Richard Williams Chiropractic--- Family & Sports Care New Patient Intake Form

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1 Richard Williams Chiropractic--- Family & Sports Care New Patient Intake Form 174 Bolick Lane, Suite 102, Taylorsville, NC PATIENT DATA DATE Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name: Middle Initial: Last Name: Address: City: State: Zip Code Home Phone ( ) Work Phone ( ) Cell Phone ( ) May we contact you by or Phone for appointment reminders or other information? Yes No Date of Birth / / Sex: Male Female Social Security Number: - - Marital Status: Single Married Other SPOUSE DATA/PARENT/GUARDIAN (IF MINOR) First Name: Middle Initial: Last Name: Home Phone ( ) Work Phone ( ) EMPLOYER INFORMATION Employed: (Circle One) Full Time Part Time Full Time Student Part Time Student Retired Unemployed Employer/School: Phone: Address: Occupation: EMERGENCY CONTACT Contact Name: Contact Home Phone ( ) Relationship to Patient Cell Phone ( ) REFERRAL INFORMATION Internet Friend Referring Physician: Existing Patient: Advertisement:

2 MEDICAL CONDITIONS (CHECK ALL THAT APPLY TO YOU) Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Other SURGERIES: (CHECK ALL THAT APPLY TO YOU) Appendectomy Cardiovascular procedure Cervical spine Hysterectomy Joint Replacement Prostate Lumbar spine Gall Bladder Brain Shoulder Thoracic spine Knee Carpal Tunnel Gastro-intestinal Uro-genital Hernia Other ALLERGIES (CHECK ALL THAT APPLY TO YOU) Eggs Fish and Shellfish Milk or lactose Peanuts Soy Sulfites What/Glutens Other SOCIAL HISTORY: (CHECK ALL THAT APPLY TO YOU) Caffeine use: occasional often never Drink Alcohol: occasional often never Exercise: occasional often never Chew Tobacco: occasional often never Wear Seat Belts: occasional often never OTC Stimulants: occasional often never Water: occasional often never Recreational Drugs: occasional often never Other: FAMILY HISTORY: (CHECK ALL THAT APPLY) Arthritis: Parent Sibling Cancer: Parent Sibling Diabetes: Parent Sibling Heart Disease: Parent Sibling Hypertension: Parent Sibling Stroke: Parent Sibling Thyroid: Parent Sibling Other: WOMEN ONLY Are you pregnant or think you might be pregnant? Yes No Are you nursing? Yes No Are you taking birth control? Yes No Do you have irregular cycles? Yes No Do you have excessive menstruation? Yes No Do you experience painful periods? Yes No Are you taking any hormonal replacement? Yes No Do you have breast implants? Yes No Date of last menstrual period:

3

4 How are your symptoms changing? Getting better Not changing Getting worse Who have you seen for your symptoms? No One Medical Doctor Other Other Chiropractor Physical Therapist When and what treatment? What tests have you had for your symptoms and when were they performed? X-rays (date: ) CT Scan (date: ) MRI (date: ) Other (date: ) Have you had similar symptoms in the past? Yes No If you have received treatment in the past for the same or similar symptoms, who did you see? This Office Medical Doctor Other Other Chiropractor Physical Therapist WORKER S COMPENSATION INJURY/AUTO/PERSONAL INJURY: Have you filed an injury report with your employer? Yes No Date: / / Time: am/pm HIPAA PRIVACY PRACTICES I acknowledge that I have received and/or have been given the opportunity to review this Chiropractic Office s Notice of HIPAA Privacy Practices for protected health information. Do you want to give permission to share your records with any individual? Yes No If so, please list the following information: Name of Individual Relationship to Patient Date Print Patient s Name Patient s Signature Date Consent to Treat a Minor: (Minor s Printed Name) Guardian/Spouse s Signature Authorizing Care Date

5 PAYMENT/INSURANCE INFORMATION: Who is responsible for your bill? Self Health Insurance Spouse Worker s Comp Auto Insurance Medicare Other Personal Health Insurance Carrier: Insurance Card ID# Policyholder s Name Group # Policyholder s Date of Birth Primary Care Physician

6 What do you hope to get from your visit/treatment (select all that apply): Reduce symptoms Explanation of condition/treatment How to prevent this from occurring again Resume/increase activity Learn how to take care of this on my own Other: PATIENT SIGNATURE Date or Parent/Guardian if patient is a minor

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