Patient Intake Form

Information

Name

Today's Date (mm/dd/yyyy)

Mailing Address

City

State

Zip

Email Address

Home #

Cell #

Work #

Can we call you at work?

Yes No

Do you prefer to have appointments confirmed by:

Text Email Phone (check all that apply)

Date of Birth (mm/dd/yyyy)

Social Security #

Sex

Male Female

Occupation

Employer

Employer Address

Phone #

Person to be notified in the case of an emergency:

Name

Relation

Phone #

How did you hear about our practice?

Problem

1. What is your chief complaint?

2. How do you think your problem began?

3. Is today's problem caused by an:

Auto Accident Injury at work Other:

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?

Days

Weeks

Months

Years

6. How often do you experience your symptoms?

Intermittently (1-25% of the time) Occasionally (26-50% of the time) Frequently (51-75% of the time) Constantly (76-100% of the time)

8. How are your symptoms changing with time?

Getting Worse Staying the Same Getting Better

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

11. Do you consider this problem to be severe?

Yes Yes, at times No

12. What makes your problem better?

13. What makes your problem worse?

14. What is your:

Height (ft/inch)

Weight (lbs.)

Age

16. What type of exercise do you do?

Strenuous Moderate Light None

17. What is your daily intake of the following?

Caffeine

cups/day

Alcohol

drinks/wk

Cigarettes

packs/day

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.

20. List all prescription & over the counter medications you are currently taking

21. List any medications you are allergic to

22. List any surgical procedures and/or hospitalizations you have had

23. List any significant past trauma you have had

24. What activities do you do at work?

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? NO YES

29. Do you have a weakness, numbness, tingling, or burning in your shoulders, arms, or hands? NO YES

30. Do your arms or hands fall asleep regularly? NO YES

31. Do you have reduced feeling (sensation) or swelling in your arms or hands? NO YES

32. Do you suffer from a loss of handgrip strength? NO YES

33. Do you suffer from back pain with pain in your buttocks, legs, or feet? NO YES

34. Do you have weakness, numbness, or burning in your buttocks, legs, or feet? NO YES

35. Do your legs or feet fall asleep regularly? NO YES

36. Do you have reduced feeling (sensation) or swelling in your legs or foot? NO YES

37. Do you suffer from cold hands or feet? NO YES

38. Have you tried any Physical Therapy before? NO YES

If yes, when? For how long? What kind?

39. Have you tried any Chiropractic treatments before? NO YES

If yes, when? For how long? What kind?

40. Have you had an MRI? NO YES

If yes, when? Who ordered it? What was it ordered for?

41. Have you had X-rays? NO YES

If yes, when? Who ordered it? What was it ordered for?

42. Have you used any splint or braces or other prescribed treatments by an M.D.? NO YES

If yes, when? What kind? Who ordered it?

43. Is there anything else pertinent to your visit today?

Weight Loss

44. Check ALL areas of treatment that interest you:

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

Yes No

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

Yes No

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?

Yes No

Please describe

54. Does your weight problem cause physical pain?

Yes No

Please describe

55. Are you embarrassed by your excessive weight?

Yes No

Please describe

56. Does being overweight and unhealthy limit your activities?

Yes No

57. Do you binge eat

Yes No

58. Do you suffer from uncontrollable cravings?

Yes No

59. Do you feel that food controls you?

Yes No

60. Do you eat because of your emotions?

Yes No

61. Do you eat between meals?

Yes No

62. What do you choose to eat between meals?

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

Yes No

64. Briefly describe your daily eating behaviors:

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

Yes No

66. Is successful weight loss a top priority?

Yes No

Please explain

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?

Yes No

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

Yes No

71. Can you remember being at your ideal weight?

Yes No

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?

Effectiveness: "My results are my top priority" Time: "I want results quickly" Service: "I need extra support along the way" Affordability: "I need this to be affordable"

INSURANCE INFORMATION

Name of person responsible for this account

Relationship to patient (if other than self)

Phone #

Name of Policy Holder

Date of Birth of Policy Holder (mm/dd/yyyy)

Do you have a Secondary Insurance?

Yes No

Name of Carrier

Are you enrolled in a

(HSA) Health Savings Account (FSA) Flex Spending Account (HRA) Health Reimbursement Account

Credit/Debit Card Information: (please print legibly)

Name of Card Holder

Card Type

Exp. Date

Credit Card #

CVV Code (3 or 4 digit #)

I authorize this medical practice to process the above credit card as “card on file”. I understand this authorization will remain in effect until the expiration of the credit card account; patient may also revoke this form by submitting a written request to the medical practice.

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 24 hours in advance as to any appointment changes to avoid being charged.
For no call/no show appointments or cancellations less than 24 hours in advance, there is a non-refundable $100.00 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.

*REQUIRED I have read and understood the consent to care. I certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my health. I also understand that my insurance company may be mailing checks payable to me or the insurance subscriber for services rendered. If this should occur I agree that I will sign and bring all check(s) {along with explanations of benefits and/or all documents attached to said check(s)} to the office within 7 days. I am also aware that failure to do so will result in my account being forwarded to the collection department of our attorneys, making me liable for all account balances, attorneys, and court fees. I further certify that I have read, understood, and agree to this practice's office policies, including the card-on-file authorization above, the requirement to provide at least 24 hours notice of any appointment change or cancellation, and the non-refundable $100.00 charge that applies to any no call/no show appointment or any cancellation made less than 24 hours in advance.

Electronic Signature (type your full legal name to sign)

Print Name

By typing your name above, you are electronically signing this form and agreeing to all terms stated on this page.

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.