that apply)

If other, please specify.

Surgeries: (Check all that apply)

If other, please specify.

Allergies: (Check all that apply)

Animal

Chemical

Milk/Lactose

Mold

Seasonal

Sulfites

Wheat/Glutens

Other

If chemical, please specify.

If other, please specify.

Social History: (Check all that apply)

Caffeine use

Occasional Often Never

Drink Alcohol

Occasional Often Never

Exercise

Occasional Often Never

Drink Water

Less than 64 oz/day More than 64 oz/day Never

Cigarettes

Less than 1 pack/day More than 1 pack/day Never

Sleep

Less than 8 hours/night More than 8 hours/night Insomnia

Family History: (Check all that apply)

Arthritis

Parent

Sibling

Cancer

Parent

Sibling

Diabetes

Parent

Sibling

Heart Disease

Parent

Sibling

Hypertension

Parent

Sibling

Stroke

Parent

Sibling

Thyroid

Parent

Sibling

Other

Parent

Sibling

For other, please specify.

Please list all current medications being taken

Review of Systems: (Check box if you have had trouble with any of the following)

Cardiovascular

Respiratory

Poor Circulation

Past Present No

Asthma

Past Present No

Hypertension

Past Present No

Tuberculosis

Past Present No

Aortic Aneurism

Past Present No

Short Breath

Past Present No

Heart Disease

Past Present No

Emphysema

Past Present No

Heart Attack

Past Present No

Cold/Flu

Past Present No

Chest Pain

Past Present No

Cough

Past Present No

High Cholesterol

Past Present No

Wheezing

Past Present No

Pacemaker

Past Present No

Eyes

Jaw Pain

Past Present No

Glaucoma

Past Present No

Irregular Heartbeat

Past Present No

Double Vision

Past Present No

Swelling of legs

Past Present No

Blurred Vision

Past Present No

Genitourinary

Allergic/Immunologic

Kidney Disease

Past Present No

Hives

Past Present No

Burning Urination

Past Present No

Immune Disorder

Past Present No

Frequent Urination

Past Present No

HIV/AIDS

Past Present No

Blood in Urine

Past Present No

Allergy Shots

Past Present No

Kidney Stones

Past Present No

Cortisone Use

Past Present No

Lower Side Pain

Past Present No

Hematologic

Ear, Nose and Throat

Hepatitis

Past Present No

Difficulty Swallowing

Past Present No

Blood Clots

Past Present No

Dizziness

Past Present No

Cancer

Past Present No

Hearing Loss

Past Present No

Bruising

Past Present No

Sore Throat

Past Present No

Bleeding

Past Present No

Nosebleeds

Past Present No

Fever, Chills

Past Present No

Bleeding Gums

Past Present No

Sweating

Past Present No

Sinus Infections

Past Present No

Varicose Vein

Past Present No

Neurologic

Musculoskeletal

Stroke

Past Present No

Gout

Past Present No

Seizures

Past Present No

Arthritis

Past Present No

Head Injury

Past Present No

Joint Stiffness

Past Present No

Brain Aneurysm

Past Present No

Muscle Weakness

Past Present No

Numbness

Past Present No

Osteoporosis

Past Present No

Severe Headaches

Past Present No

Broken Bones

Past Present No

Pinched Nerves

Past Present No

Joints Replaced

Past Present No

Parkinson’s

Past Present No

Neck Pain

Past Present No

Carpal Tunnel

Past Present No

Low Back Pain

Past Present No

Vertigo

Past Present No

Upper Back Pain

Past Present No

Gastrointestinal

Constitutional

Gall Bladder Problems

Past Present No

Weight Loss/Gain

Past Present No

Bowel Problems

Past Present No

Low Energy Level

Past Present No

Constipation

Past Present No

Difficulty Sleeping

Past Present No

Liver Problems

Past Present No

Endocrine

Ulcers

Past Present No

Thyroid

Past Present No

Diarrhea

Past Present No

Diabetes

Past Present No

Nausea/Vomiting

Past Present No

Hair Loss

Past Present No

Bloody Stools

Past Present No

Menopausal

Past Present No

Poor Appetite

Past Present No

PMS

Past Present No

Psychiatric

Depression

Past Present No

Anxiety

Past Present No

Stress

Past Present No

Payment and Insurance

I understand and agree that the health and accident policies are an arrangement between the insurance carrier and myself. This office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.

MINOR CHILD - Consent to Treatment

If applicable, I authorize the licensed doctor and whomever he/she may designate as assistant to administer chiropractic care as deemed necessary to my

Relationship

Name

⠀

FEMALE Patients

This is to certify that to the best of my knowledge I am NOT PREGNANT and that Sterling Chiropractic has my permission to take x rays as needed.

Patients’ Rights

Sterling Chiropractic respects the unique differences of our patients and will ensure that health care ethics are maintained for all patients. The following rights will be exercised on our patients’ behalf.

The patient has the right to considerate and respectful care.
The patient has the right to and is encouraged to obtain from his/her doctor and staff relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.
The patient has the right to know the identity of everyone involved in his/her care.
The patient has the right to make decisions about the plan of are prior to and during the course of treatment and to refuse a recommended treatment of plan of care to the extent permitted by law, and to be informed of the consequences of this action.
The patient has the right to every consideration of privacy.
The patient has the right to expect that all communications and records pertaining to his/her care will be treated as confidential, except in cases when reporting is permitted or required by law.
The patient has the right to expect reasonable continuity of care when appropriate and to be informed of available and realistic patient care options.

Consent to Chiropractic Services

I hereby request and consent to chiropractic manipulations and procedures including various modes of physical therapy, diagnostic xrays and/or tests by Sterling Chiropractic and staff who now or in the future treat me while employed in this office. I will have an opportunity to discuss with the doctor and/or staff the nature and purpose of treatment indicated. I understand that results are not guaranteed and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks of treatment, including but not limited to fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications and wish to rely on the doctor to exercise judgement during the course of any procedure which the doctor feels at the time is in my best interest. I have read, or have had read to me, the full above consent and have also had an opportunity to ask questions about its content, and by signing below, I agree to the above terms and procedures. I intend this consent to cover any treatment for my present condition and for any future conditions for which I seek treatment by this office and/or employed staff.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signed

Date

Sterling Chiropractic Patient Acknowledgement and Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent for Use of Health Information

Patient's Name

Date

The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy Practices Pursuant to HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual is available upon request.

The undersigned does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State Law and Federal Law.

Dated this

day of

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

If patient is a minor or under a guardianship order as defined by State law:

Parent/Guardian

Parent Guardian

Signature of Parent/Guardian (select one)

Names of persons with whom you wish to share Protected Health Information:

Add Name

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