Online Intake Form

1Patient Info

2Insurance Info

3Accident Info

4Patient Condition

5Health History

6Consent

Patient Information

Patient Birthdate*

MM slash DD slash YYYY

ie: 12/12/2012

Patient Name*

First Middle Last

Patient Email*

Enter Email Confirm Email

Patient Address

Street Address Address Line 2 City State ZIP Code

Patient Phone Numbers

Phone Number*

Type

Best Time To Reach You*

Emergency Contact

Name*

First Last

Relationship to Patient*

Phone*

Work Phone

Patient Sex*

Relationship Status*

Occupation or School Information

Occupation

Patient Employer/School

Employer or School Phone

Spouse or Guardian Information

Spouse or Guardian Name

First Last

Spouse or Guardian Birthdate

MM slash DD slash YYYY

ie: 12/12/2012

Spouse or Guardian Employer

Insurance Information

Is patient covered by insurance*

Yes

Please bring your insurance card to your first appointment.

If you have questions about your insurance coverage, please call the office at 814-238-0250.

Accident Information

Is condition due to an accident?

Yes

Date of Accident

MM slash DD slash YYYY

ie: 12/12/2012

Type of Accident*

Auto Accident

Home Accident

Work Related Accident

Other

To whom have you made a report of your accident?*

Auto Insurance

Employer

Workers Compensation

Other

Attorney Name (if applicable)

First Last

Patient Condition

Reason for Visit

When did your symptoms appear?

Is this condition getting progressively worse?

Yes

Unknown

Rate the severity of your pain on a scale from 1-10

Please enter a number less than or equal to 10.

1 = Least Pain & 10 = Severe Pain

Choose all option below where you are experiencing pain, numbness, or tingling.

Head - Left

Head - Right

Neck - Left

Neck - Right

Shoulder - Left

Shoulder - Right

Arm - Left

Arm - Right

Hand - Left

Hand - Right

Wrist - Left

Wrist - Right

Chest - Left

Chest - Right

Upper Back - Left

Upper Back - Right

Mid-Back - Left

Mid-Back - Right

Shoulder Blade - Left

Shoulder Blade - Right

Lower Back - Left

Lower Back - Right

Abdomen - Left

Abdomen - Right

Hip - Left

Hip - Right

Leg - Right

Leg - Left

Knee - Left

Knee - Right

Ankle - Left

Ankle - Right

Foot - Left

Foot - Right

Toes - Left

Toes - Right

Other

Please describe where the pain or discomfort is located.

Type of Pain

Choose all that apply

Sharp

Burning

Dull

Tingling

Throbbing

Cramps

Numbness

Stiffness

Aching

Swelling

Shooting

Other

How often do you have this pain?

When you have the pain, is it consistent or does it come and go?

Does it interfere with any of the following?

Work

Sleep

Daily Routine

Recreation

Activities or movements that cause pain

Sitting

Standing

Walking

Bending

Lying Down

Health History

What treatment have you already received for your condition?*

None

Medications

Surgery

Physical Therapy

Chiropractic

Other

Other, please explain.

Can you provide the names of the doctor(s) who have treated you?

Yes, I can supply that information

Please only list the names and phone numbers of the doctors who have seen you for the condition you are here to be treated for.

If you need more room, please write nothing or write "Not enough space". We can always get this information later.

Please provide the latest dates of services you've had below:

Leave blank if unknown.

Physical Exam

MM slash DD slash YYYY

ie: 12/12/2012

Spinal X-Ray

MM slash DD slash YYYY

ie: 12/12/2012

Blood Test

MM slash DD slash YYYY

ie: 12/12/2012

Spinal Exam

MM slash DD slash YYYY

ie: 12/12/2012

Chest X-Ray

MM slash DD slash YYYY

ie: 12/12/2012

Urine Test

MM slash DD slash YYYY

ie: 12/12/2012

Dental X-Ray

MM slash DD slash YYYY

ie: 12/12/2012

MRI, CT-Scan, Bone Scan

MM slash DD slash YYYY

ie: 12/12/2012

Please choose "Yes" or "No" to indicate if you have had any of the following below:

Each option requires an answer.

