New Patient Intake - Acupuncture and Chiropractic

Elements Holistic Wellness
New Patient Intake - Acupuncture and Chiropractic
This CONFIDENTIAL questionnaire helps us determine the best treatment plan designed specifically for you. Please fill it out as completely as possible, even if you do not feel certain questions pertain to your
present condition. Thank you!
Full Name

First NameLast Name
Gender
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
What is your preferred method of contact?
Click to edit
Can we leave a message at this number?
E-Mail
(used primarily for e-mail reminders for appointments)
Preferred Appointment Reminders Contact
Employer/Occupation
Status
Number of Children
Whom should we thank for referring you to our office?
We occasionally send newsletters to our clients with information about our services, staying healthy, and deals we are currently offering. You can opt out at any time.
Payment Type
If you answered "Health Insurance" for the last question, please answer the next three questions. Otherwise, please skip ahead to the physican questions.
Insurance Name
Insurance ID Number
Group Number
Secondary Insurance
Insurance ID
Group Number
Are you currently under the care of a physician?
Primary Care Physician
PCP Office Phone Number
PCP Specialty
Responsible Party Information (If the patient is a minor)
Name
Relationship to Patient
Address (If Different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Phone Number

Area CodePhone Number
Health Information
Please describe your current health. For major events, please include when they began and their duration.
How often are your symptoms present?
Can you perform your daily activities?
Check any pain areas that apply:
How would you describe your pain?
Please list and describe any major hospitalizations, surgeries, and/or treatment procedures, including the year they happened.
Medications, Supplements, and Herbs (please list dosage and times taken each day)
Please list any allergies you have, including your usual reaction
Have you ever had any of the following? (Check for Yes)
Have you experienced any of the following in the past year?
Do you have a blood relative with any of the following? Please indicate relationship to patient for "yes" answers.
Relationship to Patient for Above "yes" responses:
Do any of the following apply to you, or have they in the past? Please elaborate below.
Please elaborate on any checked boxes.
Health Habits
Do you eat a special diet?
If yes, please describe:
Do you exercise regularly?
If yes, how many times per week?
What method of exercise do you use?
Please indicate your use and frequency for the following:
Coffee
Soda
Water
Alcohol
Recreational Drugs
Tobacco
Women Only: Do any of the following apply to you?
Is this visit due to a Motor Vehicle Accident?
Please also fill out the Motor Vehicle Accident form.
Do you wear:
Is this visit due to an on the job injury?
Have you ever had acupuncture before?
Have you ever had chiropractic work before?
Have you ever had any x-rays taken?
If yes, of what area?
What was the date of your last physical exam?
What would you like to achieve with treatment?
Emergency Contact Information
Name
Relationship
Phone Number
I certify that the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive health care benefits through Elements Holistic Wellness, I understand that I am liable for ALL charges for services. I agree to notify Elements Holistic Wellness immediately whenever I have changes in my health plan coverage.
I understand that Elements Holistic Wellness may need to contact my primary care provider (PCP) if my condition needs to be co-managed. Therefore, I give my authorization to Elements Holistic Wellness to contact my medical doctor if necessary.
If my account is assigned to an attorney for collection and/or suit due to delinquency, the prevailing party shall be entitled to reasonable attorney’s fees and cost for collection.
I authorize any insurer to make payment for services rendered by Elements Holistic Wellness directly to Elements Holistic Wellness at 15240 SE 82nd Drive, Clackamas, OR 97015.
I authorize Elements Holistic Wellness to provide acupuncture, massage, and chiropractic services to me.
Electronic Signature: please write your full name and today's date.
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Elements Holistic Wellness

New Patient Intake - Acupuncture and Chiropractic

Responsible Party Information (If the patient is a minor)

Health Information

Health Habits

Please also fill out the Motor Vehicle Accident form.