Chiropractic/PT New Patient Intake

Name *

First

Last

Date of Birth *//

Gender *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Work Phone

Occupation *

How did you hear about us? *

Emergency Contact *

First

Last

Relationship *

Emergency Contact Phone *

Employer

Work Activity

Describe a typical work day

Dominant Hand

How many hours do you work a week?

Are you here because of a work-related injury? *

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Insurance Carrier

Do you have a health savings account?

Member #

Are you eligible for Medicare (Over 65 years old)?

Are you here because of an auto accident? *

Yes
No

What is your chief complaint? *

When did this start? *

How did it start? *

Have you had a similar condition before? *

Does anything make your pain better? *

Does anything make your pain worse? *

What does your pain feel like? *

Does your pain radiate / travel? *

Current pain level

Selected Value: 0

0 = no pain, 10 = most pain

Please indicate all your areas of complaints. *

Have you ever seen a chiropractor/PT before? *

Yes
No

Have you seen any other healthcare provider for your current condition? *

Are there any other associated symptoms, concerns, or questions pertaining to your condition that you would like the provider to address during your visit today? *

What are your hobbies? *

What type of physical activity do you like? *

What gym do you work out at? *

Do you smoke? *

Yes
No

How much alcohol do you consume weekly? *

Daily water intake *

How many hours of sleep do you get a night? *

What position do you sleep in? *

Have you ever been pregnant *

Yes
No

Are you currently pregnant? *

Yes
No

Please indicate if a parent, child, or sibling has a history of the following:

Current Medications

Allergies

Recreational Substance(s)

Please list if you have a history of the following:

Hospitalizations *

Immunizations *

Surgeries *

Trauma *

Please check any present conditions that you have NOW or in the PAST.

If NONE, leave blank.

General

	Now	Past
Weight Loss	NowWeight Loss Now	PastWeight Loss Past
Weight Gain	NowWeight Gain Now	PastWeight Gain Past

Head

	Now	Past
Headache	NowHeadache Now	PastHeadache Past
Dizziness	NowDizziness Now	PastDizziness Past
Head Trauma	NowHead Trauma Now	PastHead Trauma Past
Fainting	NowFainting Now	PastFainting Past
Concussion	NowConcussion Now	PastConcussion Past

Eyes

	Now	Past
Changes in vision	NowChanges in vision Now	PastChanges in vision Past
Light Sensitivity	NowLight Sensitivity Now	PastLight Sensitivity Past
Spots in vision	NowSpots in vision Now	PastSpots in vision Past

Mouth

	Now	Past
Jaw pain	NowJaw pain Now	PastJaw pain Past
Bleeding gums	NowBleeding gums Now	PastBleeding gums Past
Dentures	NowDentures Now	PastDentures Past

Nose

	Now	Past
Nosebleeds	NowNosebleeds Now	PastNosebleeds Past
Sinus problems	NowSinus problems Now	PastSinus problems Past

Lungs

	Now	Past
Difficulty breathing	NowDifficulty breathing Now	PastDifficulty breathing Past
Asthma	NowAsthma Now	PastAsthma Past
Persistent cough	NowPersistent cough Now	PastPersistent cough Past
Coughing blood	NowCoughing blood Now	PastCoughing blood Past

Vascular

	Now	Past
Chest pain	NowChest pain Now	PastChest pain Past
Palpitations	NowPalpitations Now	PastPalpitations Past
Ankle swelling	NowAnkle swelling Now	PastAnkle swelling Past
Cold feet / hands	NowCold feet / hands Now	PastCold feet / hands Past
Leg cramps	NowLeg cramps Now	PastLeg cramps Past
Calf pain	NowCalf pain Now	PastCalf pain Past
Varicose veins	NowVaricose veins Now	PastVaricose veins Past
Low blood pressure	NowLow blood pressure Now	PastLow blood pressure Past
High blood pressure	NowHigh blood pressure Now	PastHigh blood pressure Past

