New Patient Intake Form

Patient Information

Today's Date

Time and Date of New Patient Exam

Last Name

First Name

Middle Name

Address

City

State

ZIP Code

Gender

Male Female Prefer not to disclose

Home phone number

Cell phone number

Email address

Date of birth

Marital Status

Married Single Widowed Separated Minor Domestic partner

Occupation

Employer

Work address

Work phone number

Medical History

Have you been treated by a chiropractor in the past 12 months?

Yes No

If yes, please describe the reason for your visit, and the doctor that treated you / their information:

Date of your last physical exam

Date of your last spinal exam

Date of your last spinal x-ray

Date of your last blood test

What treatment have you already received for your condition?

Medication

Surgery

Chiropractic Services

None

Other

If you checked any of the above, please explain / list:

Emergency Contact Information

Add another emergency contact

Insurance

Who is responsible for this account?

Relationship to Patient

Insurance Company

Group Number

Member ID Number

Date of Birth

Is the patient covered by additional insurance?

Yes

Subscriber's Name

Birthdate

Relationship to Patient

Insurance Company

Group Number

Member ID Number

Date of Birth

Accident Information

Is condition due to an accident?

Yes

If so, what type of accident?

Auto

Work

Home

Other

To whom have you made a report of your accident?

Auto insurance

Workman's Comp

Employer

Other

Attorney / Auto Insurance Name (if applicable)

Patient Condition

Reason for Visit

When did your symptoms appear?

Is your condition getting progressively worse?

Yes

Unknown

Rate the severity of your pain from 1-10, (1 being the least severe to 10 being the worst possible imaginable):

Where is your pain located?

Please mark where you are experiencing pain on the one of the figures below.

Description of pain, if other:

How often do you have this pain?

Is the pain constant or does it come and go?

Does your pain interfere with any of the following?

Work

Sleep

Daily Routine

Recreation

None of the above

Does your condition make any actions difficult to perform? If so, please check an option below.

Sitting

Standing

Walking

Bending

Lying down

Other

None of the above

If other, please list:

Health History

If you marked "yes" to any options above, please explain:

Are you pregnant?

Yes No

If you are pregnant, please enter your due date:

Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?

Yes No

Are you currently waiting on the results of a COVID-19 test?

Yes No

If you marked "yes" to any options in the "Habits" column, please explain frequency / reason:

Please list any falls, head injuries, broken bones or fractures, dislocations, and surgeries below.

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Are you allergic to any medications, foods, or environmental factors? If so, please list them below.

Activities of Daily Living Questionnaire

TO BE SIGNED AND DATED IN OFFICE AT TIME OF APPOINTMENT:

I certify that I, and/or my dependents have insurance with the aforementioned insurance company above, and assign directly to Dr. Robert Dixon all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions. Dr. Robert Dixon may use my health care information and may disclose such information to the above-named insurance company or companies and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. I understand that I am financially responsible for all charges incurred on the patient's account, whether or not paid by insurance. If this account is turned over to collections, I hereby agree to pay all charges including, but not limited to, cost of collection, court costs, and reasonable attorney fees.

Signature

Date

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New Patient Intake Form

Patient Information

Medical History

Emergency Contact Information

Insurance

Accident Information

Patient Condition

Health History

Activities of Daily Living Questionnaire

Dixon Chiropractic and Acupuncture