OAK BROOK - New Patient Registration Form

1
Full Legal Name* This field is required.
First Name
Middle Name
Last Name
2
Date of Birth* This field is required.
Year
Month
Day
3
Age* This field is required.
4
Address:* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Cell Phone Number:* This field is required.(or best number to contact you)
Area Code
Phone Number
6
E-Mail Address* This field is required.
7
Gender * This field is required.
Male
Female
N/A
8
Marital Status* This field is required.
Single
Married
Partnered
Divorced
Legally separated
Widowed
9
Number of Children (type 0 if not applicable)* This field is required.
10
Employer
11
Occupation
12
Who may we thank for referring you to our clinic?* This field is required.
13
Which Clinic Location is Most Convenient for You?* This field is required.
Oak Brook: 1100 Jorie BLVD Ste 318
Lombard: 1127 S Main St
14
What is your objective with coming to our clinic?* This field is required.
Family Wellness Care
Corrective Spinal Care
Symptom Relief
15
Please select the level that corresponds with your commitment to your overall health and wellness?* This field is required.
0%
25%
50%
75%
100%
16
Do you have an active insurance policy?* This field is required.
NO INSURANCE (SELF PAY)
BCBS HMO
BCBS PPO
CIGNA PPO
CIGNA HMO
AETNA PPO
AETNA HMO
UHC PPO
UHC HMO
MEDICARE
MEDICARE & SECONDARY
MEDICARE ADVANTAGE
MEDICAID
OTHER
17
If you have an active policy, what is the member ID? (skip if you provided your card to the front desk or if you have no insurance)
18
Is this related to a workers' compensation case?* This field is required.
Yes
No
19
Is this related to an auto accident?* This field is required.
Yes
No
20
Please select condition(s) you currently have or have had in the past* This field is required.Please select all that apply.
21
Please list the past 4 traumas you have experienced (any and all of the following; auto accidents, falls, concussions, broken bones, childhood injuries, surgeries, etc.) and approximate date: * This field is required.If none, please type N/A
Huge
Large
Normal
Small
Ok
Ok
22
Taking any medications, currently?* This field is required.
Yes
No
23
If yes, please list any medications that you are currently taking and why (if applicable):Please list all medications (DRUG NAME, DOSE, FREQUENCY, ROUTE) that you are currently prescribed, if more than one, separate them with a comma.
24
Primary Complaint:* This field is required.What brings you into our clinic?
Huge
Large
Normal
Small
Ok
Ok
25
Use the RED MARKER ICON to draw on the image below.To erase, use the BACK ARROW ICON if needed.
26
What solutions have you attempted to solve this problem?* This field is required.Type N/A if not applicable
27
When did this condition(s) begin?* This field is required.Type N/A if not applicable
28
Has it ever occurred before?* This field is required.
Yes
No
29
Type of Pain * This field is required.Please select all that apply
30
Quality of Pain * This field is required.Please select all that apply
31
Is there anything that makes it better? Please describe.* This field is required.
32
Is there anything that makes it worse? Please describe. * This field is required.
33
Severity on a scale from 0 (no pain) to 10 (disabling pain):* This field is required.
0
1
2
3
4
5
6
7
8
9
10
34
Does the pain travel or radiate? If so, where?* This field is required.Type N/A if not applicable
35
Timing of the pain:* This field is required.
Not Applicable
Constant
Frequent
Intermittent
Occasional
Infrequent
36
At what time of day is the pain the worst?* This field is required.
Not Applicable
Morning
Midday
Night
Consistent All Day
37
Please select any area of your life that is affected by your condition:* This field is required.Please select ALL that apply
38
Have you been to a Chiropractor before? * This field is required.
Yes
No
39
If so, what is the Name and/or Location of the Chiropractor?Skip if not applicable
40
When was your last Chiropractic visit?Skip if not applicable
41
Pain Intensity * This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain
1- Mild Pain
2- Moderate Pain
3- Severe Pain
4- Worst Possible Pain
42
Sleeping* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- Perfect Sleep
1- Mildly Disturbed Sleep
2- Moderately Disturbed Sleep
3- Greatly Disturbed Sleep
4- Totally Disturbed Sleep
43
Personal Care (washing, dressing, etc)* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain; no restrictions
1- Mild Pain; no restrictions
2- Moderate Pain; need to go slowly
3- Moderate Pain; need some assistance
4- Severe Pain; need 100% assistance
44
Travel (driving, etc.)* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain on long trips
1- Mild Pain on long trips
2- Moderate Pain on long trips
3- Moderate Pain on short trips
4- Severe Pain on short trips
45
Work* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain
1- Mild Pain
2- Moderate Pain
3- Severe Pain
4- Worst Possible Pain
46
Recreation* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- Can do all activities
1- Can do most activities
2- Can do some activities
3- Can do a few activities
4- Cannot do any activities
47
Frequency of Pain* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain
1- Occasional pain; 25% of the day
2- Intermittent pain; 50% of the day
3- Frequent pain; 75% of the day
4- Constant pain; 100% of the day
48
Lifting* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain with heavy weight
1- Increased pain with heavy weight
2- Increased pain with moderate weight
3- Increased pain with light weight
4- Increased pain with any weight
49
Walking* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain; any distance
1- Increased pain after 1 mile
2- Increased pain after 1/2 mile
3- Increased pain after 1/4 mile
4- Increased pain with all walking
50
Standing* This field is required.Please select a rating from 0-4 as it pertains to your neck and/or back right now (today).
0- No Pain after several hours
1- Increased pain after several hours
2- Increased pain after 1 hour
3- Increased pain after 1/2 hour
4- Increased pain with any standing
51
Informed Consent for Chiropractic Care* This field is required.Patient Acknowledgment
52
Consent to Evaluate and Adjust a Minor (please skip if not applicable) I am the parent or legal guardian of this patient and have read and fully understand the the above informed consent and hereby grant permission for my child to receive chiropractic care.
ClearParent or Guardian Signature
53
Pregnancy Release (applicable to all women) This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.Please skip if not applicable
ClearPatient Signature
54
Pregnancy Release ContinuedDate of Last Menstrual Cycle (skip if not applicable)
Date
Year
Month
Day
55
HIPAA Practice Requirements* This field is required.Patient Acknowledgment
56
I hereby certify the statements & answers given on this form are accurate to the best of my knowledge. I agree to allow this office to perform an evaluation.* This field is required.
ClearPatient Signature
57
Today's Date* This field is required.
Date
Year
Month
Day
58
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