Chiropractic Intake Form

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: ______________________ Employer: _________________________

Work Phone: ______________________

Social Security #: ________-______-________

Birth Date: _____/_____/________

E-Mail:______________________

Can We Contact You Here?
Yes
No Age: ______

Sex:
Male


Female

Name of Spouse/Partner or Guardian (if underage):___________________________________ Birth Date: _____/_____/_______ Emergency Contact: ______________________________ Relationship: ______________ Phone #:_______________________ Names and Ages o f Children: _______________________________________________________________________________ I 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 physician.. I 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. However, your insurance is a contract between you and your insurance company, NOT between Total Health Chiropractic and your insurance company. You are fully responsible for all charges due to services rendered. If payment is denied for any reason by your insurance company, you are then responsible for 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 be received by Total Health Chiropractic no later than one week from receipt and endorsed to this clinic. 4) Please make payments on time. If you experience financial difficulties, please call us. We will do our best to work out a payment plan. If balances are not paid within 90 days from the time of first statement, and arrangements for payment have not been made, your account will be referred for legal action. 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 by 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 insurance company/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.g. spinal adjustment, ultrasound, heat and cold, etc.) are considered remarkably safe and effective, please understand that occasionally there may be adverse reactions. Although the chances of experiencing any of these complications are extremely small, it is the practice of this office to fully inform and educate all our patients. These complications include, but are not limited to: Pain Burns Bleeding Bruising

Swelling Nausea Sensory Changes Stroke

Inflammation Dizziness Bone Fracture Weakness

Disc Injury Worsening of condition Soft Tissue Injury

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 providers 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: ______

Please indicate areas of pain or other symptoms.

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:

1 2 3 4 5 6 7 8 9 10 (worst pain)

(no 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? 1 – Not at all

2 – A little bit

3 – Moderately

4 – Quite a bit

(Including both work outside the home and housework)

5 – Extremely

7. How are your symptoms changing? 2–

1 – Getting Better

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: _______________________

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