Digital Patient Intake Form

Welcome to our office!


Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 




About this Patient 

Gender*
Please select one option
Marital Status*
Please select one option

My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


Employer Information

Experience with Chiropractic 

Have you been adjusted by a chiropractor before?*
Please select one option

Reason for this Visit

Is the purpose of this appointment related to:
If job related, have you made a report of your accident to your employer?
Does this condition interfere with
Has this condition occurred before?
Have you seen other doctors for this condition?

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point

Initial Consultation Form 


What type of complaint?*
Please select at least one option
Please rate your pain level*
Please select one option
What percentage of the time you are awake do you experience the above symptom at the above intensity?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where?*
Please select at least one option
Is complaint getting better or worse?*
Please select one option
Symptom relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Have any recent diagnostic imaging?*
Please select one option
Activity of daily living most affected*
Please select at least one option
Are you having pain anywhere else? Please go to next complaint*
Please select one option
What type of complaint?*
Please select at least one option
Please rate your pain level*
Please select one option
What percentage of the time you are awake do you experience the above symptom at the above intensity?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where?*
Please select at least one option
Is complaint getting better, worse?*
Please select one option
Symptom relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has patient received any past care?*
Please select at least one option
Have any recent diagnostic imaging?*
Please select one option
Activity of daily living most affected*
Please select at least one option
Are you having pain anywhere else? Please go to next complaint*
Please select one option
What type of complaint?*
Please select at least one option
Please rate your pain level*
Please select one option
What percentage of the time do you experience the above symptom at the above intensity?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where?*
Please select at least one option
Is complaint getting better, worse?*
Please select one option
Symptom relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has patient received any past care?*
Please select at least one option
Have any recent diagnostic imaging?*
Please select one option
Activity of daily living most affected*
Please select at least one option

Health Habits

Do you wear:

Health Conditions 


Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

Have you had any of the following musculoskeletal (bone/muscle-related) issues?*
Please select at least one option
Have you had any of the neurological (nerve-related) issues?*
Please select at least one option
Have you had any of the following psychological issues?*
Please select at least one option
Have you had any of the following cardiovascular (heart-related) issues or procedures?*
Please select at least one option
Have you had any of the following pulmonary (lung-related) issues?*
Please select at least one option
Have you had any of the following gastroenterological (stomach-related) issues?*
Please select at least one option
Have you had any of the following renal (kidney-related) issues?*
Please select at least one option
Have you had any of the following endocrine (glandular/hormonal) issues?*
Please select at least one option
Have you had any of the following dermatological (skin-related) issues?*
Please select at least one option
What allergy or sensitivity issues?*
Please select at least one option
Have you had any of the following hematological (blood-related) issues?
Patient's surgical history?*
Please select at least one option
Drugs and medication(s)?*
Please select at least one option
Please indicate if you have a history of any of the following:*
Please select at least one option
Past history of accidents*
Please select at least one option
Patient's Immediate Family Health History*
Please select at least one option
Work?*
Please select at least one option
Exercise routine?*
Please select at least one option
Please indicate which of these you do/have on a consistent basis:
Diet and nutrition?*
Please select at least one option

FOR WOMEN ONLY:

Are you pregnant?

Authorization for Care


I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Who should receive bills for payment on your account?*
Please select at least one option

Ownership of X-ray Films if taken


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

Insurance:


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. 

Agreement:

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state's statutes. I certify that I, and/or my dependent(s), assign directly Lodes Chiropractic Center 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 above named facility may use my health care information and may disclose such information to the above named 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 signed below,

I have read and agree to the above statement.

Thank you for taking the time to fill out this form.

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy describes how we may use and disclose your protected health information (PHI) to carry our treatment, payment or health care operations (TPO) for other purposes that are permitted or required by law. “Protected Health Information” is information about you, including demographic information that may identify you and that related to your past, present, or future physical or mental health or condition and related care services.

Use and Disclosures of Protected Health Information:

Your protected health information may be used and disclosed by your physician, our staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, pay your health care bills, to support the operations of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your health care information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities and employee review activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations included as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and organ donation. Required uses and disclosures under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITYTO OBJECT UNLESS REQUIRED BY LAW.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

____________________________________ ________________________

Signature of Patient or Representative Date

____________________________________

Printed Name

Lodes Chiropractic Center

Address

Shipley Building, 3411 Silverside Rd # 101,
Wilmington, DE 19810

Monday  

7:30 am - 5:30 pm

Tuesday  

1:30 pm - 5:00 pm

Wednesday  

7:30 am - 6:30 pm

Thursday  

2:00 pm - 5:30 pm

Friday  

7:30 am - 12:00 pm

Saturday  

Closed

Sunday  

Closed

CONTACT US

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Please do not submit any Protected Health Information (PHI).