Intake - PHI Manager

1) Patient Info

2) Medical History

3) Consent & Sign

Patient Information

First Name *

Last Name *

M.I.

DOB

Address *

Address Line 2

City *

State *

Zip *

Primary Phone *

Secondary Phone

Sex

Email *

Race

Ethnicity

Preferred Language

Relationship Status

How did you hear about our office?

Employment Status

Occupation

Employer/School

Employer Phone

Employer Address (Street)

Employer City

Employer Zip

Emergency Contact

Emergency Contact Name

Relationship

Phone

Insurance Information

Primary Insurance

Policy #

Group #

Subscriber Name

Subscriber Relationship

Subscriber DOB

Secondary Insurance

Policy # (Secondary)

Group # (Secondary)

Subscriber Name (Secondary)

Subscriber Relationship (Secondary)

Subscriber DOB (Secondary)

Accident Information

Are you here today because of an accident?

Date of Accident

Type of Accident

To whom did you report your accident?

Medical History

Injuries/Surgeries (Falls, Head Injuries, Broken Bones, Dislocations, Surgeries)

Medications

Allergies

Pain Diagram (tap up to 10 spots). Use Clear to redo.

Informed Consent

Please read this entire document before signing. It is important that you understand the information contained in this document. Please ask questions before you sign if anything is unclear.

The nature of the chiropractic adjustment

The primary treatment used by a Doctor of Chiropractic is spinal manipulative therapy; I may use my hands or a mechanical instrument to move joints in a way that seeks to restore proper motion. You may hear or feel a "pop" or "click" and may feel temporary soreness similar to when you "crack" your knuckles.

Analysis / Examination / Treatment

Palpation/range of motion and orthopedic/neurological/postural testing
Spinal manipulative therapy
Physiotherapy / massage therapy / decompression therapy

The material risks inherent in chiropractic adjustment

As with any healthcare procedure, complications are possible though uncommon. These include but are not limited to: fractures, disc injury, dislocations, muscle strain, cervical myelopathy, costovertebral sprains, and burns. Some patients may feel soreness or stiffness following the first few days of treatment. It is important to inform the doctor about conditions such as osteoporosis, severe arthritis, or other health issues.

The availability and nature of other treatment options

Self-administered care: rest, ice/heat, exercise
Medical care and prescription drugs (anti-inflammatory, muscle relaxants, pain relievers)
Hospitalization / surgery

The risks and dangers of remaining untreated

Remaining untreated may allow adhesions to form and reduce mobility, which may set up a pain reaction that further reduces mobility. Over time this may complicate treatment, making it more difficult and less effective.

Notice of Privacy Practices

I understand the “Notice of Privacy Practices for Protected Health Information,” describing how my medical information may be used and disclosed, and how I can get access to this information. (A copy can be provided to me at any time.)

Minor Consent

I hereby authorize PHI Manager, together with whomever they may designate, to treat the minor child/children whose name(s) appear above. When necessary, chiropractic care (including X-rays and appropriate evaluations) may be administered if, in the treating judgment, care is necessary. I acknowledge that I have legal authority to provide such written consent.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTOOD THE ABOVE

Signature (use finger)

Printed Name *

Date *

Witness (optional)

Email me a copy of my intake (may include sensitive info).