Patient Demographics Today’s Date: __________________

Name: ____________________________________________ Birth Date: _____-_____-_______ Age: ______ Male Female

Address: ___________________________________________________ City: ______________________ State: ______ Zip: ____________

Home Phone: ___________________________ Cell Phone: _________________________ Work Phone: ____________________________

Email: ______________________________________________________________________________@________________________.com

Preferred method of communication for patient reminders: Email Phone Mail

Social Security #: _____________________________________ Driver's License #: ______________________________________________

Marital Status: Married Single Divorced Widowed Other

Is there a possibility of pregnancy? No Yes Maybe

Race: American Indian or Alaska Native Asian African American Caucasian Native Hawaiian or Pacific Islander I Decline to Answer

Ethnicity: Hispanic or Latino Not Hispanic or Latino I Decline to Answer

Spouses Name: _______________________________________________ Occupation: _________________________________________

Children’s Names & Ages: ___________________________________________________________________________________________

Are you: Employed Homemaker Retired Unemployed Full-time Student Part-time Student

Employer: _____________________________________________________ Occupation: _________________________________________

Seasonal Resident: From: ________________ To: ________________ Northern Phone #: _____________________________________

Northern Address: _______________________________________________ City: ___________________ State: ______ Zip: ___________

Name & Relationship of Emergency Contact: ___________________________________________________ Phone #: _________________

Who may we thank for referring you to this office? ______________________________________________________________________

□ I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and

frequency of chiropractic care.)

Financial Responsibility/Insurance Information - Please notify the Front Desk if your visit is related to an accident or injury

Does your insurance have chiropractic, acupuncture, and/or physical therapy benefits?

No, I will be self-pay Yes, I have insurance benefits – PATIENT MUST COMPLETE FOLLOWING (PI patients need not complete)

I. Primary Insurance Company & Plan Name: ____________________________________________________________________________

ID Number: _________________________________________ Grp/Policy #:____________________Effective Date: ___________________

Subscribers Name: ________________________________________________________________ DOB: ____________________________

Subscriber is my: Self Spouse Parent Other

II. Secondary Insurance Company & Plan Name: __________________________________________________________________________

ID Number: _________________________________________ Grp/Policy #:____________________Effective Date: ___________________

Subscribers Name: ________________________________________________________________ DOB: ____________________________

Subscriber is my: Self Spouse Parent Other

NEW CHIROPRACTIC & PHYSICAL THERAPY PATIENTS

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Social History

Smoking: Cigars Pipe Cigarettes How often? Daily Weekends Occasionally Former Smoker Never Smoked

Alcohol Consumption: Daily Weekends Occasion Never Recreational Drug Use: Daily Weekends Occasion Never

Are you currently taking any medications? (Include regularly used over the counter medications) Use a second sheet if necessary

Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.)

Do you have any medication allergies or allergies to shell-fish?

Medication Name Reaction Onset Date Additional Comments

Family History

Does anyone in your family suffer with the same condition(s)? No Yes

If yes, whom: Grandmother Grandfather Mother Father Sister Brother Son Daughter

Have they ever been treated for their condition? No Yes I don't know

Any hereditary conditions the doctor should be aware of? No Yes _______________________________

Family Medical History (Record one diagnosis in your family history and the affected relative)

Diagnosis

Father Mother Sibling:

(___________)

Offspring:

(___________)

History of Complaint

Please identify the condition(s) that brought you to this office:

When did the problem(s) begin? _________________________ When is the problem at its worst? AM Mid-day PM Late PM

How did the injury occur? __________________________________ Is your problem the result of ANY type of accident? Yes No

Condition(s) ever been treated by anyone in the past? No Yes, When: __________ By Whom? ______________________________

Name of previous chiropractor: ________________________________________________________________________________ N/A

How long were you under care? _______________ What were the results? ___________________________________________________

My present problem affects my: Sleep Hobbies Recreational Activities Exercise Regime

Are there any symptoms such as: Headache Difficulty Sleeping Indigestion Urinary or Bowel Changes

Dizziness Blurred Vision Ringing in the ears Tiredness Difficulty Breathing Difficulty Concentrating

Fainting Unexplained Weight Loss or Gain Change in Appetite Falling Hot/Cold Flashes Night Sweats

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**Please identify the area on the diagram and answer the questions to describe your PRIMARY symptom:

