ARP INTAKE FORM

MUST be filled out 24 hours before your scheduled appointment.

Today's Date Today's Date / MM / DD YYYY
Name Name Title First Middle Last Suffix
Preferred Name
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female Other Other
Height
Weight
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Occupation
Employer
Whom my we thank for referring you?
Please upload a picture of your drivers license.

Attach Files
If you are using insurance, please upload a picture of your insurance card.

Attach Files
Emergency Contact
Name Name First Last
Phone Phone - ### - ### ####
Relationship
Primary Care Physician or Referring Physician
Name Name Title First Middle Last Suffix
Phone Phone - ### - ### ####
REASON FOR VISIT
What is your primary problem or concern we can address today?
Do your symptoms travel from the primary region or do you feel any weakness associated with this problem? Please explain.
Roughly when did your symptom's begin?
What do you think caused your current symptoms?
How would you describe your severity (mild/moderate/severe or something in between)
How often do you experience your symptoms? Weekly, Daily, hourly, constant, frequent, seldom, etc.
In your own words, how would you describe your symptoms (dull, ache, stiff, sharp, numb, weak, etc)?
Are your symptoms worse during particular times of the day (Mornings, evenings, after work) or just with activity (See below if activity)?
What activities or positions aggravate your conditions? (ie sitting, standing, running, walking, bending at the waist, turning your neck, etc). Please explain.
Does this interfere with work, sleep, daily routine, or recreation? Please explain.
What things can you do to improve your symptoms?
What else would you like us to know about your condition?
HEALTH HISTORY
What other treatments have you done for this condition? (medications, injections, surgery, physical therapy, chiropractic, etc)
Have you had any previous imaging (xray, MRI, CT, other)? Please list the approximate study date and the doctor who ordered it.
Please list any surgeries - date and procedure.
List any current medications or supplements you take - name and amount.
Current illnesses or injuries

Current illnesses or injuries Dizziness Arthritis Digestive Disorders Backaches Headaches Nervousness Heart Trouble Numbness Sinus Trouble Diabetes Asthma Anemia Hernia Neuritis Cancer Disc Bulge Pinched Nerve Whiplash NONE Other Other
Please list any injuries we should be aware of and when? (significant MVA's, Broken bones, falls, sprains/strains, etc)
WOMEN ONLY
Are you pregnant?
Related to bone density
Do you have irregular cycles?
Are you taking birth control?
FAMILY HISTORY
Please list diagnosed health conditions and untimely deaths (condition, relationship to you). Family members include: Parents and siblings and maternal and paternal grandparents/aunts/uncles (Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)
LIFESTYLE
Do you smoke?
Do you drink alcohol?
Do you exercise?
Do you have a healthy and balanced diet?
How are your stress levels?
Please mark any of our other services you would be interested in learning more about.

Please mark any of our other services you would be interested in learning more about. Dry Needling Endurance Coaching and Programming 60 or 90min Massage VO2max and FATmax Testing Video Gait Analysis Personal Training Orthotics Small Group Training (3-6 people) Supplements Nutrition Coaching TransformME Program
I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. I agree with this statement of authorization
Draw your signature into the box below.

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Full Name

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ARP INTAKE FORM

ARP INTAKE FORM

Emergency Contact

Primary Care Physician or Referring Physician

REASON FOR VISIT

HEALTH HISTORY

WOMEN ONLY

Related to bone density

FAMILY HISTORY

LIFESTYLE