PATIENT INTAKE FORM

Patient Information

Patient Name

Address

City

State

ZIP

Home Phone

Cell Phone

Email address

SS#

Birth date

Age

Occupation

Employer

Work Phone

Married Separated Widowed Divorced Single Minor Partnered

Partnered for:

IN CASE OF EMERGENCY

Name

Relationship

Home Phone

Cell Phone

Which of the following of our marketing have you seen?

Direct mail

Friend

Internet

Magazine

Radio

Talk:

Sign

Other:

If Magazine, Which one?

If Talk, Specify:

If Other, Specify:

What specifically prompted you to choose us for your healthcare needs?

Name of Primary Care Provider:

City, State:

Last check up:

Are you under a doctor’s care at the present time?

Yes No

If yes, for what?

Name of Doctor:

City, State:

Insurance Information

Primary Subscriber

Relationship to Patient

Insurance Co.

ID #

Is there a Secondary Insurance?

Yes No

Insurance Co.

ID #

ASSIGNMENT AND RELEASE

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay

the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of any health insurance or medical plan benefits directly to

for medical services rendered and for any supplies, tests, or medications provided. I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other legal remedies necessary in connection with same. I hereby assign directly to

all current and prior rights, if any, to payment and benefits and all legal and other health plan rights that I (or my child, spouse, or minor dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). This assignment includes, but is not limited to, a designation that

personnel can act on my / our behalf, as our representative or ERISA representative, as to any initial claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals to obtain benefits and/or payments that are due to me/us as a result of services rendered by

and authority to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan or insurer. This assignment and designation remains in effect unless revoked in writing, and a photocopy is to be considered as valid and enforceable as the original.

FINANCIAL POLICY

We are honored to be of service to you and your family. This is to inform you of our billing requirements and our financial policy. Please be advised that payment for all services will be due at the time services are rendered, unless prior arrangements have been made. For your convenience, we accept Visa, Mastercard and Care Credit. I agree that should this account be referred to an agency or an attorney for collection, I will be responsible for all collection costs, attorney’s fees and court costs.

I have read and understand all of the above and have agreed to these statements

Signature of Patient, Parent, Guardian or Personal Representative

Please print name if patient, Parent, Guardian or Personal Rep.

Relationship to Patient

Date

Medical History

Gynecologic History

Are you currently pregnant?

Yes No

Pregnancies #:

Date

Deliveries #:

Onset:

Natural delivery or C-section?

Menstrual Onset:

Duration:

Last menstrual period:

General History

If Other, specify:

Medications

Add Medications

Birth Control:

Medication Allergies:

General Allergies:

Do you have any surgical devices in your body? (i.e. screws, pins, plates, etc?)

Yes No

If yes, where are they located?

ACTIVITY LEVEL

Select one of the following:

Inactive: no regular physical activity with a sit-down job Light Activity: no organized physical activity during leisure time Moderate Activity: Occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling. Heavy Activity: consistent lifting, stair climbing, heavy construction, etc. or regular participation in jogging, swimming, cycling or active sports at least three times per week. Vigorous Activity: participation in extensive physical exercise for at least 60 minutes per session, 4 or more times per week.

FAMILY HISTORY

Possible Hereditary Disease:

Social Habits

Habits (please select all that apply)

Smoking

Alcohol

Coffee/Caffeine drinks

High Stress level

Packs/day:

Smoking

Drinks/week:

Alcohol

Cups/day:

Coffee/Caffeine drinks

Reason:

High Stress level

Surgical History

Past Surgical History

Nutrition

Present height

Feet

Present Weight

Ideal Weight

Weight at age 20

Do you eat/snack after your evening meal? (i.e. screws, pins, plates, etc?)

Yes No

If yes, what and how much do you eat?

What beverages do you drink throughout a day?

PHYSICAL MEDICINE CURRENT CONDITIONS

Reason for Visit?

When did your symptoms appear?

Is this condition getting progressively worse?

Yes No Unknown

Short textHow often do you have this pain?

Is it constant or does it come and go?

Does it interfere with your

Work

Sleep

Daily Routine

Recreation

Indicate activities which are painful to perform:

Sitting

Standing

Walking

Bending

Lying Down

What treatment have you already received for your condition?