Skin

	Now	Past
Rash	NowRash Now	PastRash Past
Easy bruising	NowEasy bruising Now	PastEasy bruising Past
Itching / peeling	NowItching / peeling Now	PastItching / peeling Past
Changes in moles	NowChanges in moles Now	PastChanges in moles Past

G-I System

	Now	Past
Heartburn	NowHeartburn Now	PastHeartburn Past
Indigestion	NowIndigestion Now	PastIndigestion Past
Ulcers / Vomiting	NowUlcers / Vomiting Now	PastUlcers / Vomiting Past
Abdominal Pain	NowAbdominal Pain Now	PastAbdominal Pain Past
Persistent diarrhea	NowPersistent diarrhea Now	PastPersistent diarrhea Past
Constipation	NowConstipation Now	PastConstipation Past
Blood in stool	NowBlood in stool Now	PastBlood in stool Past
Hemorrhoids	NowHemorrhoids Now	PastHemorrhoids Past

G-U System

	Now	Past
Difficulty urinating	NowDifficulty urinating Now	PastDifficulty urinating Past
Pain urinating	NowPain urinating Now	PastPain urinating Past
Blood in urine	NowBlood in urine Now	PastBlood in urine Past
Incontinence	NowIncontinence Now	PastIncontinence Past
Increase in urination	NowIncrease in urination Now	PastIncrease in urination Past

Neurologic

	Now	Past
Seizures / Epilepsy	NowSeizures / Epilepsy Now	PastSeizures / Epilepsy Past
Stroke / TIA	NowStroke / TIA Now	PastStroke / TIA Past
Tingling	NowTingling Now	PastTingling Past
Numbness	NowNumbness Now	PastNumbness Past
Weakness	NowWeakness Now	PastWeakness Past
Difficulty Walking	NowDifficulty Walking Now	PastDifficulty Walking Past
Poor Coordination	NowPoor Coordination Now	PastPoor Coordination Past

Muscle & Bone

	Now	Past
Joint pain	NowJoint pain Now	PastJoint pain Past
Stiffness	NowStiffness Now	PastStiffness Past
Muscle ache	NowMuscle ache Now	PastMuscle ache Past
Bone pain	NowBone pain Now	PastBone pain Past

Conditions

	Now	Past
Anemia	NowAnemia Now	PastAnemia Past
Osteopenia	NowOsteopenia Now	PastOsteopenia Past
Osteoporosis	NowOsteoporosis Now	PastOsteoporosis Past
Arthritis	NowArthritis Now	PastArthritis Past
Cataracts	NowCataracts Now	PastCataracts Past
Glaucoma	NowGlaucoma Now	PastGlaucoma Past
Tuberculosis	NowTuberculosis Now	PastTuberculosis Past
Gallbladder disease	NowGallbladder disease Now	PastGallbladder disease Past
Liver disease	NowLiver disease Now	PastLiver disease Past
Urinary infection	NowUrinary infection Now	PastUrinary infection Past
Pneumonia	NowPneumonia Now	PastPneumonia Past
Thyroid condition	NowThyroid condition Now	PastThyroid condition Past
ADHD	NowADHD Now	PastADHD Past
Anxiety	NowAnxiety Now	PastAnxiety Past
Depression	NowDepression Now	PastDepression Past
Multiple Sclerosis	NowMultiple Sclerosis Now	PastMultiple Sclerosis Past
Parkinson’s disease	NowParkinson’s disease Now	PastParkinson’s disease Past
Gout	NowGout Now	PastGout Past
High cholesterol	NowHigh cholesterol Now	PastHigh cholesterol Past
Cancer	NowCancer Now	PastCancer Past

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

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Signature of Patient (or guardian if minor) *

Date *

Informed Consent

I, the undersigned, have voluntarily requested that the Doctors and/or other providers at Well Set assist me in the management of my health concerns. I understand and agree to all policies and terms provided in the office policies and producers.

