Intake Form 2021 Intake Form [PDF to print at home] Online Intake Form Name* First Last Home Phone*Cell PhoneBusiness PhoneEmail 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth* MM DD YYYY Marital StatusSingleMarriedPartnershipGenderPreferred Pronoun/sSocial Security NumberOccupationHow did you hear about our office?Proof of InsuranceAccepted file types: jpg, gif, png, pdf.Please upload a clear picture of your insurance card or verification documentPersonal HistoryHave you ever had your spine or nervous system examined professionally?If yes, when, and by whom?Have you ever received chiropractic adjustments by a Doctor of Chiropractic?If yes, when was your last visit?For how long were you receiving chiropractic adjustments?How often did you go?If you stopped, why did you stop going?Do you know what type of adjustments the doctor performed, or what technique(s) or methods she/he used?Were you pleased with his/her service? ExplainDoes your immediate family receive chiropractic adjustments?What do you hope to receive at our office?SubluxationsThe practice of chiropractic is based upon the location and adjustment of subluxations. Subluxations are caused by any stress that your body is unable to adapt to and use. These stresses may be physical, chemical, or emotional in nature. Physical StressBirth HistoryMy birth was:at homein a birthing centerin a hospitalWere you incubated or isolated after birth?YesNoWas your mother outwardly ill prior to pregnancy with you?YesNoDid your mother have a difficult pregnancy with you?YesNoDid your mother have any falls, accidents, or physical injuries during pregnancy?YesNoWas your delivery traumatic?YesNoWas there any physical or mechanical stress to you or mother as labor progressed, during delivery, or as a newborn?YesNoCheck any that may apply to your delivery: Drug Induced Forceps or Suction C-Section Cord Around Neck Breech Prolonged General Physical TraumaWere you ever knocked unconscious?YesNoIf yes, when and how?Have you ever used crutches, a walker, or cane?YesNoIf yes, when and why?Have you ever had any impacts, falls, or jolts that you feel specifically may have injured your spine?YesNoIf yes, when and how?Have you had extensive dental work performed?YesNoOrthodontic work?YesNoDuring the day I:SitStandWalkDriveDuring the day I am:At my DeskOn the PhoneHeavy LiftingSports and LeisureI exercise:DailyWeeklyMonthlyWhat sports are you active in?Have you been hurt in any of these activities?Comments:Automobile AccidentsHave you, even as a passenger, even if you do not think you were hurt, been involved in a vehicle collision or near collision (motorcycle, snowmobile, plane, etc.)?Please list approximate dates and describe the resulting injuries.Please list any remaining issues you have as a result of these injuries. Medical Treatment Have you ever been hospitalized?YesNoWhen and why?Have you had surgery?YesNoWhen and why?Do you still have all your body parts?How do you assess your physical health?ExcellentGoodFairPoorGetting BetterGetting WorseIf you consider yourself ill, why do you feel you are ill?If you consider yourself well, why do you feel you are well?Pain AssessmentFrequency:ConstantDailyIntermittentWith ActivityOccasionalSeverity of complaint or level of pain at onset:Please enter a number from 1 to 10.Scale 1-10 low/less high/moreSeverity of complaint or level of pain presently:Please enter a number from 1 to 10.Scale 1-10 low/less high/moreSite of PainDescription of Pain (i.e. burning, aching, etc…)How and when did it start?How has the frequency or intensity changed?Is there anything else that may help us understand you better?Chemical StressWas your mother regularly taking any drug during her pregnancy with you?YesNoWas your mother regularly consuming alcohol during her pregnancy with you?YesNoWas her labor chemically induced or altered?YesNoDuring delivery, my mother was:conscioussemi-consciousunconsciousPlease list any other chemical stress that your mother may have been subjected to.Please indicate how much Alcohol you consume.NeverSeldomOftenType of AlcoholPlease indicate how much Coffee you consume.NeverSeldomOftenType of CoffeePlease indicate how much Recreational Drugs you consume.NeverSeldomOftenType of Recreational DrugsPlease list any allergies you haveDo you have an active diagnosis of hypertension?YesNoSmoking:DailySome daysFormer smokerNever smokedAre you taking any medications (prescription or over-the counter)?YesNoList medication(s), What used to treat, and Duration/For how long*Were you previously taking any medication regularly?Do you work with any chemical, fume, dust, powder, or smoke for prolonged periods?Emotional StressChildhood StressMildModerateExtremeSchool StressMildModerateExtremePlay/Recreation StressMildModerateExtremeFamily StressMildModerateExtremePersonal Relationships StressMildModerateExtremeStress of SicknessMildModerateExtremeWork-related StressMildModerateExtremeStress of CommutingMildModerateExtremeLoss of Loved OneMildModerateExtremeChange in LifestyleMildModerateExtremeChange in VocationMildModerateExtremeAbuseMildModerateExtremeHow do you assess your emotional-mental health?ExcellentGoodFairPoorGetting BetterGetting WorseAgreementsMUTUAL AFFIRMATION OF PURPOSE & FINANCIAL RESPONSIBILITIES AND INSURANCE RELEASE AUTHORIZATION* I agreeAs a chiropractor, I recognize that all living things possess an innate intelligence, which orchestrates all healing, growth, and learning for that individual. I recognize