Patient Intake Form

Welcome to our office!


Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 




About this Patient 

Male
Female
Other
Married
Single

About the Spouse 

Employer Information

Reason for this Visit

Job
Sports
Auto
Fall
Chronic Discomfort
Home Injury
Other
Yes
No
Gotten worse
Stayed Constant
Comes and goes
Carrying Groceries
Changing Positions
Sit to Stand
Climbing Stairs
Pet Care
Driving
Extended Computer Use
Household Chores
Lifting Children
Reading/Concentrating
Self Care
Sexual Activities
Sleep
Sitting Still
Standing Still
Yard Work
Walking
Yes
No
No
Yes

Place an X on the image below, where you feel pain, numbness or tingling:

Experience with Chiropractic 

Yes
No
Yes
No
Yes
No

Awareness of Chiropractic Principles 


Were you aware that...

Yes
No
Yes
No
Yes
No
Yes
No

Goals for my Care 


People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

Nerve Pills
Pain Killers (including Aspirins)
Muscle Relaxers
Blood Pressure Medicine
Insulin
Stimulants
Blood Thinners
Tranquilizers

Health Habits

Daily
Moderately
No
Heel lifts
Sole Lifts
Inner Soles
Arch Supports

Health Conditions 


Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.


Severe or Frequent Headaches
Sinus Problems
Dizziness
Cancer
Loss of Sleep
Hepatitis
Pain Between the Shoulders
Frequent Neck Pain
Numbness or Pain in Arms/Legs/Hands
Lower Back Problems
Digestive Problems
Ulcers/Colitis
Heart Attack/Stroke
Thyroid Problems
Kidney Problems
Congenital Heart Detect
Heart Surgery/Pacemaker
High/Low Blood Pressure
Psychiatric Problems
Difficulty Breathing
Rheumatic Fever
Asthma
Arthritis
Alcohol/Drug Abuse
Venereal Disease
HIV/AIDS
Diabetes
Tuberculosis
Shingles
Chemotherapy
Anemia

FOR WOMEN ONLY:

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Authorization for Care


I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Patient
Spouse
Parent
Workers Comp
Medicare
Personal Health Insurance
Auto Insurance

Ownership of X-ray Films


It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office.

Emergency Contact

My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


ABOUT THE INSURED PERSON

Nutrition and self-care are just two of the components in obtaining optimal wellness. 


Please let us know what you are currently doing for your health.

Drink plenty of water
Exercise regularly
Get plenty of rest
Acupuncture
Pray/Meditate
Yoga/Pilates/Aerobics
Alcohol in moderation
Homeopathic remedies
Maintain positive attitude
Self-improvement books
Eat organically grown foods
Vitamins, minerals or herbs
Maintain the proper weight
Receive regular massages
Counseling/Therapy
Orthotics/Heel Lefts
Use a cervical pillow
Attend religious services
Annual physical examinations
Eat fast food
Work long hours
Feel overwhelmed/Exhausted/Fatigued
Experience gas/Bloating/Indigestion
Experience food sensitivities/Allergies
Periods of constipation/Loose stools/Irregularities
History of pinched nerve/Slipped or herniated disc/Joint degeneration
Popping/Crackling/Stiffness in your joints
Family diagnosed with Osteoporosis/Thin brittle bones
Muscle cramps (sports or menstrual)
Anxiety/Nervousness
Weak or thin/Hair/Nails/Skin
Tooth decay
Family history of heart disease
Low energy/Loss of vitality
Family history of colds/Flus/Infections/Poor immune system
Poor gum health/Gingivitis
Cravings for sugary foods
Struggle with weight loss
Lack of protein in diet
High cholesterol
Struggle with eating healthy throughout the day
Currently taking vitamin supplements

Initial Consultation Form 


Constant - 100% of the time
Frequent - 75%
Intermittent - 50%
Occasional - 25%
Minimal (An annoyance but has no effect on activity)
Slight (Tolerable with some impairment to activity)
Moderate (Tolerable with marked impairment of activity)
Severe (Intolerable and cannot perform any activities)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

Missed Appointments 


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.
  • In the instance of a no show without notice by phone we reserve the right to charge you a $100.00 fee.


Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Cash
Check
Credit Card

Insurance:


We will verify all insurances and your benefits per your agreement with your carrier prior to your initial visit.  We will have that information ready for you when you come in or you may call us ahead of time. After your initial visit with the Doctor she will give her recommendations and an appropriate plan will be designed for you. 

Agreement:


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

Thank you for taking the time to fill out this form.

Contact Us

Questions, Comments, Concerns - all are welcome.

Our Location

950 Yale Ave, Suite 29. Wallingford, CT 06492

Office Hours

Open Monday through Thursday

Monday:

9:00 am-11:00 AM

3:00 pm-6:00 pm

Tuesday:

3:00 pm-6:00 pm

Wednesday:

9:00 am-11:00 AM

3:00 pm-6:00 pm

Thursday:

8:15 am-10:45 am

Friday:

By Appointment Only

Saturday:

By Appointment Only

Sunday:

Closed