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Patient Intake (PDF)


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									                                                                       Patient Intake

                                                                              Today’s Date:______/______/_______

Name:____________________________________________ Age_______ Date Of Birth____________________
Local Address__________________________________ City___________________State____ Zip____________
Out of Town Address____________________________ City___________________State____ Zip____________
Marital Status_________ Sex_______ S.S.#__________________ Phone______________ Alt. Phone__________
Email Address:_____________________________________________
Employer_________________               Occupation ____________ Address ________________________________
Phone_____________ Spouse ________________________ Employer__________________________________
Emergency Contact_____________          Phone____________Relationship__________________________________
How did you hear about our office___________________________

Health Insurance Information ( please complete all )
Primary Ins._________________________ Policy Holder’s Name_______________________                DOB_________
Policy holder’s relation to patient__________Policy Holder’s Employer_______________ Other Ins. ___________

Accident Information ( please complete all )
Condition due to an AUTO INJURY? Date of Accident_________________ Place (city/state)_______________
Auto Ins. Co.______________________________ Insured’s Name & DOB _______________________________
Have you reported your accident to your ins. Co.?     Yes     No Claim #_________________________________
Please provide dates and details of ALL prior auto-related accidents
Condition due to Work Injury? Date of Accident_________________ Place (city/state)_____________________
Work Comp Ins. __________Claim#_________ Who have you reported your injury
Condition due to Other injuries? Date of Accident_________________ Place (city/state)___________________
Have you reported this injury?    Yes    No Contact Person____________________ Claim #_________________
Do you have an Attorney for your injury? Attorney name, address, phone #_______________________________

Current complaint
Please list the reason you are here to see the Doctor__________________________________________________
How long have you had these symptoms__________ are they           Improving   Worsening   About the same
How did the condition start___________________________________ Is it           Mild   Moderate   Severe
What makes it worse __________________________ What makes it better_______________________________
Is the pain more    Dull and Achy        Sore and Stiff   Sharp and Stabbing        Numb and Tingly or       Shooting
Is the pain generally worse    in the morning       after the day wears on         at night or   fairly steady

Current Health
Name, address and phone # of family doctor_______________________________________________________
Are you currently under any doctor’s care for an illness or injury? If so, please list his/her name and
address_______________________________________ Nature of illness or injury__________________________
If you are currently taking any prescription or nonprescription medications, list them below
Medication____________ Dose____________ Medication_______________ Dose_________
Medication____________ Dose____________ Medication_______________ Dose_________
Please list any medications you are allergic to_______________________________________________________
Please indicate your height and weight ___________________What is your usual blood pressure______/_______

Health History
List any operations, surgeries or medical procedures
Date______ Procedure__________________ Date_______ Procedure___________________
Date______ Procedure__________________ Date_______ Procedure___________________
If you have ever had in the past or currently have any serious illnesses or injuries, please list
Date______ Condition___________________ Date_______ Condition___________________
Date______ Condition___________________ Date_______ Condition___________________
Please list any significant family illnesses___________________________________________________________
Have you had spinal X-Rays within the past 5 years? If yes, when & where_________________________________

Do you have a pacemaker?           Yes      No If yes, please alert our chiropractic assistant

Please list any other electrical device that you currently wear___________________________________________
Do you smoke       Yes    No ___pack/day/wk Do you drink alcohol             Yes      No ____oz/day/wk
Have you ever had chiropractic care?        Yes    No If yes, last date of treatment____________________________
By Whom? Dr._________________________ Results________________________________________________
What are your overall expectations from your treatment with our

I, the undersigned, hereby give my consent for the Doctor to examine and treat my condition as he/she deems
appropriate through the use of Chiropractic care. I also give my consent to the Doctor to take X-Rays (if needed)
or to perform other diagnostic aids as he/she deems appropriate in my case. Wome n only I hereby declare that to the
best of my knowledge,      I am    I am not pregnant. If there is a chance that I may be pregnant, I will inform the
Doctor prior to my examination.

