Patient Intake Form

About this Patient

First Name *

Last Name *

Phone *

Date of birth *

Address *

City *

State *

Postal code *

Gender *

Male

Female

Other

How did you hear about us? *

Marital Status *

Married

Single

Spouse First Name

Spouse Last Name

Spouse Phone Number

Employer Information

Employer

Email *

Work Phone

Type of Work

Reason for this Visit

If job related, have you made a report of your accident to your employer?

Yes

No

When did this condition begin?

Has this condition:

Gotten worse

Stayed Constant

Comes and goes

Has this condition occurred before?

Yes

No

Does this condition interfere with

Work

Sleep

Daily Routine

Other Activities

Explain

Have you seen other doctors for this condition?

No

Yes

Doctor's Name (s)

Type of Treatment

Results

Experience with Chiropractic

Have you been adjusted by a chiropractor before?

Yes

No

Has any adult in your family seen a Chiropractor?

Yes

No

Has any child in your family seen a Chiropractor?

Yes

No

Other Chiropractor's Name

Approximate date of last visit?

Reason for those visits?

Awareness of Chiropractic Principles

Were you aware that..

Doctors of Chiropractic work with the nervous system? *

Yes

No

The nervous system controls all bodily functions and systems? *

Yes

No

Chiropractic is the largest natural healing profession in the world? *

Yes

No

If Chiropractic care starts at birth, you can achieve a higher level of health throughout life? *

Yes

No

Health Habits & Conditions

Do you smoke? *

Yes

No

Do you drink alcohol? *

Yes

No

Do you drink coffee? *

Yes

No

Do you exercise regularly? *

Daily

Moderately

No

Do you wear:

Heel lifts

Sole lifts

Inner soles

Arch supports

Are you pregnant?

Yes

No

Are you nursing?

Yes

No

Are you taking birth control?

Yes

No

Are you experiencing painful periods?

Yes

No

Do you have irregular cycles?

Yes

No

Do you have breast implants?

Yes

No

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

Emergency Contact First & Last Name

Emergency Contact Phone Number

Relationship with Emergency Contact

DISCLOSURE & CONSENT

CHIROPRACTIC ADJUSTMENTS AND CARE

TO THE PATIENT: You have a right as a patient to be informed about your condition and the recommended chiropractic adjustments and other chiropractic procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the potential risks and hazards involved. This dis loser is not meant to scare or alarm you: it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy and diagnostic X-rays, on me (or the patient named below, for whom I am legally responsible) by the Doctor of Chiropractic named below and/or other licensed Doctors of Chiropractic or those working at the clinic or office who now or in the future treat me while employed by, working or associated with, or serving as a backup for the Doctor of Chiropractic named below.

I have had the opportunity to discuss with the Doctor of Chiropractic named below, my diagnosis, the nature and purpose of chiropractic adjustments and other procedures and alternatives.

I understand and I am informed that, in the practice of chiropractic there are some risks to exam and treatment including, but not limited to, fractures, disc injuries, strokes, dislocations, sprained, and increased symptoms and pain or no improvement of symptoms or pain. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of treatment for my present condition and for my future condition(s) for which I seek treatment.

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from Mecham Chiropractic. Message frequency varies. Message & data rates may apply. Text HELP to (801) 905-8202 for assistance. You can reply STOP to unsubscribe at any time.

I am filling this form out for: *

Myself

another individual I legally have guardianship for

Printed Patients Name

Patient's Signature

Clear

Printed name of Guardian or Spouse

Guardian or Spouse's Signature

Clear

Authorization for Care Date

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