New Patient Intake

New Chiropractic Patient Intake

Please complete this form prior at least 24 hours prior to your appointment. Feel free to call if you have problems with this form 919-322-4383. We look forward to seeing you soon!
Personal Information
Name *

First Name Last Name
Please enter your date of birth *

Month Day Year
Please enter your social security number *
Please note: We are unable to set up any payment plan arrangement without a valid social security number. If you chose to not provide your social security number, payment will be expected in full at time of service.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Who referred you to our office? *

family member a friend my doctor Google/internet search my health insurance
If referred by friend, family or your physician, please provide their name:
Please provide a contact in case of emergency *

First Name Last Name
Emergency contact phone number *

Area Code Phone Number
Primary care physician

First Name Last Name
Primary care physician phone number

Area Code Phone Number
Health insurance policy information

Please complete this section entirely. ***Please note*** insurance benefits quoted to us are not a guarantee of payment or coverage. We make every effort to verify your benefits, however, you are responsible for any amount shown on your EOB (explanation of benefits) once your claims have been filed. If you are self pay (do not participate with a health insurance plan) please select self pay and move to the next section.
Please select the name of your health insurance provider *

Blue Cross Blue Shield Cigna Medcost United Healthcare Aetna Medicare No insurance / Cash patient
Subscriber ID / Member ID
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Group number
Please list your relationship to the insured

I am the policy holder My spouse is the policy holder I am a dependent of the policy holder No insurance / Cash patient
Provider/benefits services phone number (usually listed on the back of the ID card)

Area Code Phone Number
If you are not the policy holder, please enter the policy holder's name

First Name Last Name
If possible, please attach a picture of the front of your insurance card

Browse Files

Cancel of
If possible, please attach a picture of the back of your insurance card

Browse Files

Cancel of
Is your pain a result of any of the following? *

motor vehicle accident personal injury worker's compensation none of the above
If your pain is a result of a recent (within the last 30 days) motor vehicle accident or personal injury case, please follow the link below and do not complete the rest of this form.

Personal Injury Intake New Patient
Current condition information

Please use the following fields to describe what brings you into our office today.
I am seeking pain relief I am not currently experiencing pain, I am seeking services to improve overall health function (wellness / lifestyle care) I am seeking prenatal/postpartum chiropractic care
If pregnant, Please enter the names and contact numbers of your birth providers (doula, midwife/ob)
Name

First Name Last Name
Phone Number

Area Code Phone Number
Please list your health concerns/pain complaints (i.e., shoulder pain, migraines, autoimmune disease, etc.) or enter 'Wellness' *
Please use the drawing tool to circle your area of complaint (s) From left to right the bodies represent Back, Front and Side positions

Please rate your pain *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme pain

The quality of my pain listed above is characterized as *

burning stabbing dull/ache stiff pins and needles / tingling
This pain is *

constant on and off
Does this pain radiate/shoot to any of the following areas (please indicate which side)? *

shoulder / arm / hands / fingers buttocks / leg ankle / foot right left not applicable
Please list all things which make your pain better *

ice heat rest movement / position change sitting standing stretching Rx medication OTC medication
Please list all the things which make your pain worse *

sitting standing movement / position change walking lying down sleeping heat

Please indicate how your condition impacts the following activities of daily living - an answer for each is required. *

painful

some pain

not affected

bending

lifting

stairs

sitting

standing

walking

exercising

housework

kneeling

Please list any other providers who have treated this condition

my primary care physician orthopedic doctor massage therapist physical therapist another chiropractor
Please list any imaging you have had in the last three months (please bring recent images with you to your first appointment if possible)

spinal xray spinal MRI
Lifestyle history

Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.
Please list any supplements and over the counter medications you currently take or write none *
Please list any prescription medications you are currently taking or write none *
Do you use tobacco products?

no Yes occasionally
Which statement best describes your exercise habits

I exercise regularly and frequently (3+ times per week on a regular basis) I exercise regularly but in-frequently (1-2 times per week on regular basis) I exercise every once in a while I don't exercise
How often to you consume alcoholic drinks?

rarely / never 1-3 drinks per week 3-5 drinks per week over 6 drinks per week
Which statement best describes your eating habits?

I eat fast food regularly (3+ times per week) I eat out sometimes and make healthy choices I eat clean (organic, whole foods most of the time)
Health history

Please indicate any past or present conditions listed below. Check all that apply.
General: *

recent unintentional weight loss fever extreme fatigue none in this category
Musculoskeletal *

broken bones previous surgery (please explain below) none in this category
Please list any surgeries in the field below. List surgery type and year performed.
Neurological *

numbness or tingling sensations stroke loss of feeling dizziness or lightheaded frequent or recurrent headaches head injury / concussion none in this category
Gastrointestinal *

loss of appetite bloody stool constipation diarrhea nausea or vomitting regular abdominal pain / bloating none in this category
Cardiovascular / heart *

chest pain rapid or heartbeat changes blood pressure regulation problems high cholesterol swelling of ankles and feet history of heart attack diagnosed cardiovascular disease none in this category
Respiratory *

difficulty breathing persistent cough asthma coughing blood none in this category
Eyes / vision *

blurred or double vision eye disease or injury wear glasses / contacts none in this category
Genitourinary *

kidney stones burning / painful urination frequent urination urinary leakage / bed wetting blood in urine none in this category
Endocrine, hematologic, lymphatic *

thyroid problems diabetes cold hands / feet immune system disorder none in this category
Skin and breasts *

rash / itching non-healing sores breast pain breast lump none in this section
Are you pregnant?

yes no it's possible
If yes, what is your estimated date of delivery?

Month Day Year
Date
Do you have an immediate family history of any of the following? (check all that apply) *

cancer heart disease stroke none of the above
During your examination the doctor may decide it is medically necessary to include digital xray imaging of one or more areas of your spine or extremity. Women who think they may be pregnant will not be imaged. Please let your doctor know if there is a chance you may be pregnant.

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation/ massage therapy / acupuncture / cold laser. These complications include but are not limited to: muscle strain, tenderness, fractures, soft tissue injuries, cervical radiculitis and costovertebral strains. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. We use comprehensive examinations to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.
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You're done! Thank you for completing this form, click 'Submit' below and we'll receive your information. We look forward to helping you live life well!

Gard Wellness Center

455 Swiftside Drive #103

Cary NC 27518
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New Chiropractic Patient Intake

Personal Information

Health insurance policy information

Current condition information

Lifestyle history

Health history