Chiropractic / PT

Chiropractic/PT healthcare is predominantly concerned with the relationship between structure (primarily of the spine) and function (primarily of the nervous system). The Doctor of Chiropractic/PT evaluates the patient using standard examination and testing procedures (such as orthopedic and neurologic evaluation and possibly x-rays) along with specialized chiropractic/PT evaluation including observation, inspection, auscultation, and palpation. The chiropractic examination focuses on structural or functional abnormalities called “segmental dysfunction”. Segmental dysfunction exists when one or more vertebrae in the spine or bones in the extremity are fixated sufficiently to result in damage or irritation to either nearby nerves, joints, and/or tissues such as muscles and ligaments. The primary goal of chiropractic treatment is to remove the fixation. This is accomplished by performing a procedure unique to chiropractic, called an adjustment. An adjustment involves the application of a quick, precise force directed over a very short distance to a specific vertebra or bone. Adjustments are usually performed by hand, but may include a hand-guided instrument. Additionally, other treatments used by chiropractors/PT include physiotherapy modalities (ice, heat, soft tissue manipulation), nutritional recommendations and rehabilitative procedures.

As is the case with all health care interventions, the benefits of care must be weighed against the inherent risks and limitations of receiving treatment. Chiropractic treatments are one of the safest interventions available to the public as evidenced by malpractice statistics. While there are risks involved with treatment, these are seldom great enough to contraindicate.

Manual Therapy

A large part of our treatment involves manual therapy performed by hand or using instruments. Manual therapy is generally performed to increase range of motion, reduce scar tissue and/or treat sprains and strains. Some common side effects of manual therapy include soreness and bruising, and in rare cases exacerbation of the current complaint.

Results from Treatment

I understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I understand there is no certainty that I will achieve these benefits. I realize that the practice of medicine, as well as chiropractic/PT/massage, has limitations and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the procedures by my doctor/provider and such other persons of the doctor’s choosing.

Possible Risks & Side Effects from Treatment:

One research study indicated that within the first 2 months of care, approximately half of the patients reported some “reaction” to treatment. Of those who reported a reaction, the following were the most commonly reported reactions to initial chiropractic care:

Local Discomfort (53%)
Headache (12%)
Tiredness (11%)
Radiating Discomfort (10%)

*Most appeared within 4 hours of treatment and resolved within 24 hours.

Rare, Yet Possible Side-Effects / Complications:

Rib fracture
Disc herniation
Cauda Equina Syndrome (1 case per 100 million adjustments)
Compromise of the vertebrobasilar artery (ie. Stroke) (1 case per 400,000 to 1 million cervical spine adjustments)

Stretching & Exercise Disclaimer:

Additional risks are present with stretching and exercise. These risks are increased if you have had surgery, have had a surgical implant or device, or have a history of dislocations. Please consult your treating and/or operating physician prior to engaging in any stretching or exercise program.

Alternative Treatments Available:

Reasonable alternatives to these procedures include but are not limited to:

Medications: I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side-effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks that I should discuss with my medical doctor.
Rest / Exercise: Simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat, or other home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Exercise is valuable yet is not corrective of inured nerve and joint tissue.
Surgery: Surgery may be necessary for conditions such as joint instability or serious disk rupture, among others. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery.
Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making full recovery and rehabilitation more difficult and lengthy.

Possible Risk Factors

Please answer the following questions below by checking YES or NO. These questions help us determine possible risk factors:

Have you ever had an adverse (i.e. bad) reaction to or following chiropractic care? *

Yes
No

Have you ever been diagnosed with osteoporosis or osteopenia? *

Yes
No

Do you take corticosteroids (ie. Prednisone)? *

Yes
No

Have you ever been diagnosed with a fracture of the spine? *

Yes
No

Have you ever been diagnosed with cancer? *

Yes
No

Do you take Warfarin (Coumadin), Heparin, or other “blood thinners”? *

Yes
No

Have you ever had a stroke or TIA (transient ischemic attack)? *

Yes
No

Have you ever become dizzy while turning your head? *

Yes
No

Have you ever had spinal / back surgery? *

Yes
No

Have you ever been diagnosed with spinal stenosis? *

Yes
No

Have you ever been diagnosed with the following?

