williams_MSK

CHIROPRACTIC, PHYSIOTHERAPY, MASSAGE NEW PATIENT INTAKE FORM
Name

First NameLast Name
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal Code
Age
Birth Date

DayMonthYear
Date
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Email
example@example.com
YesNo
Emergency Contact
Relationship
Phone #
Format: (000) 000-0000.
How did you hear about us?

In the past have you received:

Rows	Yes	No
Chiropractic
Physiotherapy
Acupuncture
Massage Therapy

Medical Doctor's name
YesNo
YesNo
Claim #
YesNo
Claim #
Adjuster's Name & Phone
YesNo
DOB of Insured

DayMonthYear
Date
YesNo
Provider
Name on Account Primary
Policy #
Member ID #
CONSENT FOR COLLECTION, USE & DISCLOSURE OF PERSONAL INFORMATION
All personal information collected will remain safe and secured and will not be shared with anyone without patient permission. The information may be collected via phone, personal interview, direct examination, transfer of medical information from other healthcare professionals, and third parties including insurance companies. Personal information will only be seen by Williams Chiropractic & Williams Physiotherapy and its staff. By signing this form, | consent to the collection, use, and disclosure of my personal information.
Patient Name Print
Patient Signature

Clear
Date

MonthDayYear
Date
Describe your main concerns
When & How did this pain start?
Who else have you seen for this concern?
ConstantIntermittent
Has your pain traveled elsewhere?
What aggravates your condition the most?
What tends to relieve your pain?
Do you have any additional complaints?
WorkFamilySportsEveryday Life
What is your main goal when seeking treatment?
AllergiesAnxietyAutoimmune diseaseBlood in stool or urineChest painConcussionDepressionDifficulty breathingDigestion issuesEating disorderFracturesHeadachesHepatitis A/B/CInsomniaKidney issuesLoss of strength
Low bone densityMenstrual issuesNauseaNumbness or tinglingProblems speakingProblems swallowingProstate troublePsychological disorderRashes/itchingRinging in the earsSmokingSpitting blood/phlegmSurgeryVertigo
CancerHeart Condition / Disease / Attack / AnginaStrokeHypertensionDiabetesBleeding or Clotting DisorderOther
Bowel or Bladder incontinenceDizzinessDouble visionWeight lossWeight gainNight sweatsFever
YesNo
which body area?
YesNo
Medicare #
YesNo
# weeks gestation
Current Medications/Supplements:
1
2
3
4
5
6
Use this diagram to indicate using the corresponding letter, where you have discomfort
012345678910
(ADLs = Activities of Daily Living)
1-3 = mild pain; minimal impact on ADL's
4-6 = moderate pain; moderate impact on ADL's
7-10 = severe pain; major impact on ADL's
Anything else you would like to bring to your practitioner's attention?
Thank you for trusting us with your care, see you soon!
Should be Empty:

CHIROPRACTIC, PHYSIOTHERAPY, MASSAGE NEW PATIENT INTAKE FORM

CONSENT FOR COLLECTION, USE & DISCLOSURE OF PERSONAL INFORMATION

Current Medications/Supplements:

Thank you for trusting us with your care, see you soon!