Patient Intake Form - Dr. John Fitzgerald & Dr. JD Brooks

Name

First Last

Date of Birth

Age

Cell Phone

Email

Address

Street Address City State ZIP Code

Who Referred You

Sex

Male
Female

Weight

Emergency Contact Name

First Last

Emergency Contact Phone #

Employer/Company Name

Job Title/Position

Currently Working

Yes
No

Date Stopped Working

What are the major complaints/symptoms for your visit today? (Please be as specific as you can)

When did you first notice the problem/pain and how do you believe it began?

Have you ever had Chiropractic care before?

Yes
No

When and for what problem?

Were the results satisfactory?

Yes
No
N/A

Have you ever had this condition or a similar condition before?

Yes
No

When?

Have you ever had any cosmetic surgery, breast implants, etc.?

Yes
No

List any operations and the years you had them.

Year

Please check if you have had or currently have any of the following (within the past 12 months)

Headaches

Now
Past

Neck Pain / Stiff Neck

Now
Past

Shoulder Pain

Now
Past

Sleeping Problems

Now
Past

Back Pain

Now
Past

Motor Vehicle Collision/Personal Injury Questionnaire

Please describe the accident in your own words:

Where did it occur? (City)

Date of accident:

Were you the:

Driver
Passenger
Pedestrian

Which seat were you in?

Front Seat
Right Rear Seat
Left Rear Seat

Did your vehicle strike the other vehicle?

Yes
No

Was your car struck by the other vehicle?

Yes
No

How much damage was there to the outside of the vehicle?

None
Some
A Lot

Immediately after the accident were you:

Conscious
Dazed
Unconscious

How long were you unconscious?

Did you go to the hospital?

Yes
No

What was the name of the hospital/doctor?

Diagnosis/Treatment

Any medication or medical supplies given:

Consent for Purposes of Treatment, Payment & Healthcare Operations

In this document, “I” and “my” refer to the patient and “Chiropractor” refers to Dr. John Fitzgerald DC.

I consent to the use or disclosure of my protected health information by Chiropractor for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Chiropractor. I understand that analysis, diagnosis or treatment of me by Chiropractor may be conditioned upon my consent as evidenced by my signature below.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Chiropractor agrees to a restriction that I request, the restriction is binding on the Chiropractor. I have the right to revoke this consent, in writing, at any time, except to the extent that Chiropractor has taken action in reliance on this Consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I have been provided with a copy of the Notice of Privacy Practices of Chiropractor and understand that I have a right that Notice’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiropractor. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information.

Chiropractor reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of Chiropractor and requesting a revised copy by sent in the mail or asking for one at the time of my next appointment.

Today's Date

Signature

I do hereby authorize the above provider to furnish to you, my attorney, with a full report of his case history, examination, diagnosis, treatment and prognosis of myself in regard to my injury. I hereby give a lien to said provider on any settlement as a result of my injury, and authorize and direct you, my attorney, to pay directly Dr. John Fitzgerald such sums as may be due and owing him for services rendered to me, and to withhold such sums from such settlement as may be necessary to protect Dr. John Fitzgerald adequately. I fully understand that I am directly and fully responsible to Dr. John Fitzgerald for all bills submitted by him for care rendered to me. This agreement is made solely for Dr. John Fitzgerald additional protection and in consideration of his awaiting payment. I understand that I am responsible for any and all outstanding bills relating to this office. I would like a separate check written to Dr. John Fitzgerald for my care.

Today's Date

Signature