**Please identify the area on the diagram and answer the questions to describe your SECONDARY symptom:

Previous Surgeries and Illnesses

Identify any other injury(s) to your spine, minor or major, the doctor should be aware of:

__________________________________________________________________________________________________________________

Have you suffered with this or a similar problem in the past? No Yes, How many times? ___________________________________

When was the last episode? ________________________ What brought on the episode? _______________________________________

I have tried other forms of treatment: No Yes, please state what type of treatment: _______________________________________

Who provided this treatment: _______________________________________________________ How long ago? ____________________

Were the results? Favorable Unfavorable, Please explain: ____________________________________________________________

Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:

__________________________________________________________________________________________________________________

If you have ever been diagnosed with any of the following conditions, please indicate a P for Past, C for Current and N for Never

__ Broken Bone __ Dislocations __ Tumors __ Rheumatoid Arthritis __ Fracture __ Disability __ Cancer

__Heart Attack __Osteo Arthritis __Diabetes __ Cerebral Vascular __ other serious conditions: ______________________

Please, identify ALL PAST and any CURRENT conditions you feel may be contributing your present problem:

How Long Ago Type of Care Received By Whom

Injuries

Surgeries

Childhood diseases

Adult diseases

_____________________________________________________________ ___________________

Patient or Parent/Guardian’s Signature Date Completed

_____________________________________________________________ ___________________

Doctor's Signature Date Form Received

Type of discomfort: (Choose all that apply) Sharp Dull Aching Burning Numbing Shooting Tightness Throbbing Diffuse Tingling

Frequency of discomfort through-out the day: Constant (100%-75%) Frequent (75%-50%) Intermittent (50%-25%) Occasional (25%-1%)

Intensity of discomfort (1-least severe, 10-most severe) 1 2 3 4 5 6 7 8 9 10

Discomfort increases with: (Choose all that apply if applicable) Movement Applied Pressure Prolonged Sitting Coughing/Sneezing

Discomfort decreases with: (Choose all that apply if applicable) Rest Chiropractic Care Medication Movement Ice Heat Type of discomfort: (Choose all that apply) Sharp Dull Aching Burning Numbing Shooting Tightness Throbbing Diffuse Tingling

Frequency of discomfort through-out the day: Constant (100%-75%) Frequent (75%-50%) Intermittent (50%-25%) Occasional (25%-1%)

Intensity of discomfort (1-least severe, 10-most severe) 1 2 3 4 5 6 7 8 9 10

Discomfort increases with: (Choose all that apply if applicable) Movement Applied Pressure Prolonged Sitting Coughing/Sneezing

Discomfort decreases with: (Choose all that apply if applicable) Rest Chiropractic Care Medication Movement Ice Heat

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Contact Consent and Medical Information Sharing

At times our staff will need to contact you at the phone numbers provided by you on your intake paperwork. By

filling out the information below, we will be better able to serve you.

UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO, WE WILL NOT:

LEAVE MESSAGES WITH ANYONE EXCEPT THE PATIENT OR LEGAL GUARDIAN

LEAVE INFORMATION ON AN ANSWERING MACHINE, VOICE MAIL OR ANY OTHER

ELECTRONIC RECORDING DEVICE

COMMUNICATE WITH YOU THROUGH EMAIL, FACEBOOK MESSENGER, OR ANY OTHER

ELECTRONIC, INTERNET OR SOCIAL MEDIA MESSAGING SYSTEMS, INCLUDING TEXT

MESSAGES

Please read below and consider carefully whom you want to have access to your medical information.

I, __________________________________, hereby consent and state my preference to have my physician,

Dr. Aaron M. Taylor and other staff at Taylor Chiropractic & Oriental Medicine may communicate with me by email

or standard SMS/text messaging, in addition to or to replace leaving phone messages, regarding various aspects of my

health care, which may include, but shall not be limited to, test results, appointments, and billing. I understand that

email and standard SMS/text messaging are not confidential methods of communication and may be insecure. I

further understand that, because of this, there is a risk that email and standard SMS/text messaging regarding my

medical care might be intercepted and read by a third party. I understand that if I share an email address with

another person, that person will also have access to information sent to me regarding my care.

I give my permission to leave both appointment reminders AND my private health information at the

following (please fill-in the ones you agree to). At this time Taylor Chiropractic & Oriental Medicine only confirms

appointments through phone calls.

