Patient Intake Form

Information

Can we call you at work?

Do you prefer to have appointments confirmed by:

(check all that apply)

Sex

Marital Status

Person to be notified in the case of an emergency:

Problem

3. Is today's problem caused by an:

4. Indicate on the drawings below where you have pain/symptoms
(appear a red circle on the location by clicking on it):

5. How long have you had this problem?

6. How often do you experience your symptoms?

7. How would you describe the pain?

8. How are your symptoms changing with time?

9. Using a scale from 0-10 (10 being the worst), how would you rate your problem?

10. Who else have you seen for your problem?

11. Do you consider this problem to be severe?

14. What is your:

15. How would you rate your overall Health?

16. What type of exercise do you do?

17. What is your daily intake of the following?

Caffeine
Alcohol
Cigarettes

18. Indicate if you have any immediate family members with any of the following:

19. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.

Headaches
Neck Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Shoulder Pain
Elbow/Upper Arm Pain
Wrist Pain
Hand Pain
Hip Pain
Upper Leg Pain
Knee Pain
Ankle/Foot Pain
Jaw Pain
Joint Pain/Stiffness
Muscular Incoordination
Arthritis
Rheumatoid Arthritis
Systemic Lupu
Cancer
Tumor
Epilepsy
Visual Disturbances
Stroke
Dizziness
High Blood Pressure
Heart Attack
Chest Pain
Angina
Hepatitis
Liver/Gall Bladder Disorder
Abdominal Pain
Ulcer
Kidney Stones
Kidney Disorders
Bladder Infection
Painful Urination
Loss of Bladder Control
Allergies
Chronic Sinusitis
Dermatitis/Eczema/Rash
Excessive Thirst
Frequent Urination
Abnormal Weight Gain/Loss
Loss of Appetite
General Fatigue
Smoking/Tobacco Use
Drug/Alcohol Dependence
Depression
HIV/AIDS
Diabetes
Asthma
Birth Control Pills
Hormonal Replacement
Pregnancy
Prostate Problem
Other

24. What activities do you do at work?

Sit
Stand
Computer work
On the phone
Other

26. What concerns you the most about your problem?

27. How much has the problem interfered with your work?

28. Do you suffer from neck pain with pain in your shoulders, arms, or hands?
29. Do you have a weakness, numbness, tingling, or burning in your shoulders, arms, or hands?
30. Do your arms or hands fall asleep regularly?
31. Do you have reduced feeling (sensation) or swelling in your arms or hands?
32. Do you suffer from a loss of handgrip strength?
33. Do you suffer from back pain with pain in your buttocks, legs, or feet?
34. Do you have weakness, numbness, or burning in your buttocks, legs, or feet?
35. Do your legs or feet fall asleep regularly?
36. Do you have reduced feeling (sensation) or swelling in your legs or foot?
37. Do you suffer from cold hands or feet?
38. Have you tried any Physical Therapy before?
39. Have you tried any Chiropractic treatments before?
40. Have you had an MRI?
41. Have you had X-rays?
42. Have you used any splint or braces or other prescribed treatments by an M.D.?

Weight Loss

44. Check ALL areas of treatment that interest you:

45. Did you know that all treatments above are 100% safe?

46. Have you ever used any of the above treatments before?

47. What do you consider to be your ideal weight?

48. How much weight do you want to lose?

49. When was the last time you were at your goal weight?

50. How many times a year do you diet?

51. What is stopping you from losing weight on your own?

52. What have you tried in the past that has failed?

53. Does your weight problem make you physically uncomfortable?

54. Does your weight problem cause physical pain?

55. Are you embarrassed by your excessive weight?

56. Does being overweight and unhealthy limit your activities?

57. Do you binge eat

58. Do you suffer from uncontrollable cravings?

59. Do you feel that food controls you?

60. Do you eat because of your emotions?

61. Do you eat between meals?

62. What do you choose to eat between meals?

63. Do you feel that your eating behaviors are normal?

64. Briefly describe your daily eating behaviors:

65. Do you feel tired, run-down, or out of energy?

66. Is successful weight loss a top priority?

67. How fast do you want to be slim, trim, and fit?

68. What's more important to you: fast or permanent?

69. Does your family support your weight loss efforts?

70. Is your family excited that you're working with us?

71. Can you remember being at your ideal weight?

72. What do you remember most about it?

Check the following conditions you would like help with or more information on:

What is the most important element in deciding to use our services?

INSURANCE INFORMATION

Do you have a Secondary Insurance?

Are you enrolled in a

Credit/Debit Card Information: (please print legibly)



  • It is the sole responsibility of the patient to make sure that their insurance policy is effective, which is primary and which is secondary if applicable and to inform us of any and all insurance plans and/or changes; insurance policies are an arrangement between the insurance carrier and the patient. Failure to do so will result in the patient being billed for any outstanding claims or money recoveries requests.
  • After the verification of your coverage & deductibles and/or copays this office may accept assignment on most policies provided the insured/patient signs and appropriate statement of benefits and/or a lien authorizing payment to be sent to the doctor. Any medical or other records or information necessary to process any claims will be released from our office. If you have any questions concerning this or any other matter, please speak with the new patient coordinator.
  • If you are unable to make your appointment due to an emergency, please call us and let us know so we can reschedule your appointment. If you need to change the time of your appointment, plan to come another time on the same day. If the same day is not possible, try to make up the missed appointment within one week as not to disrupt your treatment plan. With the exception of an unexpected emergency, we require that you notify us 6 hours in advance as to any appointment changes to avoid being charged.
  • For no call/no show appointments or cancellations less than 6 hours in advance, there is a non-refundable $50.00 service charge that will be billed to you or your credit card/debit card on file.


Assignment and Release (insured patients)

I, certify that I (or my dependent) have insurance coverage with
and I AUTHORIZE, REQUEST, AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICAL/MEDICAL PRACTICE INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorized the doctor to release all information necessary, including diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.

Consent to Care

A patient coming to the doctor gives his/her permission and authority to care for them in accordance with the appropriate tests, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities, or pat or pathologies may render the patient susceptible to injury. The doctor, of course, will not provide specific healthcare if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through healthcare procedures from whatever he/she is suffering from latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the physician. I affirm that I am not an agent or representative of any insurance company or any other business trying to collect information. All injuries/problems mentioned are true and I am here solely for the treatment of the said problem.

NOTE: Your health information will be kept strictly confidential. Any information that we collect about you on this form will be kept confidential in our office.