Patient Signature_______________________________________________
                         (Parent/Guardian signature if under 18 years of age)

Welcome to Advanced Spinal Care of Lakeland. It is our mission to provide you with quality Chiropractic care in a clean, friendly, and
professional setting. Because we know that your time is very important to you, we make all efforts to run on schedule. In the event that you
cannot make your scheduled appointment with the doctor or therapist we kindly ask that you provide us with a 24-hour notice. There is a
$25.00 charge for missing an appointment without a 24-hour notice. Our office pre-verifies your primary insurance coverage for your
Chiropractic care. Coverage information is obtained from your insurance company using information provided by you, the patient/insured, at
the time of the initial visit. We use this to determine your financial responsibility for services provided to you. The information provided by
your insurance company is not a guarantee of payment, only an estimate of what might be covered under your policy. Final determination of
benefits available is determined when the claim is sent to your insurance company and we receive an explanation of benefits from them. We
will send to them all required claim forms and documentation as required, to ensure your claims are processed in a timely manner. Although
we strive to be as accurate as possible, we will not be responsible for any errors, omissions or false information provided to us by your
insurance company. It is your responsibility, as the patient/insured, to be aware of and comply with all of the restrictions for services
provided in your policy. After all co-pays, contracted plan reductions and insurance payment credits are applied to your account, any
remaining portion will be the patient’s/insured’s responsibility. In the event that a particular service provided at this facility is found to not
be a covered service, then that particular service will be the patient’s/insured’s responsibility. Self-pay patients will be expected to pay for
services received at this facility at the time of service. We take cash, checks, credit and debit cards.

NOTE TO MEDICARE PATIENTS: Advanced Spinal Care of Lakeland is a participating Medicare facility which means that we accept
payment from Medicare. Medicare sets our fees and updates them every January. Please be aware that Medicare only covers the Spinal
Adjustment, but Medicare may deny coverage for Spinal Adjustments if they feel that the number or frequencies of adjustments are beyond
Medicare’s policy coverage or they are not reasonable or necessary for your condition. Medicare DOES NOT pay for the Items or Services
below, even though some of those that you or your health care provider has good reason to think you need; and if received, you will have to
pay. We expect Medicare to not pay for X-rays and Examination (est. cost $50-150), Physical Therapy or Massage Therapy (est. cost $10-40
per thirty minutes), pillows, braces, vitamins or creams (est. cost $10-75).By signing below you acknowledge, and agree to these conditions.


I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read and understand them or that I declined the
opportunity to read them. I understand that this form will be placed in my file and maintained for 7 years. I hereby acknowledge that I have
read and agree to the above policies.

________________________________________           ________________________________________________             ______________
Printed Name                                       Signature of Patient/Parent/Legal guardian                   Date


In the event that you ever wish to have a family member or friend come to our office and get a copy of your medical records for whatever
reason, we ask that you sign below allowing them to do so. By signing below I hereby give my consent for Advanced Spinal Care of Lakeland
to release my medical records to:

________________________________________           ________________________________________________             ______________
Printed Name                                       Signature of Patient/Parent/Legal guardian                   Date


I hereby authorize and give consent for the Chiropractic Physicians at Advanced Spinal Care of Lakeland to examine, and if needed, treat my
minor child _____________________________________________.
                      Print child’s name here

________________________________________           ________________________________________________             ______________
Printed Name                                       Signature of Patient/Parent/Legal guardian                   Date
                                                                             History of Auto Accident

