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Adult Intake Form

How did you hear about us?
Do you have a preference for your main chiropractor at Active Chiropractic?
Medical History
Family Medical History
Your Current / Past Medical History
Do you have any of the following going on?
Primary Complaint
Please rate your pain giving the lowest and highest number if 0 was no pain and 10 was the worst pain you ever had:
Is your pain?
Describe your pain? (can choose more than one)
What aggravates your pain? (can choose more than one)
Home care?
In the past year have you had any of the following special studies?
Depression Screening
Fall Risk Screening Questions
Pregnancy Waiver

By choosing no this verifies that I am not pregnant and in the case that x-rays would taken by Active Chiropractic.  Xrays are harmful to a fetus.

Authorizations and Responsibilities

The information that I have given is correct to the best of my knowledge.  I hereby give my permission to Active Chiropractic to:

  • release or discuss my care with my primary care physician or any other physician associated with my care if deemed necessary

  • release any information acquired in the course of treatment that is requested by my insurance company

  • direct my insurance benefits to be paid directly to Active Chiropractic

  • send appointment reminders via email or text

  • understand I am financially responsible for all services even non-covered services

Active Chiropractic Protecting Your Health Information

New Regulation Passed

This new regulation is part of the Health Insurance Portability and Accountability Act or HIPAA and does three primary things:

1. It helps standardize and simplify the way healthcare organizations exchange healthcare data.

2. It provides consumers with additional protections for getting and maintaining health insurance coverage although, it does not guarantee coverage.

3. It creates new security rules to ensure the safety and privacy of individual and medical records.


Our Pledge Regarding Medical Information

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our office. We need this record to provide you with quality care and to comply with certain legal requirements. In addition, we have a policy in effect that makes every attempt to maintain the confidentiality of all patients’ information.


Disclosure of Medical Information

In addition to disclosing your medical information for treatment, payment and health care operations, we may disclose medical information for the following purposes: for a court order, subpoena, discovery request or other lawful process. We may disclose medical information to appropriate authorities if we reasonably believe that you are a victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose health information when authorized and necessary to comply with laws relating to worker’s compensation, auto accidents, personal injury or other similar issues.

If someone calls or comes by, they will not be given any information about your care and/or appointments unless otherwise specified and noted in your file.


Your Rights

You have the right to look at or get copies of your medical records and to receive a list of all the times we shared your medical information for purposes other than treatment, payment and health care operations.


Open Adjusting Concept

Because of the open adjusting concept in this office, it is possible for doctor/patient discussions to be overheard by other patients. Most discussions will involve spinal health, but may also include anything concerning the primary health care of that patient.


Notification by Mail or Phone

Patients may be contacted by mail, email or phone unless written notification request that contact be only in person.



If you feel that your rights have been violated, contact the Office Manager or the U.S. Department of Health and Human Services.


Email/ Cell

Your email or cell number may be used to send you appointment reminders and will be entered into our database. If you do not wish to receive our appointment reminders or practice updates, please use the unsubscribe feature on email or text messages. Our email and cell list will not be sold to any outside agencies.

Informed Consent:

I give the doctor permission and authority to care for me in accordance with his/her exam findings and analysis. Chiropractic adjustments and adjunctive procedures are usually beneficial and seldom cause any problems. In rare cases due to underlying physical defects, deformities or pathologies you could be susceptible to injury. It’s very important that you make known to the doctor any health issues in your current and past medical history. The doctor will not give any treatment or care if he/she is aware that such issues may be contra-indicated to your treatment. Also, your doctor of chiropractic is licensed as a specialist and is able to work with other types of providers in your health care regimen. I understand as a patient at Active Chiropractic, I am authorizing them to proceed with any treatment that they deem necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request.


Please list who we are able to communicate your healthcare information to?  (ie Spouse, child, parent,friend)


I have read and fully understand the above statements. I have reviewed the notice of privacy practices (HIPAA) and have been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy.

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