New Patient Intake Form

1. Patient Information

Legal Last Name:

Legal First Name:

Primary Phone:

Home

Cell

Work

Address:

City:

State:

Zip Code:

Sex:

M F

Age:

Birth Date:

Social Security # or DL #

Married Single Partnered Widowed

If have children, How many:

Occupation:

Patient Employer/School:

Address:

Primary Phone:

In case of emergency, contact:

Relationship:

Phone:

Whom may we thank for referring you? Event you attended?

Values: Please list your interests in order of importance from 1 to 7 (1= most important)

Family

Financial

Social

Physical

Mental

Spiritual

Work

2. Payment/Insurance Information

Who is financially responsible for this account:

Self-Pay Other

If insured, who is the main subscriber/policy holder?

Birth Date:

Phone:

Relationship to Patient:

Address:

City:

State:

Zip:

Health Insurer Insurance Co Name:

Name:

ID #:

Group #:

Government Program

Name:

ID #:

Group #:

Is this policy associated with an

HSA FSA HRA

Is patient covered by additional/ secondary insurance?

Yes No

Insurance Co. Name:

ID #

Group #

Subscriber Name:

Birth Date:

Relationship to Patient:

Assignment and Release

On behalf of yourself and any patient for whom you are the parent or legal guardian, you 1) certify that the information on this form is accurate and up-to-date, 2) consent to treatment by Chiro One, 3) assign to Chiro One, any healthcare insurance or reimbursement benefits to which you are entitled for the care provided by Chiro One, authorize their payment directly to Chiro One, and authorize the use of your signature for this limited purpose, 4) agree to be primarily responsible for all charges owed to Chiro One (other than those included in any pre-paid offer), including attorney fees, court costs, and other expenses of collection, 5) consent to Chiro One releasing any “protected health information,” as defined by federal HIPAA regulations, for the purposes allowed by law, and 6) acknowledge receipt of Chiro One’s Notice of Privacy Practices.

Printed name of Patient, Parent, Guardian or Personal Representative

Signature of Patient, Parent, Guardian or Personal Representative

Relationship:

Date:

3. Medication

NONE

Add Medication

Vitamins/Supplements

NONE

Add Vitamins/Supplements

Allergies

NONE

Add Allergies

4. Family History

5. Medical History

Name and address of other doctor(s):

Date of last:

Physical Exam

Spinal X-ray

Spinal Exam

Chest X-ray

MRI, CT-Scan, Bone Scan

Blood Test

Urine Test

Are you pregnant?

Yes No

If other, specify:

6. Motor Vehicle Accident

Denied

Add new row

7. Motor Vehicle Accident

Denied

Add new row

8. Physical & Trauma Information

Please indicate any physical and/or trauma occurences below, making sure to note any minor injuries as well by checking ‘Yes’. Please describe when applicable.

Work Activities:

Sitting

Standing

Light Labor

Heavy Labor

Retired

Work Injuries:

Yes No

If yes:

Sport Activities:

Sport Injuries:

Yes No

If yes:

Exercise:

None Light Moderate Heavy

Home Injuries:

Yes No

If yes:

Habits:

Nicotine

Alcohol

Coffee/Caffeine Drinks

High Stress Level

None

How Much?

How Often?

Daily Weekly Occasionally

Falls:

Yes No

If yes:

Head Injuries:

Yes No

If yes:

Dislocations:

Yes No

If yes:

Broken Bones:

Yes No

If yes:

Surgeries:

Yes No

If yes:

9. Primary Complaint

Please note ONE complaint in the following section. The Primary Complaint is your chief complaint or most problematic concern at this time that brought you in today.

Primary complaint:

Please describe the condition:

When did your symptoms first appear?

Most recent occurence date:

What do you think caused this problem?

Is this condition getting progressively worse?

Yes No Unknown

Mark an X on the picture where you have pain, numbness or tingling:

Add Pain

Does the pain travel from one location to another? From where to where?

How often do you have this pain?

Constantly Comes and goes Infrequently Daily Weekly Monthly

Do activities make it worse in the AM or PM?

AM PM N/A

Past Treatments:

Medications

Surgery

Physical Therapy

Chiropractic Services

None

Other

Were they successful?

Yes No

Pain worsens with:

Pain improves with

Notes:

10. Additional Complaint

Please note ONE complaint in the following section. The Additional Complaint I is any other problem/complaint you may be experiencing that you would like the office to be made aware.

Denied

Add new row

11. Additional Complaint II

Please note ONE complaint in the following section. The Additional Complaint II is any other problem/complaint you may be experiencing that you would like the office to be made aware

Denied

Add new row

12. Is there anything else you would like the Doctor of Chiropractic to know?

FOR OFFICE USE ONLY

Clinical Comments:

Examiner’s Name:

Examiner’s Signature:

Date:

Physician/Provider Name:

Physician/Provider Signature:

Date:

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