Medication

Surgery

Physical Therapy

Chiropractic Services

None

Other

Name and address of other doctor(s) who have treated you for your condition:

Date of Last:

Physical Exam

Chest X-Ray

Spinal Exam/X-Ray

Lab work

MRI, CT-Scan, Bone Scan

Is your condition due to an accident?

Yes No

Type of Accident:

Auto Work Home Other

To whom have you made a report of your accident?

Auto Insurance Employer Work Comp. Other

Please be sure to fill this form out extremely accurately. Mark the area(s) on your body where you feel the described sensation(s). Use the appropriate symbol(s). Mark areas of radiating pain and include all affected areas. You may draw on the face as well.

Indicate the severity of your symptoms by marking an “X” on the lines below:

X-ray Consent:

I authorize the use of diagnostic x-rays if the doctor deems it necessary or advised in my treatment. Every effort will be taken by the doctor to conform with the Illinois Department of Radiation Bureau’s Regulations when it comes to radiation exposure.

Signature

Date

Minor:

I am the Parent/Legal Guardian of

and authorize the use of diagnostic x-rays if the doctor deems it necessary or advised in my treatment. Every effort will be taken by the doctor to conform with the Illinois Department of Radiation Bureau’s Regulations when it comes to radiation exposure.

Parent/Legal Guardian Signature

Date

Females Only:

Pregnancy Release:

I certify that, to the best of my knowledge, I am not pregnant. I authorize the use of diagnostic x-rays if the doctor deems it necessary or advised in my treatment. Every effort will be taken by the doctor to conform with the Illinois Department of Radiation Bureau’s Regulations when it comes to radiation exposure. I have been advised that certain x-ray examinations, especially of the pelvis, can be harmful to an unborn child.

Signature

Date

HIPPA and Cancellation Policy

HIPPA Release of Medical Records: I authorize any, legal representative, attorney, medical, psychological, psychiatric, osteopathic or chiropractic physician, any other medical practitioner of healthcare provider, hospital, clinic, rehabilitation facility to disclose information from the medical and health care records/bills of the injured person. I understand that the specific type of information to be disclosed includes but not limited to, breakdown of any settlement, medical records/bills, including history, treatment, diagnosis, and billing records. This authorization also permits discussion in person, by telephone, electronically, or by mail.

Consent to Treatment & Release of Information:

I voluntarily consent to receive medical and health care services that may include diagnostic procedures examinations and treatment. I authorize the release of any medical information necessary to process this claim. Risks and benefits to therapy have been explained to me.

Cancellation Policy

In order to provide equal opportunity to all our patients and provide the best care possible, we really need your cooperation with keeping up with your appointments. Maintaining your schedule will help us give you the best clinical outcome possible. So please:

Please kindly give 24-hour notice if you are unable to keep your appointment, otherwise you will be charged a cancel fee:

Physical Therapy/Chiropractic Cancel Fee-$60
Dietician Cancel Fee-$60
Massage Cancel Fee - $60

Nurse Practitioner Cancel Fee- $30
Naprapathic Cancel Fee- $75
Court Representation Hourly-$300

I certify that I have read this form and understand its contents. I agree to the terms and agree to abide

Name:

Signature:

Date

Financial Disclosure and Responsibility

In some instance your insurance carrier may deem the services as not payable. In the event that my health insurance plan determines a service to be “not payable”, I agree to pay the costs of all services provided.

If I am uninsured, I agree to pay for the medical services rendered to me at time of service.

Customer Signature

Date

Credit Card Authorization Form

Please complete allfields. Youmay cancelthis authorizationatany time by contactingus.This authorizationwill remainineffectuntilcancelled.

hereby authorize Health First Wellness Center to charge my credit card below for agreed upon services as stated in the Financial Disclosure and Responsibility clause above. I understand that my information will be saved to file for future transactions on my account.

Credit Card Information

Card Type:

MasterCard VISA Discover AMEX Other

If other, specify:

CardholderName (asshown on card):

Card Number:

Expiration Date (mm/yy):

Cardholder ZIP Code (from credit card billing address):

Customer Signature

Date

Your information will be encrypted.