that subluxations interfere with these transmissions, thus interfering with the proper functioning of the organism. When released, the potential stored within subluxations leads to greater ease and increased awareness. I choose to help people express better health by detecting and correcting these subluxations. I recognize that the presence or absence of symptoms or dis-ease is not necessarily an indication of the quality of health, nor is it an indication of the presence of subluxations. I recognize that symptoms are a part of an intelligent process, serving both as integral parts of the healing mechanism, and as signals to alert the individual of the need for change. I do not treat symptoms, conditions, or ailments other than subluxations. I will not venture into the practice of medicine by advising about the need for alterations of medications. I suggest you speak with your medical physician to determine the objective and goal to be obtained by receiving the medical treatment. Determine if this is consistent with your desire for wellness at this point and time. Your medical physician may guide you in changing any medication or treatments you are taking to accommodate for your changing body-mind. Consistent with these concepts, I choose to help each individual member of my practice to a greater level of wellness, empowerment, and healing by locating and adjusting with whatever technique appears most honoring to that individual. Sincerely, Grace Johnstone, D.C. Rick Eschholz, D.C. I have read this statement of purpose and understand its contents. I understand that the adjustments offered in this office are not a replacement for diagnosis or treatment provided by other types of practitioners. I understand that I am not being treated from any condition or symptom other than subluxations. I therefore accept chiropractic care on this basis. I assume full responsibility for paying for the care and services I receive here should my insurance company, for any reason, elect not to pay. I have read and understand the fee schedule offered at this office. We may charge interest on balances that are 30 days or more overdue. This is computed at the rate of 1 ½ % per month (18% APR) on the total amount owed. Additionally, I authorize the release of any medical or other information necessary to process insurance claims. Signature*Date* Date Format: MM slash DD slash YYYY MinorIs patient a minor?*YesNoCONSENT TO TREATMENT OF A MINOR I hereby authorize the physicians at Hardwick Chiropractic to administer treatment, as she/he deems necessarySignatureDate Date Format: MM slash DD slash YYYY Witnessed byWitness SignatureHIPPA Consent For Use or Disclosure of Health Information Consent* I have read your consent policy and agree to its terms. I am also acknowledging that I have received a copy of this notice.Our Privacy Pledge Hardwick Chiropractic is very concerned with protecting your privacy. While the law requires us to give you a copy of this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information. We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services. We may need to use your health information within our practice for quality control or other operational purposes. We may send you correspondence in the form of postcards, birthday cards, thank you letters, health information, monthly newsletters, and other information. We may also send gift certificates for referring others patients to us. You have the right to refuse such correspondence. We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form (§ 164.520). We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy practices. Your right to limit uses or disclosures You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. Your right to revoke your authorization You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. Appointment Reminders Your chiropractor and member of the practice staff may need to use your name, address, phone #, e-mail and clinical records to contact you with appointment reminders, information about treatment alternatives or other health-related information. If this contact is made by phone and you are not at home, a message will be left on your answering machine. By signing this form, you are giving us authorization to contact you with these reminders and information. Name* First Last Signature*Date* Date Format: MM slash DD slash YYYY Communication by Email, Text Message, and Other Non-Secure MeansCONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS I consent to allow Hardwick Chiropractic/Community Hyperbaric to use unsecured email and mobile phone text messaging to transmit to me the following protected health information: * Information related to the scheduling of meetings or other appointments * Information related to billing and paymentIt may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with Hardwick Chiropractic/ Community Hyperbaric there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to: *People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages. *Your employer, if you use your work email to communicate with Hardwick Chiropractic/Community Hyperbaric. *Third parties on the Internet such as server administrators and others who monitor Internet traffic. I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this consent at any time by giving written notice to Hardwick Chiropractic/ Community Hyperbaric at the above address.SignatureDate Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
