New Patient Intake and History Form (NPIH)

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? *
Have you already set up an appointment with us? *

Yes No
Are you filling this form out for yourself or for someone else? *

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 *
Enter this and the rest of the form about THE PATIENT
Middle Initial
Last Name *
Called Name (Nickname)
Mobile Phone *
E-Mail *
Home Phone
Work Phone
Date of Birth *
Age *
Biologic Sex *

Male Female
Date of Last Menstrual Period (females) *
Type [NA] if not applicable
Social Security Number *
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 *

Single Married Divorced Widowed
Spouse's Name
If Applicable
Your Street Address (Include Apt # if necessary) *
City, State and Zip *
Employment Status *

Employed Unemployed Student Other
Employer or School Name
If applicable
Occupation (Or Area of Study)
If applicable (or "student")
How did you hear about us?
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 *
(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

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? *
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: *
IE: 1/2 pack cigarettes per day.
Do you consume caffeine? If so, how much? *
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" *
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" *
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? *
How long has it been bothering you? *
Has this ever happened before? Explain.
Did you have an injury or illness that may have caused this?
What makes it feel better? *
What makes it feel worse? *
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) *
What is the intensity On AVERAGE? (0-10) *
What is the intensity At WORST? (0-10) *
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? *
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. *
Should be Empty:

ChiroPro and Shiloh Chiropractic New Patient Intake & History Form