New Patient Intake Forms

PATIENT INFORMATION - PLEASE COMPLETE ALL SECTIONS:

Name:

Date

Age:

Birth Date:

Race:

Home Phone

Email address

Cell Phone

Address:

City:

State:

Zip:

What is your preferred method of contact? Circle one:

Home

Cell

E-mail

Occupation:

Employer:

Spouse:

Occupation:

Employer:

EMERGENCY CONTACT INFORMATION

Name of Nearest Relative:

Phone

Family Medical Doctor:

Phone

How were you referred to our office?

Friend Family CHS Website Online Local Event

Name:

FINANCIAL INFORMATION

Insurance

Worker's Comp

Self-Pay (Cash)

Personal Injury/Auto

Auto

Other

PRIMARY INSURANCE:

Insurance Name:

Insurance ID Number:

Patient SSN#

Other than self:

Insured’s Name:

Insured SSN#

Address:

City:

State:

Zip:

Phone:

Date of birth:

SECONDARY INSURANCE:

Insurance Name:

Insurance ID Number:

Patient SSN#

Other than self:

Insured’s Name:

Insured SSN#

Address:

City:

State:

Zip:

Phone:

Date of birth:

It is our office policy to pay the day of services unless otherwise arranged.

Who is responsible for payment? Self/Other (relationship) -

Other than self:

Name:

Phone:

Address:

City:

State:

Zip:

Insured’s or Authorized Person’s Signature: I authorize payment of medical benefits be made to Chiropractic Health Solutions for the Services described on the insurance form. This authorization is to apply to all services received until it is revoked in writing. I agree to pay for services not covered by insurance and understand that I am ultimately responsible for payment in full at this office. I also authorize the release of any medical or other information necessary (PHI) to process my insurance claim. This is to serve as a long-term authorization card. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable. I understand that interest is charged on overdue accounts at the annual rate of 40%. If you would like to have a more detailed of our policies and procedures concerning the privacy of you Protected Health Information (PHI) we encourage you to read the HIPPA Notice that is available to you at the front desk before signing this consent.

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

Signature

Date:

CONSULTATION QUESTIONNAIRE

Describe your current problem and how it began:

Is this related to an auto or work accident?

Date of Accident:

How many days lost from work?

Have you ever had the same or a similar condition?

Yes No

Have you ever had the same or a similar condition?

Has it become worse recently?

Yes No

Select one:

Same Better Worse Gradually Worse

If yes, when and how:

What does this prevent you from doing or enjoying?

How long does it last? All Day:

Hours:

Minutes:

Are there any other conditions or symptoms that may be related to your major symptom?

Yes No

If yes, describe:

Have you seen any other provider for this condition?

Yes No

If yes, explain treatment or prognosis:

Have you had spinal X-rays, MRI, CT scan for your area(s) of complaint?

Yes No

If yes, date

Area screened

HEALTH HISTORY

Date of last physical examination?

Have you had any major illnesses, injuries, falls, auto accidents or surgeries? (Include dates)

Have you been treated for any health condition by a physician in the last year?

Yes No

If yes, describe:

What medications or drugs are you taking? (Include vitamins):

Do you have any allergies to medications/ or other?

Yes No

If yes, explain:

Do you have any congenital (present at birth) condition?

Yes No

If yes, explain:

Women: Are you pregnant?

Yes No

Due Date?

Women, please include information about childbirth (include dates):

SOCIAL HISTORY

Please indicate beside each activity whether you engage in it and provide frequency:

Exercise

None Daily Weekly

Type of exercise

Walk Run Swim Other

If other, specify:

High stress activity

Family Pressures

Financial Pressures

Other mental stress:

Alcohol Use

None Casual Moderate Heavy

Drug Use

None Recreational Addiction

Do you smoke?

Yes No

If yes, number of packs a day

Other tobacco use

Previous smoker?

Caffeinated drinks consumed per day

0-3 3-6 6+

PATIENT WELLNESS ASSESSMENT

ILLNESS-WELNESS CONTINUUM

On the arrow diagram above:

A. What number do you think represents your health today?

B. In what direction is your health currently headed?

WHAT ARE YOUR HEALTH GOALS?

Immediate:

Short Term (What do you have to do?):

Long Term (What do you want to do?):

IMPACT OF YOUR SYMPTOMS

How is this symptom / condition interfering with your life? (check where appropriate)

Other

I certify that the information provided is accurate to the best of my knowledge:

Print Patient Name:

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

Patient/Legal Guardian Signature:

Date:

Right to Rescind:

This section is to attest that you understand your right to rescission as a patient at Chiropractic Health Solutions. You have the right to rescind payment within 72 hours of any services received above and beyond the discounted offer that you received. Due to legal restrictions, special offers are not available to all patients with state or federally funded healthcare plans such as Medicare.

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

Patient Signature:

Date:

INFORMED CONSENT

CHIROPRACTIC HEALTH SOLUTIONS

I will use my hands or mechanical instruments upon your body in such a way as to move your joints. This procedure is referred to as “Spinal Manipulation” or “Spinal Adjustment.” As the joints in your spine are moved, you may experience a “pop” as part of the process.

There are certain complications that can occur as a result of a spinal manipulation. These complications include, but are not limited to: muscle strain, cervical myelopathy, disc and vertebral injury, fractures, strains, dislocations, Bernard-Horner’s Syndrome (also known as oculosympathetic palsy), costovertebral strains and separation. Rare complications include, but are not limited to, stroke. The most common complication or complaint following spinal manipulation is an ache or stiffness at the site of the adjustment.

I am aware of these complications, and in order to minimize their occurrences I will take precautions. These precautions include, but are not limited to, my taking a detailed clinical history of you and examining you for any defect which would cause a complication. This examination may include the use of x-rays. The use of x-ray equipment may pose a risk if you are pregnant. If you are pregnant or nursing, you should tell me when I take your clinical history.

Printed Name of Patient/Legal Guardian:

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

Signature of Patient/Legal Guardian:

Date:

Your information will be encrypted.