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!
Name *

First Name Last Name
Preferred name if different than above:
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 Facebook/Social Media Ad
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 *

Aetna Blue Cross Blue Shield Cigna Medcost Medicare Veterans Affairs No insurance / Self pay
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 you are not the policy holder, please enter the policy holder's date of birth

Month Day Year
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
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
Please list your health concerns/pain complaints if present (i.e., shoulder pain, migraines, autoimmune disease, etc.) or enter 'Wellness' for if you are looking to improve overall function *
Do you have a history of any of the following conditions? *

Stroke Heart Attack None of the above
What services are you interested in? *

Chiropractic Adjustments Massage Therapy Acupuncture/Dry Needling Functional Nutrition Laser Therapy Decompression
Is your pain a result of any of the following? *

motor vehicle accident fall/trauma worker's compensation none of the above
If your injury is a result of a motor vehicle accident, please click HERE to continue. Do not proceed entering information on this form. If the link above does not work, please alert the Front Desk.

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)? *

right left shoulder / arm / hands / fingers buttocks / leg ankle / foot not applicable
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 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 you have seen for 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
I hereby authorize the aforementioned office and any of its appointed assistants to disclose the following information from the patient's healthcare record.
This information is to be disclosed to:

Agency/Business Name: Gard Wellness Center
Phone #: 919-322-4383
Fax #: 919-585-5568
Provider's Name:
Provider's Phone Number

Area Code Phone Number
Provider's Fax Number

Area Code Phone Number
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
How often to you consume alcoholic drinks?

rarely / never 1-3 drinks per week 3-5 drinks per week over 6 drinks per week
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
Fees Update:

Our comprehensive examination includes use of non-invasive scans including surface electromyography (sEMG) to measure muscle efficiency and tension, heart rate variability (HRV) to measure your stress state/adaptability to stress, and thermography to measure your autonomic nervous system function (the things you can't feel). These tests are FDA approved, but not covered by insurance and will incur a $59 charge.

The doctor may decide it is medically necessary to include digital xray imaging of one or more areas of your spine or extremity, regardless of previous imaging. Women who think they may be pregnant will not receive xrays. Please let your doctor know if there is a chance you may be pregnant. Xrays are generally covered by your insurance subject to copay/coinsurance/deductible.
Informed Consent:

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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New Chiropractic Patient Intake

Health insurance policy information

Current condition information

Health history