ChiroPro and Shiloh Chiropractic New Patient Intake & History Form
Thank you for filling out our New Patient History and Intake Form.
Which office will you be visiting?
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Columbia IL 618-719-2350 www.ChiroPro.com
Glen Carbon IL 618-692-9100 www.ChiroPro.com
Highland IL 618-651-6310 www.ChiroPro.com
Lake St. Louis MO 636-614-2139 www.ChiroPro.com
Shiloh IL 618-234-8300 www.ShilohChiro.com
Have you already set up an appointment with us?
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Yes
No
Are you filling this form out for yourself or for someone else?
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For myself (I am 18 or older)
Someone else
Information regarding the person filling out this form for the patient (below)
My Name: My Phone: My Email: My Relationship to Patient: Other:
For the rest of this form,
enter
information about the PATIENT.
Patient's First Name
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Enter this and the rest of the form about THE PATIENT
Middle Initial
Last Name
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Called Name (Nickname)
Mobile Phone
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E-Mail
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Home Phone
Work Phone
Date of Birth
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Age
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Biologic Sex
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Male
Female
Date of Last Menstrual Period (females)
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Type [NA] if not applicable
Social Security Number
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This is safeguarded. This form is HIPAA-compliant.
Upload a Photo (optional)
Emergency Contact Information
Recommended but optional. Name, relationship, phone number, etc.
Marital Status
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Single
Married
Divorced
Widowed
Spouse's Name
If Applicable
Your Street Address (Include Apt # if necessary)
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City & State
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Zip
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Employment Status
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Employed
Unemployed
Employer / Company Name
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Employer / Company - City and State
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Employer / Company Phone Number
Your Position
Physical Nature of your Job
How did you hear about us?
Google
Yahoo
Facebook
Other Internet Source
My Health Care Provider
Screening, Work Even, Health Fair
A Patient or Employee
Sign (Drive By)
Website
Attorney
What is the name of the person who referred you?
If applicable (including your doctor's name if he/she referred you)
Physician's Name
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(Type ''None'' if none.)
Your primary doctor's Phone Number
If you don't know your doctor's number, just leave this blank!
Your primary doctor's Physician's Address
If you don't know your doctor's address, just put the city or leave blank!
It is customary for our office to update your doctor. Do we have your permission in doing so?
Yes
No
Have you seen a chiropractor before?
Yes
No
Who was your last chiropractor?
If applicable
When was your last adjustment and what were you treated for?
If applicable
List all medical conditions you have
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I have no medical condition(s)
Broken Bones
Circulation Issue
Bleeding Issue
High Blood Pressure
Low Blood Pressure
Strokes
Osteoarthritis
Rheumatoid Arthritis
Seizures / Convulsions
Epilepsy
Pace Maker
Rupture
Hernia
Cancer
Coughing Blood
Ulcers
Eating Disorder
Alcoholism
Drug Addiction
Depression
Suicidal Thoughts
Gall Bladder Issues
HIV / AIDS
Medical History Explained
Explain all conditions listed above.
List all Surgeries and Procedures with Dates
List all major illnesses, injuries and accidents
List All Hospitalizations (Cause, Dates)
List Pregnancy Data
List any visit to your physician in the past year
List any Medication and/or Supplements
Do you drink? If so, how much?
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IE: 1 beer per week or 0-10 drinks per mo.
Do you smoke, chew or vape (nicotine or tobacco)? If so, quantity and method:
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IE: 1/2 pack cigarettes per day.
Do you consume caffeine? If so, how much?
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IE: 2 cu. coffee and 1 cu. tea per day.
Please list your children including name, age and any condition(s).
Do your family suffer from any of the following?
Neck Pain
Back Pain
Headaches
Migraines
Pinched Nerve
Disc Issues
Arthritis
Neuritis
Scoliosis
Explain who suffers from the condition(s) above.
Maternal History. Please indicate if your mother is alive. If not, cause of death. List ALL conditions on her side of family and who suffered. If you cannot provide this, just put "N/A"
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NOTE: The purpose of this is to determine your potential risk for genetic disease/condition. If you were adopted and cannot fill this out, please just type ''Adopted. Do not know mother.''
