Chiropractic Intake Form
Transcript of Chiropractic Intake Form
8/14/2019 Chiropractic Intake Form
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Today’s Date: ______/______/_____
Patient Information:(Please fill this form out to the best of your ability.)
Patient Name (Last, First, M.I.): _________________________________________________ Nick Name: ______________
Address: _________________________________________ City: _________________ State: _______ Zip Code: _________
Home Phone: _____________________ Cell/Alternate Phone: ______________________ E-Mail:___________________
Employer: _________________________ Work Phone: ______________________ Can We Contact You Here? Yes
Social Security #: ________-______-________ Birth Date: _____/_____/________ Age: ______ Sex: Male Fem
Name of Spouse/Partner or Guardian (if underage):___________________________________ Birth Date: _____/_____/____
Emergency Contact: ______________________________ Relationship: ______________ Phone #:____________________
Names and Ages o f Children: ____________________________________________________________________________
Chose This Clinic Because…____________________________________________________________________________
Insurance Information:Are You Covered By Health Insurance? Yes No
Name Of Primary Insurance: __________________ Group/Account #:___________________ Policy #:__________________
Policy Holder’s Name: _________________________ Birth Date: _____/_____/______ Social Security #: ______-_____-___
Patient’s Relationship to Policy Holder: Self Spouse Child Other_________________
*Name Of Secondary Insurance: __________________________ (*If Applicable)
Group/Account #:_________________________ Policy #:_________________________
Policy Holder’s Name: _________________________ Birth Date: _____/_____/______ Social Security #: ______-_____-____
Patient’s Relationship to Policy Holder: Self Spouse Child Other_________________
Billing Information:
Person Responsible For Bill: ________________________ Birth Date: _____/_____/_____ Social Security #:_____-_____-__
Address (If Different):_______________________________ City: _________________ State: ________ Zip Code: ________
Home Phone #: ______________________ Is This Person Here? Yes No Relationship: _____________________
The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physiciI understand that I am financially responsible for any balance. I also authorize the above listed clinic
or insurance company to release any information required to process my claims.
Signature (Guardian if underage):_________________________________________________ Date: ___________________
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Office Policies Regarding: Personal Health Insurance & Private Payment
1) We are providers for several insurance programs and managed care organizations. For your convenience we will verify your insurance benefits and submit claims as a courtesy to you. Howev
your insurance is a contract between you and your insurance company, NOT between Total HealthChiropractic and your insurance company. You are fully responsible for all charges due to servicesrendered. If payment is denied for any reason by your insurance company, you are then responsibfor full payment of those services rendered.
2) All charges must be paid at the time of services. This includes co-pays and deductibles.
3) Any insurance payments that have been paid directly to you by your insurance company must bereceived by Total Health Chiropractic no later than one week from receipt and endorsed to this clin
4) Please make payments on time. If you experience financial difficulties, please call us. We will do o
best to work out a payment plan. If balances are not paid within 90 days from the time of firststatement, and arrangements for payment have not been made, your account will be referred for leaction.
I have read, understand, and accept the insurance/payment policy at Total Health Chiropractic.
Patient Signature: ______________________________________ Date: _____________
HIPPA/Privacy Policies
Please see the form attached to the clipboard given to you. You may have a copy for your records simply asking the front desk. Thank you.
I have received, read, and understand the privacy policies of Total Health Chiropractic.
Patient Signature: _______________________________________ Date: ____________
Medical Record Release
I authorize Total Health Chiropractic to release any information in the event my insurancecompany/attorney requests records or information related to my treatment at your office.
Patient Signature: ______________________________________ Date: _____________
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Chiropractic Informed Consent
Any procedure intended to help, may also do harm. While chiropractic and therapeutic procedures (e.gspinal adjustment, ultrasound, heat and cold, etc.) are considered remarkably safe and effective, pleasunderstand that occasionally there may be adverse reactions.
Although the chances of experiencing any of these complications are extremely small, it is the practicethis office to fully inform and educate all our patients. These complications include, but are not limited
Pain Swelling Inflammation Disc InjuryBurns Nausea Dizziness Worsening of conditionBleeding Sensory Changes Bone Fracture Soft Tissue InjuryBruising Stroke Weakness
I have read and understand the informed consent form of Total Health Chiropractic.
Patient Signature: ______________________________________ Date: _____________
Consent to Treat a Minor
I, ___________________________________ (parent/guardian) give my permission to the provide
at Total Health Chiropractic to give spinal adjustment/manipulations and necessary therapies to
___________________________________ (child’s name).
Parent/Guardian Signature: ____________________________________ Date: ___________
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Patient Health Questionnaire
1. Symptoms began on: _____________ Height: ______ Weight: ______
2. Briefly describe your symptoms: ________________________________
__________________________________________________________
__________________________________________________________
3. How did your symptoms start? _________________________________
__________________________________________________________
4. Average pain intensity:
a. Last 24 hours: (no pain) 1 2 3 4 5 6 7 8 9 10 (worst pain)
b. Past week: (no pain) 1 2 3 4 5 6 7 8 9 10 (worst pain)
5. How often do you experience your symptoms?
1 – Constantly (76-100% of the time) 2 – Frequently (51-75% of the time) 3 – Occasionally (26-50% of the time) 4 – Intermittently (0-25% of the time)
6. How much have your symptoms interfered with your daily activities? (Including both work outside the home and housewo
1 – Not at all 2 – A little bit 3 – Moderately 4 – Quite a bit 5 – Extremely
7. How are your symptoms changing?
1 – Getting Better 2 – Not Changing 3 – Getting Worse
8. Have you seen anyone else for your symptoms? 1 –Yes 2 – No
If “yes”, who and what treatment? _____________________________________________________
9. In general, how is your overall health right now?
1 – Excellent 2 – Very Good 3 – Good 4 – Fair 5 – Poor
10. Past/Present Health History (Please indicate any other health conditions past or present in the area below)
Headaches Stroke Asthma
Back Pain Heart Attack Shortness of Breath
Neck Pain Heart Disease Depression
Joint Pain High Blood Pressure General Fatigue
Arthritis Sinus Problems/Allergies Abnormal Weight Loss/Gain
Kidney Disorders Dizziness Cancer/Tumor
Change in Bowel Function Diabetes Smoking/Tobacco Use
Change in Bladder Function Excessive Thirst Drug/Alcohol Dependence
Digestion Problems
Frequent Urination
Birth Control Pills (Female Only)
Stomach Pain Prostate Problems Pregnancy (Female Only)
11. List all prescription and over-the-counter medications, and nutritional/herbal supplements you are taking:
____________________________________________________________________________________
12. List all surgical procedures and hospitalizations:
____________________________________________________________________________________
Patient Signature: _____________________________________________ Date: ____________________
Please indicate areas of pain or other sym