New Patient Form

New Patient Form

This form is HIPAA- compliant.
Are you filling out this form for yourself or for someone else?

Myself (I am 18 or older) Someone else
Information regarding who is filling out the form.
Name
Phone
Email
Relationship to patient
Patient Information
PATIENT Name *
PATIENT Phone number *
PATIENT Email *
PATIENT Address (include: City, State, Zip, and Apt. #) *
DOB *

Month Day Year
Gender *

Male Female
Are you, or is there any possibility, that you are pregnant? *

YES NO UNCERTAIN
Marital Status

Married Single
Name of Insurance CO *
Employer and Occupation *
How did you hear about us? *
Please include the name of the person who referred you, if applicable.
Emergency Contact Info
Name
Phone
Relation
Patient History
Primary Doctor *
Primary Doctor's number *
Have you seen a Chiropractor before? *

YES NO
Who was your last chiropractor?
When was your last visit?
Do you have a history of stroke or hypertension? *

YES NO
Have you had any major illnesses, injuries, falls, auto accidents, or surgeries? (Women, please include information about childbirth)
INCLUDE DATES
Have you been treated by a physician for any health condition in the last year?

YES NO
Please explain:
List all medical conditions you have. *

Headaches Diabetes Loss of balance Neck pain Fainting Stiff Neck Sleeping Problems Breathing Problems Fatigue Depression Ears Ringing Broken Bones/Fractures Back Pain Unusual Bowel Patterns Arthritis Chest pain/tightness Muscle Spasms Dizziness Circulation Problems Rheumatoid Arthritis Seizures/ Epilepsy Excessive Bleeding Low Blood Pressure Osteoarthritis Osteoporosis Pacemaker Heart Disease Stroke Cancer Alcoholism Drug Addiction
Social History
Please indicate if you engage in each activity. *

Vigorous Exercise Moderate Exercise Alcohol Use Drug Use Tobacco Use Caffeine Family Pressure Financial Pressures Other Mental Stressors Other
Patient Complaint

*If you have two areas of pain (i.e. neck and back), please use the secondary complaint section found below*
Primary Complaint *
When did you FIRST have this symptom? *
What caused it? *
Is the pain constant since the onset, or has it been on and off? *

Constant On and Off
Are the symptoms worse at a certain time of day? *

YES NO
Please explain *
List any activities that HELP the symptoms. *
List any activities that WORSEN the symptoms. *
Has this condition affected your... *

Work Exercise Family/ Recreation time Other
Is this condition getting: *

Better Worse Staying the Same
Does the pain radiate or move anywhere, such as into the arms, legs, or head? *
Have you seen any other doctors for this condition? *

YES NO
Please explain *
On a scale of 1 (none) to 10 (extreme) rate the intensity of your symptoms.
How frequent are these symptoms?

Constant Daily Weekly Monthly
Please describe the pain.

Sharp Dull Numbness Tingling Aching Burning Stabbing Tightness Stiffness Other
Do you have another Complaint? *

YES NO
Secondary Complaint *
When did you FIRST have this symptom? *
What caused it *
Is the pain constant since the onset, or has it been on and off? *

Constant On and Off
Are the symptoms worse at a certain time of day? *

YES NO
Please explain
List any activities that HELP the symptoms.
List any activities that WORSEN the symptoms.
Has this condition affected your... *

Work Exercise Family/ Recreation time Other
Is this condition getting: *

Better Worse Staying the Same
Have you seen any other doctors for this condition? *

YES NO
Please explain *
Does the pain radiate or move anywhere, such as into the arms, legs, or head? *
On a scale of 1 (none) to 10 (extreme) rate the intensity of your symptoms. *
How frequent are these symptoms? *

Constant Daily Weekly Monthly
Please describe the pain. *

Sharp Dull Numbness Tingling Aching Burning Stabbing Tightness Stiffness Other
How has this condition(s) affected your life? *
What made you decide to seek treatment at this time? *
What do you hope to achieve with this treatment? *
*If you have any further complaints, please let the doctor know*
Please list any medications, supplements, or vitamins you are currently taking. *
Include dosage and for what condition.
Family History
Do any of your family members have any of these conditions? *

Cancer Heart Disease Stroke Aneurysm Alcohol Abuse Drug Abuse Diabetes N/A Other
Please explain who suffers from the condition(s) above.
e.g.: Grandfather- Cancer, Aneurysm
Acknowledgement of Receipt of Notice of Privacy Practices
Oswestry Disability Index
Pain Intensity *

I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment.
Personal Care (e.g. washing, dressing) *

