cr-chiro-Updated-Pediatric-Intake

New Patient Intake Form
Full Name (please print)
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
SSN
Emergency Contact
Phone Number

Area CodePhone Number
Relationship to Patient
Please circle one if you would like to be sent a reminder for future appointments:

TextEmail
If you selected Email please list one:
example@example.com
How did you hear about our office?
Reason for your visit today? (Please list areas of pain)
Is your condition due to an accident?

YesNo
Date of your accident

MonthDayYear
Date
Have you ever had any previous chiropractic experience?
Have you seen any other health care provider for the above complaint?
Have you ever served in a branch of the military? If YES what branch?
Consent for Treatment
I hereby consent to the performance of examination and treatment on myself or on
by Dr. Lindsey Rovenstine. I further understand that there can be risk associated with chiropractic care, which includes but not limited to fractures, sprains/strains, strokes and disc injuries. I am, therefore, willing to accept and consent to the risk associated with care currently and in the future. Furthermore, any risk involved with chiropractic care will be explained upon request. NOTICE: Our office often utilizes an open area for treatments, adjustments, and physical therapy. This may result in some of your care or discussions with the doctor being overheard by other patients and staff. All necessary actions will be taken to prevent or limit this during the history and review of the patient’s confidential information. If you have any concerns about your privacy, please bring it to the doctor’s attention immediately. This notice of privacy and open bay notice is effective as of February 17, 2014. This notice, and any alterations or amendments made hereto, will expire seven years after the date upon which the record was created. My signature below acknowledges that I had the opportunity to read this notice and hereby agree to its terms. I (we) hereby authorize the doctor and the staff to release any information deemed appropriate concerning my physical condition to any insurance company, claims adjuster, case nurse, claims reviewer, employer, healthcare provider, or attorney in order to process any consequences thereof. I agree that a photo static copy of this agreement shall serve as the original.
Patient Signature

Clear
Date

MonthDayYear
Date
Guardian Signature

Clear
Date

MonthDayYear
Date
I attest to the information below to be correct. Patient denies any other past illnesses, hospitalizations or surgeries. I further understand that any charges incurred in the office are my sole responsibility, despite any insurance plan, legal involvement, or settlement.
Patient Signature

Clear
Date

MonthDayYear
Date
When did your pain start?
HOW DID IT HAPPEN?
Where is the pain located?
How frequent is this condition?
On a scale of 0-10 (0 is no pain - 10 needs to go to ER) what is your pain currently?
What is your pain at its worst?
What is your pain at its best?
Describe the pain:

SharpDullNumbnessTingling AchingThrobbing BurningStiff/TightnessStabbing
Does your pain travel? If so where? Down into your arms and hands or legs and toes?
What makes the problem worse?

StandingSittingBendingLiftingTwistingOther
Do you have any pain when coughing, sneezing, laughing, or going to the bathroom?
Do you have any weakness in your arms, hands, fingers, in your legs, feet or toes?
Any difficulty controlling bowel or bladder?

YesNo
Does your pain wake you up at night?

YesNo
In what position do you sleep and how well?
What makes your pain better?
Have you had any recent weight gain or loss?

YesNo
Have you had a fever recently?

YesNo
Have you ever had x-rays, MRI, or CAT scan of your body?

YesNo
When?
(FEMALE) is there any possibility you are pregnant?

YesNoMaybe
(MALES) Have you ever had any prostate problems?

YesNo
Please list all the different doctors and their specialties you have seen in the last 3 years.
Is there any family history of serious illnesses? Cancer, heart disease, etc. If yes, please describe
Have you had any of the following:

StrokeAneurysmHeart DiseaseKidney DiseaseLiver DiseaseLung Disease
Please list all medications (prescription, non-prescription, and vitamins)
Do you have a history of cancer, high blood pressure, shingles, diabetes or any other serious illness?
Have you ever been diagnosed with a spondylolisthesis, compression fracture, spinal fracture or osteoporosis?
Please list any surgeries, major traumas, (including concussions and broken bones) illnesses, recent immunizations, car accidents or hospitalizations and dates.
Providers notes: BP
Pulse:
Additional Notes:
Appointment Cancellation Policy

We strive to render excellent care to you and the rest of our patients. Your care and treatment are a priority to us. We also ask that you respect our physician’s time and expertise as well. In an attempt to be consistent with this, we have an appointment cancellation policy that allows us to schedule appointments for our patients, with respect for your time, the next patient’s time, and the doctor’s time.

Our policy is as follows:

We request that you give 24-hour notice in the event that you cannot make it to your scheduled appointment. If you miss an appointment without contacting our office or reschedule or cancel an appointment with less than 24-hour notice, it is considered a “missed” or “no show” appointment. YOU WILL BE CHARGED $25.00 FOR THE VISIT YOU WERE SCHDULED FOR. In order to make another appointment you will need to settle your account prior to your next visit or for both visits prior to leaving your next adjustment. Additionally, if you are more than 10 minutes late for an appointment, it will be considered a “missed” or “no show” appointment, and that appointment will need to be rescheduled. Also, if you miss more than 3 appointments, Crossroads Chiropractic reserves the right to discharge you from the practice for failing to follow treatment recommendations.

You may contact the office via phone or email. Phone is preferred. Please see our business card with all the contact information.

If you have any questions regarding this policy, please let our staff know, and we will be happy to clarify the policy for you.

We look forward to being a continued part of your wellness.

I have read and understand the Appointment Cancellation Policy of Crossroads Chiropractic and I agree to be bound by its terms. I am aware that I must pay for missed appointments prior to making a new appointment or as otherwise worked out by staff.
Patient or Legally Authorized Individual Signature

Clear
Date

MonthDayYear
Date
Print Patient’s Full Name
Witness Signature

Clear
Date

MonthDayYear
Date
Consent to use PHI

Acknowledgement for Consent to Use and Disclosure of Protected Health Information

Use and Disclosure of your Protected Health Information
Your Protected Health Information will be used by CROSSROADS CHIROPRACTIC or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.

Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. I understand that a copy of the Notice of Patient Privacy Policy is available upon request and I can request this at any time.
Patient Initials
Requesting a Restriction on the Use or Disclosure of Your Information
- You may request a restriction on the use or disclosure of your Protected Health Information.
- This office may or may not agree to restrict the use or disclosure of your Protected Health Information.
- If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.
Notice of Treatment in Open or Common Areas

Occasionally we have an open treatment area, but upon notification private areas are available.

Revocation of Consent

You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

By my signature below I give my permission to use and disclose my health information.
Patient or Legally Authorized Individual Signature

Clear
Date

MonthDayYear
Date
Print Patient’s Full Name
Time

Hour Minutes

AM/PM Option
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Patient Intake Form

Consent for Treatment