Phone number: ___________________________ Email: _______________________________________________

Text: N/A – Taylor Chiropractic & Oriental Medicine will not contact you regarding your chiropractic care by text

message, Facebook, or any other social media system.

~~~~~~~~~~~~~~~~~~~~~~~~~~~

I______________________________________ DO NOT give Taylor Chiropractic & Oriental Medicine my

permission to leave phone messages, email, or text messaging regarding my medical care and test results. Without

consent Taylor Chiropractic & Oriental Medicine will be unable to leave messages for me regarding scheduled

appointments.

NOTE: Appointment reminders and private health information will be communicated to you only in the manners in which you

have given specific written authorization and you have the option to opt out of any of those methods at any time by notifying our

office. I fully understand that this consent will remain in effect until revoked in writing. Email and standard SMS/text

messaging are not confidential methods of communication and may be insecure.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

My medical care may be discussed with the following individuals. The following individuals will also serve as

emergency contacts

Name: ___________________________________________________ Relationship: _____________________

Name: ___________________________________________________ Relationship: _____________________

Signature of

Patient/Parent/Guardian______________________________________________________Date________________

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PLEASE COMPLETE THIS FORM IN OUR OFFICE

Informed Consent to Care

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including

various modes of physical therapy, diagnostic x-rays, and examinations on me (or on the patient named below, for whom I

am legally responsible) by the doctor of chiropractic at Taylor Chiropractic & Oriental Medicine.

I have had the opportunity to discuss with the doctor and/or with other office or clinic personnel the purpose and benefits of

chiropractic adjustments and other treatments. Alternatives to treatment have been reviewed. Though chiropractic adjustments

and treatments are usually beneficial and seldom cause any problem, I understand and am informed that there are some risks to

treatment.

I understand that chiropractic is not an exact science, therefore practitioners cannot guarantee results. I acknowledge that no

guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I

have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to

treatment. Signature of Patient/Parent/Guardian:

X _____________________________________________________________________________Date__________________

Financial Responsibility

I agree to be financially responsible for all charges I incur at Taylor Chiropractic & Oriental Medicine including deductibles, co-

payment, co-insurance and any specific services rejected by my insurance company. I understand that all payments are due at

the time of service and that I am financially responsible for all charges whether or not they are paid by a health insurance policy.

I understand that the office has a 24 hour cancelation policy for scheduled massages and I will be charged a $30 cancelation fee

if I miss or need to cancel a massage appointment less than 24 hours prior. I understand that if I purchase a discounted

chiropractic or massage package and later request a refund; all refunds will be calculated less the full retail price of

appointments already redeemed from the package. Signature of Patient/Parent/Guardian:

X _____________________________________________________________________________Date__________________

Authorization to bill Insurance Company/Assignment of Benefits

I authorize Taylor Chiropractic and Oriental Medicine to release any information pertinent to my care to any insurance

company, adjustor, and/or attorney involved in this case, and hereby releases this office of any consequence thereof.

I agree to be financially responsible for all charges I incur at Taylor Chiropractic and Oriental Medicine including deductibles,

co-payment, co-insurance and any specific services rejected by my insurance company. I understand that verification of my

benefits is not a guarantee of payment by the insurance company; I further understand that verification of my benefits is an

approximation of covered charges and all charges are subject to the insurance company’s approval.

I understand that some third-party payers may require that my medical information, including copies of treatment notes, be

submitted along with requests for payment. I hereby authorize Taylor Chiropractic & Oriental Medicine to release all medical

information necessary to secure payment of benefits from the third-party payers. I understand that this information may include

medical information related to drug and alcohol abuse, sexually transmitted diseases, HIV/AIDS and mental health. I understand

that this authorization shall remain valid without expiration unless expressly revoked by me in writing.

I hereby instruct and direct my insurance company to pay by check/eft made out and mailed directly to Taylor Chiropractic

& Oriental Medicine the professional or medical expense benefits allowable, and otherwise payable to me under my current

insurance policy as payment toward the total charges for services rendered by this office. A photocopy of this assignment

shall be considered as effective and valid as the original.

Signature of Patient/Parent/Guardian:

X _____________________________________________________________________________Date__________________

I have received the Notice of Privacy Practices and I have been provided with an opportunity to review it.

Signature of Patient/Parent/Guardian:

X_____________________________________________________________________________Date__________________

Staff Witness to all Patient/Parent/Guardian signatures

Signature_____________________________________________________________________________Date______________