Patient’s Name_______________________ Date of Birth ____________ Today’s Date___________________
Address_____________________________________________ Date of Accident_______________________
City______________________ State__________ Zip___________ Time of Accident____________________
Please describe how the accident happened_______________________________________________________
   I was the driver
   I was the passenger sitting in the
           middle front seat              right front seat          left rear seat          middle rear seat        right rear seat
   I was a pedestrian            standing        sitting         riding a bike        walking              other________________________
I was traveling in a vehicle: Year_______ Make_____________ Model _______________________________
Transmission type:          manual           automatic
The vehicle I was traveling in was               stopped          traveling at_________m.p.h.
Road conditions were:            dry       damp            wet
The road was made of:             concrete            asphalt       gravel         dirt         other______________________________
Did you car have a head rest:             yes         no
If your car had a head rest, what position was it in:                 up      middle            down
Were you: wearing your seat belt                yes        no Wearing your harness                yes        no
Head position: At the time of the accident my head was looking:
           straight ahead              to the right         to the left       up          down         other_________________________
Brakes: Were your brakes applied at the time of the impact                           yes         no
Elbows: My        left       right elbow was on the arm rest. Other_______________________________________
Hands:     both          right         left hand was on the steering wheel.
   can’t remember          other__________________________________________________________________
Were you aware of the impending collision before it happened:                             yes         no
Did you tighten your body and brace for the collision:                       yes      no
   Your hands, as a result of the impact:
               grabbed the steering wheel tightly                    were forced off the steering wheel/stick shift
As a result of the impact, your body was thrown:                     forward         backward              right   left
           turned to the right (clockwise)                  can’t remember

As a result of the impact, your head hit the:              front windshield        rearview mirror
   steering wheel       back of the seat ahead of me                 side driver/passenger – inside window/door
   another person’s body           nothing      other____________________________________________________
As a result of the impact your shoulders were:              Impacted with the inside of the door/car
   pressed firmly against the shoulder harness                other_____________________________________________
As a result of the collision, what other parts of your body struck the inside of the vehicle:
   ankles      elbows       face      chest          thighs          forearms      other_______________________________
Did your vehicle strike or impact with a second object after the first impact:                     yes     no
Did your vehicle strike another car:          car         truck        road/median         building
Were you wearing glasses at the time of the accident:                  none       yes        no
If yes, were your glasses still on following the accident:                       yes        no
Did you lose consciousness as a result of the accident:                 yes      no
If yes, how long were you unconscious:_________________________________________________________
Estimate cost to repair your car: $______________________________________________________________
After the accident the car was:           totaled         drivable         not drivable
At the time of the accident, how many people were in the car with you:
Names of other occupants:                                            4.______________________
1.________________________                                           5.______________________
2.________________________                                           6.______________________
3.________________________                                           7.______________________
Were the other occupants injured:            yes          no if yes, explain:____________________________________
Were the police called to the scene:           yes         no

Was a police report written:          yes      no

Was a ticket given to you:          yes      no

Was a ticket given to the other driver:             yes         no

As a result of the accident I felt my symptoms:
            immediately       within one hour              within 6 hours          during the night
            next morning       next day             other ___________________________________________________
As a result of the accident I felt:
            headaches       upper back pain           chest pain/soreness                 wrist/elbow pain/soreness
            neck pain       low back pain             stomach pain/soreness               knew/ankle pain/soreness
            shoulder pain      numb/tingling/burning arms                  numb/tingling/burning legs
            loss of bowel/bladder control             other__________________________________________________

Please list location of any cuts or bruises if applicable:_______________________________________________
Did you go to the hospital:       yes         no
        If yes:    immediately          next day         later in same day          other _____________________________
Did you go to the hospital by:      ambulance            private transportation
Name of hospital:___________________________________ City:___________________________________
Were you admitted to hospital:          yes        no
If yes, how long was your stay: ________________________________________________________________
Hospital diagnosis:__________________________________________________________________________
What recommendations were made:                 see your own doctor          see orthopedist/neurologist
           physical therapist      braces/collars          prescription        released
   other _________________________________________________________________________________
Please list all doctors you have seen since the accident
Name                                                    Address                     City      Released
1.___________________________________ _______________________ ____________ _______________
2.___________________________________ _______________________ ____________ _______________
3.___________________________________ _______________________ ____________ _______________
4.___________________________________ _______________________ ____________ _______________
Are you working now:       yes      no
Are you currently working with restrictions:             yes       no
Has the doctor placed you on:       total disability           partial disability
Please list work restrictions: __________________________________________________________________
Please list any special test ordered by the hospital or doctor _________________________________________
Since the accident do you feel:         worse       no improvement            better
Prior to this incident, have you been involved in any other past Motor Vehicle Accidents:                  yes   no
        If yes, approximately what date did the accident occur: ______________________________________
Did you experience trauma: _________________________________________________________________
        If so, what was your diagnosis: _________________________________________________________
Do you still experience symptoms from your prior accident:                 yes       no
        If yes, have the symptoms been exasperated by your most recent accident? :                 yes      no
Patient/Insured: __________________________________________ Date of loss: _________________________ Insurer: _________________Claim #: ____________________

