Patient Information for New Patients

First Name

Middle Initial

Last Name

Date of Birth

Phone Number

SSN

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about our office?

Height

Weight

What's hurting you?

Add new Area of Discomfort

Any recent Diagnostic Tests? Which ones?

If you have results from an MRI, CT scan, x-ray, etc and would like to upload them for Dr. Leipold to review, please do so below. If you have results and would rather bring them with you, that's ok to do as well.

Add file

Please upload a file

Are you seeing any other practioner for your pain or discomfort?

This could be a neurologist, surgeon, MD, DO, another DC, Physical Therapist, massage therapist, an acupuncturist, etc

Emergency Contact Information

Name

Relationship to the patient

Phone Number

Does anyone else have your permission to speak with us about your financial information?

Name

If no one is allowed to have permission to speak to us, please type no under Name.

Relationship to the patient

Phone Number

If no one is allowed to have permission to speak to us, please ignore

Does anyone else have your permission to speak with us about your treatment/care?

Name

If no one is allowed to have permission to speak to us, please type no under Name.

Relationship to the patient

Phone Number

If no one is allowed to have permission to speak to us, please ignore

Past Health History

If other, please type it here

Anything not listed under medical conditions (Or if you marked Other, please explain)::

Previous Accidents or Trauma? Please list below

Family History

Social History - How often do you ...

Employment Information

Anything not listed under allergies

Current Medications List

Medication

Dosage

If you have a medication list file you would like to upload for review, please do so below. If you would rather bring your list with you, we can make a copy here.

Add file

Please upload a file

Add new medication

If you have experienced previous trauma, or if you feel like you have suffered from something you haven't fully recovered from, please enter it in the text box below. This can include auto accidents and more.

Review of Systems

Respiratory Select all that apply

Asthma

Cold / Flu

Cough

Emphysema

Shortness of Breath

Tuberculosis

Wheezing

Other

Allergic / Immunologic Select all that apply

Allergy Shots

Cortisone Use

HIV / AIDS

Hives

Immune Disorder

Other

Genitourinary Select all that apply

Blood in Urine

Burning Urination

Frequent Urination

Kidney Disease

Kidney Stones

Lower Side Pain

Other

Constitutional Select all that apply

Difficulty Sleeping

Low Energy Level

Weight Loss / Gain

Other

Eyes Select all that apply

Blurred Vision

Double Vision

Glaucoma

Other

Endocrine Select all that apply

Diabetes

Hair loss

Menopausal

Menstrual

Thyroid

Other

Hematological Select all that apply

Bleeding

Blood Clots

Bruising

Cancer

Fever, Chills

Hepatitis

Sweating

Other

Ear, Nose, and Throat Select all that apply

Bleeding Gums

Difficulty Swallowing

Dizziness

Hearing Loss

Nosebleeds

Sinus Infections

Sore Throat

Gastrointestinal Select all that apply

Bloody Stool

Bowel Problems

Constipation

Diarrhea

Gall Bladder Problems

Liver Problems

Nausea/Vomiting

Poor appetite

Ulcers

Musculoskeletal Select all that apply

Arthritis

Broken Bones

Gout

Joints Replaced

Joint Stiffness

Muscle Weakness

Osteoporosis

Psychiatric Select all that apply

Anxiety

Depression

Stress

Other

Preferred Pronouns?

If you have pronouns you prefer, please enter them here.

Insurance Information

We are in network with most insurance companies, but not Medicaid or Tricare. We DO take Medicare. As a courtesy, we can check your benefits before your appointment to see if chiropractic is covered under your policy. This is not a guarantee of coverage and you should contact your insurance company directly if you have questions about coverage. Please be aware: Medicare only covers adjustments and there will be an additional exam fee. United and Optum and a few other companies have a daily limit. There will be an additional exam fee as well as any co-pay or co-insurance you have.

Do you have insurance you would like us to bill?

Yes No

If yes, please answer the further questions. If not, plan on $85-100 for your first appointment, which will include an initial exam and treatment.

Insurance Company Name - Example BCBS, United, Cigna, Medcost, Medicare, etc.

If there looks to be more than one company on the card, please list as much information as possible.

Who is the insured person? Please put their name below.

What is the birthday of the insured person? Please list the month, day, and year.

If you are self-insured, please put your birthday here.

What is the policy ID number?

This may also be shown as the subscriber or membership number

If there is a group number on the card, please enter it here. There may not be one.

What is the effective date?

If you have shared benefits between chiropractic and physical therapy, do you know how many visits you have left for the coverage year?

Do you know if you have a co-pay or if it is co-insurance?

We can check if you are unsure.

Do you have a secondary insurance policy? Many Medicare policies have a secondary or "Backup " policy.

If you have a secondary insurance policy, please enter the same information as for the primary insurance, including the name of the company, the effective date, your subscriber ID, and any group number present.

Please upload photos of the front and back of your insurance card

Add file

Please upload a file

Please upload a photo of the front of our ID or Driver's License

Add file

Please upload a file

Any other information?

If you have any other information you would like us to know before your appointment, please enter it below. Once you have finished, please click submit. Thank you!

Your information will be encrypted.

Patient Information for New Patients

What's hurting you?

Emergency Contact Information

Does anyone else have your permission to speak with us about your financial information?

Does anyone else have your permission to speak with us about your treatment/care?

Past Health History

Family History

Social History - How often do you ...

Employment Information

Current Medications List

Review of Systems

Insurance Information

Any other information?

Art of Chiropractic