Intake Forms

Name*

First Last

Birth Date*

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Home Phone

Work Phone

It may be necessary for the office to leave a message for you regarding medical information such as appointments, billing or account information or other health care issues. Can we leave a message on your:*

Cell Phone
Home Phone
Work Phone

Can we text your cell phone?*

Yes
No

Email*

Sex

Male
Female

Marital Status

Single
Married
Divorced
Widowed

Height

Weight

Number of Children

Employer

Occupation

Emergency Contact*

First Last

Emergency Phone*

Whom may we thank for referring you?

Do you have insurance?*

No
Yes

Insurance Policy Holder's Name*

First Last

Insurance Policy Holder's Date of Birth*

Front of Insurance Card*

Max. file size: 16 MB.

Back of Insurance Card*

Max. file size: 16 MB.

Do you have secondary insurance?*

No
Yes

Secondary Insurance Policy Holder's Name*

First Last

Secondary Insurance Policy Holder's Date of Birth*

Front of Secondary Insurance Card*

Max. file size: 16 MB.

Back of Secondary Insurance Card*

Max. file size: 16 MB.

Acknowledgement for Consent to the Use and Disclosure of Protected Health Information and receipt of Notice of Privacy Practices.*

Use and Disclosure of your Protected Health Information

Your Protected Health Information will be used by Newton Chiropractic Clinic or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.

Notice of Privacy Practices

You should review the notice of privacy practices for a more complete description of how your Protected Health
Information May be Used of disclosed. It describes your rights as they concern the limited use of the health
information, including your demographic information, collected from you and created or received by this office.

Requesting a restriction on the Use or Disclosure of your Information

• You may request a restriction on the use or disclosure of your Protected Health Information.
• This office may or may not agree to restrict the use or disclosure of your Protected Health Information.
• If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected
health information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Revocation of Consent

You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke the
consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of
consent is received will not be affected.

By checking the box below you give permission to use and disclose your health information for the purposes of treatment, obtaining payment including the processing of insurance claims for reimbursement of charges incurred, or supporting the day-to-day health care operations of this office. You authorize direct payment to Newton Chiropractic and/or Dr. Samuel Gatz any sum you now or hereafter owe Newton Chiropractic by any insurance company obligated to make payment to you or Newton Chiropractic based in whole, or in part, upon the charges made for Newton Chiropractic's services. You also acknowledge receipt of a copy of the office “Notice of patient Privacy Policy”.

I agree to the privacy policy.

Would you like to list any family members or friends we are authorized to speak with about you health care issues?

This includes spouses, children, or parents. Remember that if anyone calls us with a question, we will not be able to speak with them unless they are listed here.

No
Yes

Name*

First Last

Relationship*

Phone*

Name

First Last

Relationship

Phone

Name

First Last

Relationship

Phone

By checking this box you understand that this will remain in effect until it is revoked in writing.*

I agree

Have you consulted a chiropractor before?*

No
Yes

When?

Please check any condition that you've had or currently have:

What are your allergies?

What type of cancer do you have?

Is your mother still living?

Yes
No

Please indicate if there is history on your mother's side for any of the following:

Is your father still living?

Yes
No

Please indicate if there is history on your father's side for any of the following:

List operations, broken bones, or dislocations you have had in the past 5 years (type and date)

List actual name and dosage of any prescription medications you are currently taking*

Smoking Status*

Smoker
Previous smoker
Never smoked

The symptom(s) that have prompted me to seek care today include:*

Are they the result of...?*

When did you first notice your current symptoms?

On a pain scale of 1-10 with 0 being no pain and 10 being the highest possible level of pain, where do you grade your pain today?*

Intensity is:

The complaint came on:

Gradually
Immediately

It is getting:

Better
Staying the same
Getting worse

Frequency of this complaint is:

Intermittent
Occasional
Frequent
Constant

Does it affect other areas of your body? To what areas does the pain radiate, shoot, or travel?

What does the pain feel like?

Please describe where on your body the pain occurs

What tends to worsen the problem? (Time of day, movements, certain activities, etc)

What tends to lessen the problem? (Time of day, movements, certain activities, etc.)

What have you done to relieve the symptoms?

What can't you do now because of this problem that you would like to be able to do again?

Intake

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