Rheumatoid Arthritis *

Yes
No

Reiter’s Syndrome *

Yes
No

Ankylosing Spondylitis *

Yes
No

Psoriatic Arthritis *

Yes
No

Giant Cell Arteritis *

Yes
No

Ligamentous Hypermobility (Marfan’s, Ehlers Danlos) *

Yes
No

Have you ever had any of the following problems?

Sudden weakness in the arms or legs? *

Yes
No

Numbness in the genital area? *

Yes
No

Inability to urinate or lack of control of urinating? *

Yes
No

A thorough health history review and possible physical examination will be performed on me to minimize the risk of any complications from treatment, and I freely assume these risks. I have read (or have had read to me) the above explanation of chiropractic treatment. The doctor/provider has also asked me if I want a more detailed explanation but I am satisfied with the explanation, and do not want any further information. I have made my decision voluntarily and freely. To attest to my consent to these examinations and treatment procedures, I hereby affix my signature to this informed consent document.

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Signature of Patient (or guardian if minor) *

Date *

Financial Policy

Well Set is an out-of-network provider with all health insurance companies. It is your responsibility to verify if you have out-of-network benefits before your first appointment. If needed, Well Set can teach you how to check your out-of-network benefits. Payment is due at the time of service. If I choose to use my out-of-network benefit, I authorize and request my insurance company to pay directly to Well Set, the insurance benefits that are otherwise payable to me. I understand that my chiropractic insurance carrier may cover only a portion of, or not cover all of the services rendered. I agree to be ultimately responsible for all costs for services rendered and that they are payable when services are rendered.

No-Show Cancellation Policy

We require a minimum of 24-hours notice to cancel or reschedule all new patient chiropractic appointments and for all PT and massage appointments (new and follow-up). We also require at least 2 business hours notice before follow-up chiropractic appointments. To better serve all of our patients and ensure that they have a fair opportunity to have an appointment as promptly as possible, please observe our cancellation policy for all appointments.

Fees

No shows / late cancels will be billed at half the price for the first missed appointment for all massage appointments, chiropractic, and PT, and full price for any subsequent missed appointments.

Packages/Refunds

All prepaid packages for chiropractic and PT are non-refundable. These packages include a discounted rate for service, and the balance of the package must be used for the specific service. All services rendered are non-refundable.

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Signature of Patient (or guardian if minor) *

Date *

HIPAA Privacy Practices

I understand that I may request and review the privacy practice for Well Set and understand the situations in which this practice may need to utilize or release my medical records. I also understand that I agreed to the use of those when I initiated care at this office on my first visit, whenever that may have occurred.

I understand that this office will properly maintain my records and will use all due means to protect my privacy as outlined in this privacy practices statement.

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Signature of Patient (or guardian if minor) *

Date *

Exceptions and Records Release

I authorize the doctor to release any information including the diagnosis and the records of treatment or examination rendered to me or my dependent during the period of such chiropractic care to third party payers and/or health practitioners. I allow the providers and staff at Well Set to discuss my treatment and diagnosis with the following doctors, health care professionals, coaches, lawyers, spouses, etc. :

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Title:

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Signature of Patient (or guardian if minor) *

Date *

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Chiropractic/PT New Patient Intake

Please list if you have a history of the following:

Informed Consent

Chiropractic / PT

Manual Therapy

Results from Treatment

Possible Risks & Side Effects from Treatment:

Rare, Yet Possible Side-Effects / Complications:

Stretching & Exercise Disclaimer:

Alternative Treatments Available:

Possible Risk Factors

Have you ever been diagnosed with the following?

Have you ever had any of the following problems?

Financial Policy

No-Show Cancellation Policy

Fees

Packages/Refunds

HIPAA Privacy Practices

Exceptions and Records Release

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