Premiere Healthcare
New Patient Intake Form
Please complete this registration form
start
 
Section 1: Patient Demographics

 
What is your full name? *

As it appears on your birth certificate or medical records.
 
What is your date of birth? *

Format Example: Month/Day/Year
 
What is your street address?

 
What is your city and state?

 
What is your postal or zip code?

 
What is your phone number?

Please enter the best available phone number to reach you.
 
Who were you referred by?

 
What is your age?

 
Who is your emergency contact?

 
What is your emergency contact's phone number?

 
Section 2: Insurance

 
Will you be a medical insurance patient? *

If you answer no, you will be forwarded to the next section.


 
What is the name of the primary insured ?

 
Is the name of the primary insured the same as the patient? *



 
What is the name of the patient?

 
What is the name of your insurance company?

 
Please enter the provider's customer service phone number

 
What is your insurance member ID number?

 
What is your group number?

 
Were you in an auto accident? *

If you answer no, you will be forwarded to the next section.


 
Will you be a medical insurance patient? *

If you answer no, you will be forwarded to the next section.


 
Insurance: What is the date of your accident?

Format Example: Month/Day/Year
 
Insurance: What is the name of the primary insured?

 
Insurance: What is the name of your insurance company?

 
Insurance: What is the phone number of your provider/customer service?

 
Insurance: What is your member ID?

 
Insurance: What is your group number?

 
Insurance: What is the name of your auto insurance?

 
Insurance: What is the phone number of your auto insurance?

 
Insurance: What is the name of the Auto Insurance Contact Person?

 
Insurance: What is the claim or policy number?

 
Please read the insurance legal notes below and accept to continue. *

I understand and agree that health/auto insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
     
 
Section 3: Medical History

Almost there! You'll need to enter your medical history information next.
 
Have you ever been treated for any conditions in the last year?



 
Please describe the conditions you were treated for...

 
What is the date of your last physical exam?

Format Example: Month/Day/Year
 
What is the date of your last blood work?

Format Example: Month/Day/Year
 
Is there a chance that you are pregnant?



 
Female Patients Pregnancy Release *

This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/ her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
     
 
Have you had X-rays taken?



 
Where were the X-rays taken?

 
Are you currently taking medications? *



 
What medications are you currently taking and for what conditions?

Please list dosage and amounts, etc. :
 
What vitamins, herbs or nutritional supplements do you currently take?

Please list for what condition, dosage and frequency
 
Let's play a quick game of "have you ever?"

Not really a game. Just some yes or no questions about your medical history. We gotta make these forms fun somehow :)
 
Have you ever... Broken any bones? *



 
Briefly explain...

 
Have you ever... Been hospitalized? *



 
Briefly explain...

 
Have you ever... Been in an auto accident? *



 
Briefly explain...

 
Have you ever... Had sprains or strains? *



 
Briefly explain...

 
Have you ever... Been struck unconscious? *



 
Briefly explain...

 
Have you ever... Had surgery? *



 
Briefly explain...

 
Section 4: Lifestyle Habits

 
How often do you drink alcohol? *

Please be honest. Your answers are secure.
 
How often do you intake caffeine? *

Please be honest. Your answers are secure.
 
How often do you smoke or vape? *

Please be honest. Your answers are secure.
 
How often do you use drugs (prescribed or recreational)? *

Please be honest. Your answers are secure.
 
How often do you exercise? *

Please be honest. Your answers are secure.
 
How many hours do you normally sleep? *

Please be honest. Your answers are secure.
 
How strong is your normal appetite? *

Please be honest. Your answers are secure.
 
How often do you drink soft drinks / energy drinks? *

Please be honest. Your answers are secure.
 
How much water do you drink daily? *

Please be honest. Your answers are secure.
 
How often do you eat salty foods? *

Please be honest. Your answers are secure.
 
How often do you eat sugary foods? *

Please be honest. Your answers are secure.
 
How often do you use artificial sweeteners? *

Please be honest. Your answers are secure.
 
Section 5: Current Ailments

Almost done! This is the last section.
 
What is the nature of your injury?


 
When was the date of your injury?

