Patient Intake FormKevEvolve2025-01-22T15:06:06+00:00 Evolve Chiro Patient Intake Form Name First Last Date Of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gender Male Female Email Extended Healthcare CoverageInsurance Company Name:Group ID/Policy Number:Member Number:Relationship to Cardholder:Name of Cardholder:Workers' CompensationInsurance Company Name:Insurance Company Phone #Insurance Company Fax #:Claim Number:Workers' Compensation #:Date of Injury:Adjuster Name:No-Fault InsuranceInsurance Company Name:Insurance Company Phone #:Insurance Company Fax #:Claim Number:Date of Injury:Adjuster Name:Reason for AppointmentChief Complaint:Pain Onset Date:Pain Location:Pain Origin:Pain Assessment"Select Pain Locations A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA BB CC DD EE FF GG HH II JJ KK LL MM OO PP Pain Level 1-10 (10 being highest pain)Please enter a number from 1 to 10.Pain Characteristics Sharp Dull Throbbing Burning Aching Other Injury DetailsWork-Related Injury? Yes No If work related, describe the mechanism of injury:Motor Vehicle Accident? Yes No If motor vehicle accident, describe the mechanism of injury:Medical HistoryPrevious Imaging (X-rays, MRI, etc.): Yes No If yes, list type and dates:Surgeries: Yes No If yes, list type and dates:Current MedicationsReview of SystemsGeneral: Fever Weight loss Fatigue Cardiovascular: Chest pain Palpitations Respiratory: Shortness of breath Cough Gastrointestinal: Nausea Vomiting Diarrhea Musculoskeletal: Joint pain Muscle weakness Neurological: Headaches Dizziness Numbness Other Activities of Daily Living (ADL) Assessment FormInstructions: Please indicate your level of pain for each activity by checking the appropriate box. Dressing No Pain Mild Pain Moderate Pain Severe Pain Not Performed Bathing/Showering No Pain Mild Pain Moderate Pain Severe Pain Not Performed Grooming (hair, nails, teeth) No Pain Mild Pain Moderate Pain Severe Pain Not Performed Using the toilet No Pain Mild Pain Moderate Pain Severe Pain Not Performed Managing incontinence No Pain Mild Pain Moderate Pain Severe Pain Not Performed Walking No Pain Mild Pain Moderate Pain Severe Pain Not Performed Transferring (bed to chair) No Pain Mild Pain Moderate Pain Severe Pain Not Performed Climbing stairs No Pain Mild Pain Moderate Pain Severe Pain Not Performed Cleaning No Pain Mild Pain Moderate Pain Severe Pain Not Performed Laundry No Pain Mild Pain Moderate Pain Severe Pain Not Performed Shopping No Pain Mild Pain Moderate Pain Severe Pain Not Performed Lifting less than 10 pounds No Pain Mild Pain Moderate Pain Severe Pain Not Performed Lifting more than 10 pounds No Pain Mild Pain Moderate Pain Severe Pain Not Performed Sleep No Pain Mild Pain Moderate Pain Severe Pain Not Performed Sexual function No Pain Mild Pain Moderate Pain Severe Pain Not Performed Additional Comments:Office Policies Appointment Scheduling and Cancellations: Appointments must be scheduled in advance. Cancellations require 24-hour notice. Late cancellations or no-shows may incur a fee. Payment Policies: Payment is due at the time of service unless prior arrangements have been made. We accept cash, credit/debit cards, and checks. Insurance and Billing: We will bill your insurance as a courtesy. However, patients are responsible for understanding their coverage and benefits. Any remaining balance after insurance has paid is the patient's responsibility. Privacy and Confidentiality: Your health information is confidential and protected. We comply with HIPAA regulations. High Deductible Plan Agreement: Understanding Your Plan: High deductible health plans (HDHPs) require patients to pay a higher out-of-pocket amount before insurance coverage begins. It is important to understand your deductible amount and how it affects your payments. Payment Responsibilities: Patients are responsible for paying the full cost of services until the deductible is met. After the deductible is met, patients may still be responsible for co-pays or co-insurance. Payment Options: We offer flexible payment plans to help manage high deductible costs. Please speak with our billing department to arrange a payment plan if needed. Acknowledgment and Agreement: Consent I agree to the office policies.Authorization to Release Medical RecordsPurpose of Release: Continuation of Care Personal Use Legal Purposes Other Description of Information to be Released: Complete Medical Record Specific Records X-rays and Imaging Reports Treatment Notes Billing Information Other Authorization: I hereby authorize the release of my medical records as specified above to the recipient named. I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice to the chiropractic office. I acknowledge that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. Consent I agree to the Release of Medical Records.Informed Consent for Chiropractic Treatment Risks and Benefits of Chiropractic Treatment Benefits: Relief from pain and discomfort Improved mobility and function Enhanced overall well-being Risks: Temporary soreness or discomfort Minor bruising Rare but serious complications such as stroke or nerve damage I have read and understood the above information regarding the risks and benefits of chiropractic treatment. I consent to the treatment provided by my chiropractor. Consent I agree to the Informed Consent for Chiropractic TreatmentIf you have any questions or concerns about your treatment, please list them below: Δ