Electronic Health Records Intake Form

In compliance with the requirements for the government EHR incentive program
Please supply the Front desk with Drivers License and Insurance Card

Patient's First Name

Patient's Last Name

Patient's Middle Name

Gender

Male Female

Date

Birth Date

Age

Social Security #

Mailing Address

City

Postal/Zip Code

Home Phone

Work Phone

Email address

Marital Status

Minor Single Married Other

Family Info:

Spouse

Children

How Did You Hear About Our Office?

REASON FOR VISIT

Cause of current problem?

Work Chronic Car Accident Unknown Home/Sports Accident

Please describe your problem and its location:

When did the condition begin:

Is it...

Worsening Unchanging Getting Better

Have you experience this in past?

Is this interfering with your work, sleep, daily activities? please explain.:

Have you seen any other health professional for this condition?

Have you been treated by a Chiropractor before?

PLEASE INPUT BELOW THE LOCATION(S) OF YOUR PAIN BASED ON THE DIAGRAM

Add another pain location

On a scale of 1 to 10, with 10 being the worst possible pain, what do you rate your pain as, at it's worst?

Describe your pain:(ex. burning, aching, throbbing, shooting)

HEALTH HISTORY

Are you taking any of the following medications?

Nerve pills

Muscle relaxers

Blood pressure medication

Pain killers

Stimulants

Other (both prescription or over the counter)

Please list any additional serious health concerns or elaborate on any positive finding from above.

Please list all significant accidents (home, work, recreational, car) (Yes, 20 years ago does make a difference!)

Smoke? (frequency)

Alcohol? (frequency)

Exercise? (frequency)

INSURANCE INFORMATION

Type of Insurance

Health

Automobile

Third Party Liability

Insurance ID#

Group#

Insurance Company Name and Address

Primary Insured Name:

Birth Date

Primary SS#

Relationship to Patient:

Preferred method of communication for patient reminders

Phone

Mail

Birth Date

Social Security#

Gender

Male Female

Your Employer

Occupation:

Work Phone

Preferred Language

English Spanish Other

Smoking Status

Every Day Smoker Former Smoker Occasional Smoker Never Smoked

CMS requires providers to report both race and ethnicity

Race:

American Indian or Alaska Native Black or African American I Decline to Answer Asian Other White(Caucasian) Native Hawaiian or Pacific Islander

Ethnicity

Hispanic or Latino I Decline to Answer Not Hispanic or Latino

Are you currently taking any medications? (Please include regularly used over the counter medications)

Add Medication

Do you have any medication allergies?

Yes No

Add Medication Allergies

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

Height:

Weight:

Temp:

Blood Pressure:

Heart Rate:

Family Health History

Please mention below any health conditions or concerns you may have about your :

Did you mother or father have any of the following:

High Blood Pressure

Mother Father Both

HIV Positive

Mother Father Both

Ulcer or Stomach Problems

Mother Father Both

Mental Illness

Mother Father Both

Heart Attack

Mother Father Both

Asthma

Mother Father Both

Emphysema

Mother Father Both

Diabetes

Mother Father Both

Seizure-Convulsions

Mother Father Both

Thyroid Disease

Mother Father Both

Arthritis-Rheumatism

Mother Father Both

Circulation Problems

Mother Father Both

Cancer

Mother Father Both

Kidney Disease

Mother Father Both

Stroke

Mother Father Both

Please indicate age when stroke occurred

Mother

Father

Comments:

-FINANCIAL RESPONSIBILITY /LIEN AUTHORIZATION & CONSENT TO CARE AND PRIVACY-

We invite you to discuss with us any and all questions rega rding our services. The best health services are based "on a friendly, mutual u ndersta nding between provider and patient. Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made. If an accou nt is not paid within 90 days of service, you will be responsible for legal fees, collection fees and/or any other expenses incu rred in collecting your account.
"I authorize and direct insu ra nce companies, and/or attorneys, to pay directly to Robbins Chiropractic Center, PLLC such sums as may be due and owing this office for services rendered to me both by reason of an accident or illness, and by reason of any other bills that are due this Office, and to with hold such sums from any disa bility benefits, medical payment benefits, No-Fault benefits, health and accident benefits, worker's compensation benefits or any other insurance benefits obligated to reim burse me, or from any settlement, judgment or verdict on my behalf as may be necessa ry to adequately protect said Office. I hereby further give a lien to said Office against any and all insura nce benefits named herein, and any and all proceeds of settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by said Office. This is to act as an assignment of my rights and benefits to the extent of the Office's services provided.
I understand and agree that this u nderstanding does not constitute any consideration for the office to await payments and may demand payments from me immediately upon rendering services at their option. I authorize the office to release any information pertinent to my case to any insurance company, adjuster or attorney to facilitate collection under this agreement. I authorize the staff to perform any necessa ry services needed du ring diagnosis and treatment. I u nderstand X-Rays remain property of this clinic. I herby state and agree that a photocopy of this document will be as valid and binding on all parties involved as the original copy. I guarantee the above information to be correct to the best of my knowledge.
I have received a copy of this office's 'Notice of Privacy Practices' and will make myself aware of this office's and my own rights and obligations rega rding the protection and utilization of my own medical information.

Patient Name

Date

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 or Guardian's Signature:

X-RAY CONSENT FORM

During your examination, the doctor may feel that x-rays will be needed in order to diagnosis your condition. We would like to make you aware that x-rays may be required, in order, to administer treatment. In order to perform x-rays on any patient our office requires the. patients consent for such tests to be performed.

I understand that my doctor may need x-rays in order to diagnosis my condition and I give permission of all needed diagnostic tests.

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

FEMALES ONLY:

I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus.

I have been advised that the ten (1O days following onset of a menstrual period are generally considered to be safe for x-ray exam.

With those factors in mind, I am advising my doctor that:

I am pregnant

Yes No Don't Know

I have had a tubal ligation

Yes No Don't Know

I could be pregnant

Yes No Don't Know

I have had a hysterectomy

Yes No Don't Know

My menstrual period is late

Yes No Don't Know

I have begun menopause

Yes No Don't Know

I have an IUD

Yes No Don't Know

I have irregular menstrual periods

Yes No Don't Know

My last menstrual period began

With full understanding of the above, and believing that I am not currently at risk, I wish to have an x-ray examination performed today if requested by my doctor.

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

Your information will be encrypted.