Evolve Chiro Patient Intake Form

Name
MM slash DD slash YYYY
Address
Gender

Extended Healthcare Coverage

Workers' Compensation

No-Fault Insurance

Reason for Appointment

Pain Assessment

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Select Pain Locations
Please enter a number from 1 to 10.
Pain Characteristics

Injury Details

Work-Related Injury?
Motor Vehicle Accident?

Medical History

Previous Imaging (X-rays, MRI, etc.):
Surgeries:

Review of Systems

General:
Cardiovascular:
Respiratory:
Gastrointestinal:
Musculoskeletal:
Neurological:

Activities of Daily Living (ADL) Assessment Form

Instructions: Please indicate your level of pain for each activity by checking the appropriate box.
Dressing
Bathing/Showering
Grooming (hair, nails, teeth)
Using the toilet
Managing incontinence
Walking
Transferring (bed to chair)
Climbing stairs
Cleaning
Laundry
Shopping
Lifting less than 10 pounds
Lifting more than 10 pounds
Sleep
Sexual function
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:

Authorization to Release Medical Records

Purpose of Release:

Description of Information to be Released:

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.
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.