wellness901.com - New Patient Intake Form

New Patient Intake Form
Full Name:

First NameLast Name
DOB:

MonthDayYear
Date
Gender:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Email:
example@example.com
Marital Status:

SingleMarriedWidowedDivorced
Occupation:
Emergency Contact Name:
Phone:
Please enter a valid phone number.
How did you hear about us? Please select one

WebsiteInternetRadioTVSocial MediaFriend or FamilyPhysician Referral
If referred by whom?
Please select one:

InsuranceSelf PayPersonal InjuryWorkers Comp
Who is financially responsible for this account?
Relationship to Patient:
Insurance Information
Primary Insurance:
Insurance Provider:
Member ID#:
Subscriber’s Name:
Subscriber’s DOB:
Secondary Insurance:
Insurance Provider:
Member ID#:
Subscriber’s Name:
Subscriber’s DOB:
Reason for Visit
Draw on Image
Problem 1:
Rate the severity of pain on a scale of 0 (no pain) to 10 (severe pain).

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Severe Pain
Problem 2:
Rate the severity of pain on a scale of 0 (no pain) to 10 (severe pain).

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Severe Pain
Problem 1: *main concern
This was a result of:
When did your symptoms first appear:
Is this condition worsening?

YesNoUnknown
How often do you have this pain?

ConstantAMPMComes and Goes
What makes the symptoms worse?
What makes the symptoms better?
Symptoms interfere with:

WorkSleepDaily RoutineRecreational Activity
Have you experienced this before?

YesNo
Number of previous episodes?
Have you been seen for this condition before?

YesNo
If so by whom:
Medications for this condition:
Previous imaging:

YesNoUnknown
Problem 2:
This was a result of:
When did your symptoms first appear:
Is this condition worsening?

YesNoUnknown
How often do you have this pain?

ConstantAMPMComes and Goes
What makes the symptoms worse?
What makes the symptoms better?
Symptoms interfere with:

WorkSleepDaily RoutineRecreational Activity
Have you experienced this before?

YesNo
Number of previous episodes?
Have you been seen for this condition before?

YesNo
If so by whom:
Medications for this condition:
Previous imaging:

YesNoUnknown
Physician Notes:
Personal Health History
Medications:
*Please include supplements
Allergies:
*Please include type of reaction
Recent illness:
Hospitalization including surgeries:
Smoking/Vaping:

NeverPreviousCurrent
If Current: number of years
If Previous: End Year
Recreational Drug Use:

YesNoOccasional
Alcohol:

NeverSocialDaily
Estimated Drinks Per Week:
Caffeine:

YesNoOccasional
Estimated Daily Amount:
Health History
Constitutional:

Weight LossWeight GainLoss of AppetiteRecent Fever/ChillsFatigueCancerChange in Bowel or Bladder FunctionFainting /Loss of ConsciousnessRecent Falls
Skin:

Frequent RashesOpen WoundsSkin LesionItchy/Red SkinSkin Cancer
Eye:

Blurred VisionVision LossDouble Vision
ENT:

TMJ/Jaw PainNose BleedsHearing LossRinging in EarsHoarseness/Sore ThroatDifficulty SwallowingSinus Infections
Lungs/Respiratory:

Shortness of BreathWheezingChronic CoughExercise IntoleranceAsthma
Cardiovascular:

Chest PainIrregular HeartbeatCalf PainHigh CholesterolHigh BloodPressure
Digestive:

HeartburnNausea/VomitingBlood in StoolLiver/Gallbladder
Kidney/Bladder:

Painful UrinationProblems UrinatingIncontinenceKidney StonesKidney ProblemsUTIDialysis
Glands:

Excessive ThirstFrequent UrinationDiabetesAlways Hot/ColdThyroid ProblemsSwelling
Blood:

AnemiaEasy Bruising or BleedingClotting DisorderBlood Transfusion
Neurological:

HeadachesMigrainesDizzinessVertigoWeaknessChange in sensationEpilepsyStrokeConcussion
Skeletal:

ArthritisOsteoporosisBroken BonesPainful JointsSports Injury
Psychiatric:

Drug/AlcoholAbuseDepressionAnxietyPhobias
Male Reproductive:

Erectile DysfunctionProstate ProblemsDribbling UrineLow TestosteroneInfections/STD’sDischargePain in genitals
Female Reproductive:

Last CyclePregnanciesPain/DischargeYeast InfectionsBirth Control or Hormone ReplacementIrregular CyclesPost-Menopause
Last Cycle:
Pregnancies #:
Family History

Check all of the following that apply to your FAMILY MEMBERS (Mother/Father/Brother/Sister):

	Mother	Father	Brother	Sister
Cancer:
Blood Pressure:
Diabetes:
Arthritis/Rheumatoid Arthritis:
Neurological Disorder:
Autoimmune Disorder:
Stroke:
Thyroid Disease:
Heart Disease:

If Cancer: List type(s)
AUTHORIZATION FOR TREATMENT
I HEREBY REQUEST AND CONSENT to the performance of Chiropractic procedures which may include but are not limited to various modes of physical medicine, therapies, joint manipulation, needling, and diagnostic tests on me by a licensed physician, residencies, chiropractic interns and/or other healthcare providers who are now or in the future employed by RESILIENT SPINE AND SPORTS HEALTH, LLC as deemed necessary. I understand I may refuse treatment(s) at any time.

I CERTIFY that all information provided to this office is true and correct, to the best of my knowledge, and will have the opportunity to discuss the nature of my case, including treatment, procedures, and other options. I understand that results are not guaranteed. I understand and am informed that in the applicable methods of treatment (chiropractic, dry needling, therapeutic exercise, etc.) there are some risks, including fracture, disc injuries, stroke, dislocation, sprains, pneumothorax, and infection. I do not expect the physician(s) or other provider(s) to be able to anticipate and explain all risks and complications, and I wish to rely upon the physician(s) or other providers judgement during the course of the treatment or procedure, given the facts known then to him/her, acting in my best interest.

I HAVE READ, or have had read to me, the above consent, and have been offered the amendment document “Informed Consent.” I have had the opportunity to ask questions about its content. By signing below, I agree to the above-named procedures. 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.

ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO THE FACILITY

I do hereby authorize RESILIENT HEALTH AND WELLNESS to furnish the insurance company, my attorney, or other interested party with full report of examination, diagnosis, treatment, prognosis, etc. regarding this injury or accident.

I hereby authorize and direct the insurance company, attorney, or other interested party to pay directly to RESILIENT HEALTH AND WELLNESS such as sums as may be due and owing for services rendered me and to withhold such sums for any settlement, judgement, or verdict as may be necessary to adequately protect RESILIENT HEALTH AND WELLNESS

I fully understand that I am directly and fully responsible to RESILIENT HEALTH AND WELLNESS for all bills submitted for services rendered, and that agreement is made solely for said facility’s settlement, judgement, or verdict by which I may eventually recover said fee. I further understand that I am fully responsible for all fees, court costs and all other fees associated with collection of this debt.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have been offered a copy of the RESILIENT HEALTH AND WELLNESS “Notice of Privacy Policies.” This notice describes how RSSH may use and disclose my protected health information, certain restrictions on the use and disclosure of that information and rights I may have regarding my protected health information.
Printed Name:
Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

New Patient Intake Form

Insurance Information

Primary Insurance:

Secondary Insurance:

Reason for Visit

Personal Health History

Health History

Family History

AUTHORIZATION FOR TREATMENT