Patient Intake Form
Welcome to our online Patient Intake Form. The information
you fill in will be sent directly to our office, speed up your office visit, and
will help us to better serve your healthcare needs. Please take a moment to completely
fill out this form, and upon completion of all form categories click the
[Submit] button at the bottom of this form.
Welcome to our office of chiropractic. Thank you for taking a moment to fill in
our Patient Intake Form. Please fill this form completely
and to the best of your knowledge. Let our staff know if you have any questions.
When complete return it to our office with the bottom authorization checked and
appropriate signatures filled in.
For your protection and security; Navigating away from this form before clicking
the [Submit] button will dismiss all completed
form fields. Successful submission will redirect you to a confirmation page.
Patient Information
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Personal Information
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Contact Information
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(We will NOT share your email with any third party. We will only use your email
to contact you in relation to your care with our practice.)
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Complaint Information
If you have more than one complaint, address your primary complaint in your responses to the questions in this section and select Yes to indicate that you have an additional complaint.
The form will populate a secondary question section for you to address your additional complaint. You may address up to four complaints.
Mechanism of Injury
The injury was due to: (choose one)
What date did the accident happen?
FOR WORKMAN'S COMPENSATION-RELATED VISITS ONLY: How did the injury occur? Choose all that apply.
As a pedestrian, what were you (or was the patient) doing at the time of the accident?
Where were you (or was the patient) looking at the time of impact?
Did you (or the patient) receive an injury to the head?
Did your (or the patient) lose consciousness?
What part of your (or the patient’s) vehicle was impacted? Choose all that apply.
In what direction was your (or the patient's) vehicle moving?
What was the estimated speed of your (or the patient’s) vehicle?
What was the extent of the damage to your (or the patient's) vehicle?
What was the extent of the damage to the other vehicle?
In what direction was the other vehicle moving?
What was the estimated speed of the other vehicle?
Was your (or the patient’s) vehicle towed from the scene?
Did police arrive at the scene?
Was an accident report taken?
Did Emergency Medical Services arrive at the scene?
Were you (or was the patient) transported to a medical facility (ER or hospital)?
Have you (or has the patient) received any treatment since the accident?
What was the location of symptoms felt at the time of the accident? Choose all that apply.
Head
Neck
Back
Trunk
Upper Extremity
Lower Extremity
Describe the discomfort felt at the time of the accident. Choose all that apply.
Are there any additional symptoms which appeared since the accident happened? Choose all that apply.
Describe the status of your symptoms since the accident. Choose all that apply.
Review of Systems
Musculoskeletal
Neurological
Head, Eyes, Ears, Nose and Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Endocrine
Dermatological and Bleeding
Draw Your Symptoms
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Click on a crayon and draw on the body above to indicate your symptoms
How did you find out about our office?
Did you hear about our office from an advertisement?
If Yes, Where:
Did you hear about our office from a phone or professional directory?
If Yes, Where:
Employment Information
Insurance & Payment for Care
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Primary Insurance
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Secondary Insurance
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If an auto accident, please provide:
Personal Health History
Family/Primary Physician
Separate details with "," comma as shown above.
Separate details with "," comma as shown above.
Separate details with "," comma as shown above.
Chiropractic Experience
Please select all that apply.
Other:
If yes…
What was the reason for those visits?
Doctor's Name:
Approximate date of last visit:
Goals for Your Care
People see a chiropractor for a variety of reasons. Some go for relief of pain,
some to correct the cause of pain and others for correction of whatever is malfunctioning
in their body. Your doctor will weigh your needs and desires when recommending your
care program. Please check the type of care desired so that we may be guided by
your wishes whenever possible.
Were You Aware That...
Worker's Compensation
Describe the accident?
Do you lift from?
Do you have to reach?
Is your work area cluttered?
Do you push or pull?
Do you pick up or lift?
Do you lift in and out of a machine?
Type of Floor:
Type of ventilation:
Type of lighting:
Is your work area:
Do you have any other jobs?
Has outside help been hired?
Do you use a cart?
Electronic Health Record (EHR) Information
Authorization
Thank you for choosing ChiroFIT as part of your health care team. We are committed to providing the best possible care for you. In order to achieve this goal, we need your assistance in understanding our payment policy, which will be provided to you upon your initial visit. I understand that all fees for said services are due and payable on the date services are rendered. I agree to pay all such charges incurred in full upon presentation, unless other arrangements have been made in advance. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. It is our office policy to collect 100% payment for any deductibles, co-pays, co-insurance and non-covered charges at EACH visit. Our office requires a minimum of 4 hours for any cancellation of appointments. Any MISSED/No Call No Show (NCNS) appointments will be charged a NON-Refundable fee of $50.00. I certify that the health insurance information that I provided to the Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I am responsible for any NON-Covered Therapies and I am responsible for payment upon each visit. ChiroFIT may bill insurance upon my request for any NON-Covered Therapy. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the Provider sees' fit.
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Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature