Chiropractic Intake Form | PDF | RTF | Word
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The Chiropractic Intake Form serves multiple purposes. The first is to begin the process of evaluating your patient’s condition, and to gather in the information that you need to set a course of treatment that will provide the greatest benefit. The second purpose is to make sure that you have everything you need to successfully bill the patient’s insurance company so that you can be properly compensated for your professional efforts. And, of course, information on this form, which must be signed by the patient, may very well serve as your first line of defense in case any legal difficulties surface in the future.
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How to Write
The first information that a Chiropractic Intake Form must garner include the patient’s name, address, phone number, next of kin and primary care physician. You also need the patient’s insurance company name and the policy number.
Next, the Chiropractic Intake Form must ascertain why the patient is seeking help, and if it is from an injury sustained at work. It must then ask when the patient started experiencing the condition, the intensity of the pain and if it radiates, how often it appears and how long the symptoms last. Of course, the form must note anything else the patient is or has done in relation to the problem. It is also extremely important to ascertain what daily activities exacerbate the patient’s condition.
To make sure all the bases are covered, the Chiropractic Intake Form must ask many of the same questions that a primary care physician would want to know, with a special emphasis on muscular and neurological issues. These include numbness, arthritis, and scoliosis. It is especially important to make note of any medications that the patient is taking.
It is also important that the Chiropractic Intake Form makes note of how the problem that that caused the patient to seek chiropractic intervention may have interfered with his or her work, personal or recreational activities.
In the patient history section, an inventory must be taken of the patient’s medical history. All diseases, surgical operations, and injuries of any sort must be documented. Any past chiropractic treatments should be noted, as well as past or present medical interventions.
In order to get a more complete picture of your patient, the Chiropractic Intake Form should garner information about the patient’s tobacco, alcohol and recreational drug use. What the patient does for a living and his or her sporting activities are vitally important. A brief summary of the medical histories of the patient’s closest blood relatives can also be extremely useful.
Finally, the there must be places for the patient to give his permission for you to do chiropractic manipulation, to take x-rays, and to bill the insurance company. And again, the patient must sign and date the Chiropractic Intake Form.
Download (PDF, 324KB)
Source
www.citychiropracticcenter.com/uploads/New_Patient_Intake_Form-for_web.doc
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