I can look after myself normally without causing extra pain. I can look after myself normally but it causes extra pain. It is painful to look after myself and I have to be slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self care.
Lifting *

I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, i.e. on a table. Pain prevents me from lifting heavy weights, but I can manage light-to-medium weights if they are conveniently positioned. I can lift very light weights. I cannot lift or carry anything at all.
Walking *

Pain does not prevent me from walking any distance. Pain prevents me from walking more than one mile. Pain prevents me from walking more than 1/2 mile. Pain prevents me from walking more than 1/4 mile. I can only walk using a stick or crutches.
Sitting *

I can sit in any chair as long as I like. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting more than one hour. Pain prevents me from sitting more than 10 minutes. Pain prevents me from sitting at all.
Standing *

I can stand as long as I want without extra pain. I can stand as long as I want but it gives me extra pain. Pain prevents me from standing for more than one hour. Pain prevents me from standing for more than 30 minutes. Pain prevents me from standing for more than 10 minutes. Pain prevents me from standing at all.
Sex Life *

My sex life is normal and causes no extra pain. My sex life is normal but causes some extra pain. My sex life is nearly normal, but it is very painful. My sex life is severely restricted by pain. My sex life is nearly absent because of pain. Pain prevents any sex at all. n/a
Sleeping *

Pain does not prevent me from sleeping well. I can sleep well only by using medication. Even when I take medication, I have less than 6 hours of sleep. Even when I take medication, I have less than 4 hours of sleep. Even when I take medication, I have less than 2 hours of sleep. Pain prevents me from sleeping at all.
Social Life *

My social life is normal and gives me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests. Pain has restricted my social life and I do not go out as often. Pain has restricted my social life to my home. I have no social life because of pain.
Traveling *

I can travel anywhere without extra pain. I can travel anywhere but it gives me extra pain. The pain is bad, but I manage journeys of less than 1 hour. Pain restricts me to short, necessary journeys of under 30 minutes. Pain prevents me from traveling, except to the doctor or hospital.
Employment/ Homemaking *

My normal homemaking/ job activities do not cause me pain. My normal homemaking/ job activities increase my pain, but I can still perform all that is required of me. I can perform most of my homemaking/ job activities, but pain prevents me from performing more physically stressful activities (e.g. lifting, vacuuming). Pain prevents me from doing anything but light duties/activities. Pain prevents me from doing even light duties/activities. Pain prevents me from performing any job or homemaking chores.
Patient Certification
I certify that the above information is true and correct and I hereby authorize the release of any information required to secure payment for services rendered. I also authorize and direct that any insurance or medical coverage benefit payments to which I may be entitled shall be paid directly to Family Chiropractic Center.

I understand and agree that I am financially responsible for and will promptly pay any non-covered services including, but not limited to, deductible and co-pay. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care.

We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information please ask for the HIPPA notice before signing this. If there is anyone who you do not want to receive your medical records, please inform our front desk.
I have received a copy of this office's Notice of Privacy Practices. I authorize Family Chiropractic Center to disclose any protected health information to the individual(s) listed below.
Informed Consent
I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures including examination tests, diagnostic x-ray(s) and physical therapy techniques, on me (or the patient named below for which I am legally responsible) which are recommended by the doctor of chiropractic named below or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working for or associated with, or serving as back-up for the doctor of chiropractic named below.

I understand that, as with any health care procedure, there are certain complications which may arise during a chiropractic adjustment. Those complications include, but are not limited to: fractures, disc injuries, dislocations, muscle strain, Horner’s syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications, including stroke. I do not expect the doctor to be able to anticipate all of the possible risks and complications. I wish to rely on the doctor to exercise judgement during the course of the procedure(s) which the doctor feels and the time, based upon the facts then known, are in my best interest.

I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed.

I have read the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing recommended treatment. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Name and Address of Office or Clinic: Name of Doctor(s):

Family Chiropractic Center of Pittsburgh Dr. Kevin S. Hartung

5168 Campbells Run Rd. Dr. Jason E. Bean

Pittsburgh, Pa 15205

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE INFORMATION
Name/ relation
Contact Number
Name/ relation
Contact Number
Signature *

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Should be Empty:

New Patient Form

Information regarding who is filling out the form.

Patient Information

Emergency Contact Info

Patient History

Social History

Patient Complaint

*If you have any further complaints, please let the doctor know*

Family History

Acknowledgement of Receipt of Notice of Privacy Practices

Oswestry Disability Index

Patient Certification

Informed Consent

If you have any further complaints, please let the doctor know