AIDS/HIV*

Yes

Diabetes*

Yes

Liver Disease*

Yes

Rheumatic Fever*

Yes

Alcoholism*

Yes

Emphysema*

Yes

Measles*

Yes

Rheumatoid Arthritis*

Yes

Allergy Shots*

Yes

Epilepsy*

Yes

Migraine Headaches*

Yes

Scarlet Fever*

Yes

Anemia*

Yes

Fractures*

Yes

Miscarriage*

Yes

STD's*

Yes

Anorexia*

Yes

Glaucoma*

Yes

Monounucleosis*

Yes

Suicide Attempt*

Yes

Appendicitis*

Yes

Goiter*

Yes

Multiple Sclerosis*

Yes

Stroke*

Yes

Arthritis*

Yes

Gonorrhea*

Yes

Mumps*

Yes

Thyroid Problems*

Yes

Asthma*

Yes

Gout*

Yes

Osteoporosis*

Yes

Tonsillitis*

Yes

Bleeding Disorders*

Yes

Heart Disease*

Yes

Pacemaker*

Yes

Tuberculosis*

Yes

Breast Lump*

Yes

Hepatitis*

Yes

Parkinson's Disease*

Yes

Typhoid Fever*

Yes

Bronchitis*

Yes

Hernia*

Yes

Pinched Nerve*

Yes

Tumors, Growths*

Yes

Bulimia*

Yes

Herniated Disk*

Yes

Pneumonia*

Yes

Vaginal Infections*

Yes

Cancer*

Yes

Herpes*

Yes

Polio*

Yes

Ulcers*

Yes

Cataracts*

Yes

High Blood Pressure*

Yes

Prostate Problems*

Yes

Whooping Cough*

Yes

Chemical Dependency*

Yes

High Cholesterol*

Yes

Prosthesis*

Yes

Other*

Yes

Chicken Pox*

Yes

Kidney Disease*

Yes

Psychiatric Care*

Yes

If other, please describe.*

Activities

Exercise

None

Moderate

Daily

Heavy

Work Activity

Sitting

Standing

Light Labor

Heavy Labor

Habits

Smoking

Alcohol

Coffee/Caffeine Drinks

High Stress Level

None of these

How Many Packs of Cigarettes Do You Smoke Per Day?*

How many alcoholic drinks do you have per week?*

How many cups of caffeine do you drink per day?*

What is the reason for your stress?*

Are you pregnant?*

Yes

Due Date*

MM slash DD slash YYYY

ie: 12/12/2012

Please list any injuries and/or surgeries you have had.

Please list any medications you currently take.

Please list any allergies you have.

Please list any vitamins/herbs/mineral supplements you currently take.

Consent

I agree with the Notice of Privacy Policy.

Acknowledgement of Receipt of Notice of Privacy Policy
(To be filed in patient's medical records)

I have been presented with the notice that the Privacy Practices are available, detailing how my health information may be used and disclosed, under federal and state law, and outlining my rights regarding health information (including Appointment Reminders and Health Care Information Authorization).

I understand that I may request a copy of the Privacy Practices if I so desire.

Compliance Officer: Dr John L. Scipione

Assignment & Release Consent*

I agree to the assignment and release policy.

I certify that I, and/or my dependent(s), have insurance coverage with the company(ies) listed above and assign directly to my chosen doctor all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The below chosen doctor may use my health care information to the above names insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date of this submission.

Please type the name of the Patient, Parent, Guardian, or Personal Representative Signing This Form*

First Last

Signators Relationship to Patient*

Signature*

Use your finger or mouse to sign here.

Chiropractic Registration and Health History

Patient Information

Patient Phone Numbers

Emergency Contact

Occupation or School Information

Spouse or Guardian Information

Insurance Information

Please bring your insurance card to your first appointment.

If you have questions about your insurance coverage, please call the office at 814-238-0250.

Accident Information

Patient Condition

Type of Pain

Health History

Please provide the latest dates of services you've had below:

Please choose "Yes" or "No" to indicate if you have had any of the following below:

Activities

Consent