Patient Intake Form.pdf

This is a chiropractic office's new patient application form, which includes sections for personal and medical history, symptoms, and consent for treatment, as well as a notice of privacy practices and informed consent for chiropractic care. The form is divided into four parts:

1. Personal and medical history, including name, date of birth, address, phone number, email, occupation, and emergency contact information, as well as health concerns and previous medical treatments.

2. A checklist of potential health issues, including headaches, ear infections, sinus issues, and others, with options to mark whether the patient has experienced these issues in the past or currently.

3. A social history section, which asks about smoking, alcohol, exercise, and recreational drug use, as well as caffeine consumption, and a quadruple visual analogue scale to assess pain levels.

4. A notice of privacy practices acknowledgement and informed consent for chiropractic care, which explains how the patient's health information will be used and disclosed, and acknowledges the potential risks and benefits of chiropractic care.