Format Example: Month/Day/Year
 
When was the date your symptoms appeared?

Format Example: Month/Day/Year
 
Have you had the same injury before?



 
Please name any other practitioners you've seen for your condition or injury.

 
Have you ever been under chiropractic care?



 
Briefly explain...

 
Do you currently or have you suffered from any of the following:


 
Or any of these:


 
Any of these?


 
And lastly, do you suffer from any of these?


 
Do you experience pain or symptoms every day?



 
Briefly explain...

 
Do your symptoms interfere with daily life?



 
Briefly explain...

 
Are your symptoms worse during certain times of the day?



 
Briefly explain...

 
Do changes in weather affect your symptoms?



 
Briefly explain...

 
Does anything alleviate your symptoms?



 
Briefly explain...

 
Do you wear foot orthotics?



 
What activities aggravate your symptoms?

 
What area is bothering you? Please select your body's region.


 
What type of pain is this causing you?


 
Chiropractic Consent Form *

The California Board of Chiropractic Examiners (government licensing agency) requires all Doctor of Chiropractic practicing in California to obtain written informed consent from their patients to receive care. The doctor must also verbally obtain informed consent. If you have any questions or need to have any words defined for you please let the doctor know.
I hereby give my consent to the performance of the diagnostic tests and procedures and chiropractic and/ or clinical nutrition treatment or management of my condition(s). Chiropractic treatment or management of conditions almost always includes the chiropractic adjustment, a specific type of joint manipulation. Like most health care (medical, dental, acupuncture and therapy) procedures, the serious risks associated with the chiropractic adjustment are extremely rare. Following are the known risks: Temporary soreness/increased symptoms or pain. It is not uncommon for patients to experience temporary soreness or increased symptoms after the first few treatments. Dizziness, nausea and flushing: These symptoms are relatively rare. It is important to notify the chiropractor if you experience these symptoms during or after your care. Fractures: When patients have underlying conditions that weaken bones, like osteoporosis, they may be susceptible to fracture. It is important to notify your chiropractor if you have been diagnosed with a bone weakening disease or condition. If you chiropractor detects any such condition while you are under care, you will be informed and your treatment plan will be modified to minimize risk of fracture.
Disc herniation or prolapsed: Spinal disc conditions like bulges or herniations may worsen even with chiropractic care. It is important to notify your chiropractor if symptoms change or worsen. Other risks associated with chiropractic treatment include rare burns from physiotherapy devices that produce heat or slight muscle/tendon strains with stretching procedures of these tissues.
I understand that the practice of chiropractic, like the practice of all healing arts, is not an exact science, and I acknowledge that no guarantee can be given as to the results or outcome of my care. It is not reasonable to expect my doctor to be able to anticipate or explain all possible risks and complications of a given procedure on any particular visit, and I wish to rely on the doctor to exercise professional judgment during the course of any procedure which he feels at the time to be in my best interest.
I understand that there are other forms of treatment, including drugs and surgery, which could possibly be treatment options for my condition, but this time, I choose chiropractic and/ or nutritional care. If clinical/ therapeutic nutrition is part of my care, I understand that it may consist of but not be limited to the following: Nutritional supplementation of vitamins, minerals, amino acids, and other nutritional or therapeutic substances.
Homeopathic medicine: the use of highly dilute quantities of naturally occurring plants, animals, and minerals to gently simulate the body’s healing responses.
Lifestyle counseling and hygiene: diet therapy, fasting elimination diets, promotion of wellness to include recommendations for exercise, stress reduction and balancing of work and social activities.
I have read or had read to me this informed consent document. I have discussed or been given the opportunity to discuss any questions or concerns with my chiropractor and have had these answered to my satisfaction prior to my signing this informed consent document. I have made my decision voluntarily and freely.
     
 
Cancellation Policy *

We respect the fact that you may, on occasion, need to cancel an appointment. However, we do request 24 hours notice. Should you cancel an appointment without 24 hours notice, we reserve the right to charge for a Late Cancellation/Missed Appointment Fee of Twenty ($20) Dollars. You may or may not be charged this fee depending upon the circumstances and/or number of occurrences.
     
Thank you for submitting your form.
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