Irrevocable Doctor’s Lien

To Attorney: ___________________________________________ My Patient/Your Client: _____________________________________________________________

I hereby authorize Advanced Spinal Care of Lakeland to furnish you, my attorney, with all of my medical records in regards to my accident in
which I was involved in. I also authorize and direct you, my attorney, to withhold monies from any settlement, judgments or verdict and to pay
directly to Advanced Spinal Care of Lakeland any balances owed for professional services rendered to me both by reason of this accident and by
reason of any other bills owed to Advanced Spinal Care of Lakeland I further herby give a lien on my case to Advanced Spinal Care of Lakeland
against any and all proceeds of any settlement, judgment, or verdict which may be paid to you, my attorney, or myself as the result of the injuries
for which I have been treated or injuries in connection therewith. I also understand that, regardless of the outcome of any settlement, judgment, or
verdict, I am directly and fully responsible to Advanced Spinal Care of Lakeland for any and all balances owed for professional services. This
agreement is made solely for Advanced Spinal Care of Lakeland’s additional protection and in consideration of awaiting payment for services

Patient’s Signature: ___________________________________________________ Date Signed: __________________________ Date of Injury: ________________________
The undersigned attorney of record for the patient noted above hereby agrees to observe all of the above terms and agrees to withhold such sums
from any settlement, judgments or verdict and pay directly to Advanced Spinal Care of Lakeland any and all balances for professional services
rendered in connection with such injuries.

Attorney’s Signature: _________________________________________________ Date Signed: __________________________

Authorization to Release Auto Insurance Information and/or Obtain PIP Benefit Payout Information

I hereby grant my authorization for Advanced Spinal Care of Lakeland to request and obtain my PIP insurance policy benefits for the accident
noted above. I also hereby authorize and direct my insurer to send to Advanced Spinal Care of Lakeland an accounting ledger showing all PIP
benefit payouts for the above noted accident.

Patient/Insured Signature: ___________________________________________ Date Signed: __________________________

Assignment of PIP Benefits

I hereby assign my PIP automobile insurance policy benefits relating to the above captioned accident to Advanced Spinal Care of Lakeland for
professional services rendered and covered under my PIP and/or Medical payments policy. All payments for such services shall be forwarded
directly to Advanced Spinal Care of Lakeland All payments will be overdue if not paid within the allowed 30-day period after the insurer is
furnished with properly completed claim form and medical records. Overdue payments will bear 10% interest per annum. In the event an insurer
fails to pay Advanced Spinal Care of Lakeland the full amount of the treatment allowed by current fee schedules, I authorize and direct the insurer
to set aside/escrow an amount equal to the full amount of any such reduction until Advanced Spinal Care of Lakeland has exercised its rights
under this assignment and the dispute is resolved. This assignment will remain in effect until 48-hours after Advanced Spinal Care of Lakeland
receives written notice that it is being revoked. It is specifically agreed that any such revocation of this assignment will not apply to any treatment
or associated expenses incurred on or before the date of notice of revocation is received by Advanced Spinal Care of Lakeland. The undersigned
agrees to pay any applicable deductible and/or co-payments not covered under the available PIP and/or Medical Payments policy. Furthermore,
the undersigned agrees to pay all outstanding balances in excess of the available insurance coverage limits.

Patient/Insured Signature: ___________________________________________ Date Signed: __________________________

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