Paternal History. Please indicate if your father is alive. If not, cause of death. List ALL conditions on his side of family and who suffered. If you cannot provide this, just put "N/A"
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NOTE: The purpose of this is to determine your potential risk for genetic disease/condition. If you were adopted and cannot fill this out, please just type ''Adopted. Do not know father.''
Were you injured because of an accident or workplace injury?
Car Accident (less than 2 years ago)
Car Accident (more than 2 years ago)
Workplace Accident
None of the above
What is troubling you and where?
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How long has it been bothering you?
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Has this ever happened before? Explain.
Did you have an injury or illness that may have caused this?
What makes it feel better?
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What makes it feel worse?
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How would you describe the pain?
Dull
Achy
Sharp
Stabbing
Burning
Electric
Pins/Needles
Tingling
Numbness
Does the pain radiate/shoot? If so, explain:
What is the intensity NOW? (0-10)
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Unsure
0 (no pain)
1
2 (mild pain)
3
4 (moderate pain)
5
6 (moderately-severe pain)
7
8 (cannot work)
9 (causes me to cry)
10 (seeking E.R. / 911)
What is the intensity On AVERAGE? (0-10)
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Unsure
0 (no pain)
1
2 (mild pain)
3
4 (moderate pain)
5
6 (moderately-severe pain)
7
8 (cannot work)
9 (causes me to cry)
10 (seeking E.R. / 911)
What is the intensity At WORST? (0-10)
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Unsure
0 (no pain)
1
2 (mild pain)
3
4 (moderate pain)
5
6 (moderately-severe pain)
7
8 (cannot work)
9 (causes me to cry)
10 (seeking E.R. / 911)
What is affected?
Sleeping
Focus
Eating
Hygiene
Urination
Defecation
Sitting
Standing
Walking
Working
Social Life
Parenting
Houskeeping
What is the timing pattern for this complaint?
Constant (unceasing)
Intermittent (comes and goes)
If intermittent, how frequently does the pain come and go?
Is there any pattern to the pain?
IE: Worse in the morning. Worse in the winter.
List anything else we may need to know here.
How do you want us to bill your visits?
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Major Medical / Commercial Insurance {Not for accidents}
Auto Accident (often no cost to you)
Worker's Comp
Medicare
Self Pay
Unsure
NOTE: If this is due to an accident, select ''UNSURE.''
Insurance Information (From Card)
Company: Provider Relations Ph#: Member Name: Member DOB: Member ID: Group#: Relationship to Member: If you have a secondary insurance, type the same information below:
Also see back of card. Fill out what you can!
I agree and understand completely. (do not submit this form if you do not agree.)
I agree and understand completely. (do not submit this form if you do not agree.)
Submission Agreement: The information I have entered is authentic and true to the best of my knowledge. I authorize payment of insurance benefits directly to Shiloh Chiropractic or ChiroPro. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers, services and payers and to secure the payment of benefits. I understand that I am ultimately responsible for all costs of care incurred at Shiloh Chiropractic as determined by my treating doctor; any fees for professional services will be immediately due and payable. I agree to pay a $50 "no call no show fee" if I do not keep my appointment or cancel within 24 hours of the appointment time. I understand and agree to allow Shiloh Chiropractic and ChiroPro to use information in this form for the purpose of the diagnosis, treatment, payment, healthcare operations and coordination of care. I am aware that this patient health information is going to be used in Shiloh Chiropractic and ChiroPro and my rights concerning the privacy of said information is safeguarded. I understand that Shiloh Chiropractic and ChiroPro has a published HIPAA policy at its office and that I can request to view that in its entirety at any time. By submitting this form, you acknowledge and understand that the data is being submitted electronically. You can abstain from sending any filed by simply typing "abstain" in that field. If you are not comfortable submitting your data electronically, you may opt to fill out an alternative paper form in the office or you can download it on our website ChiroPro.com or ShilohChiro.com. If you opt to fill it out in office, simply make arrangements to get to the office 20-30 minutes prior to your scheduled appointment. If you have questions, please call our office.
I have read the "submission agreement," understand it, and I agree.
Full Name of person filling out this form.
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