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New Patient Intake Form

19199 15 Mile Rd. Clinton Township MI, 48035
PHONE (586)791-5555 | FAX (586)791-5575

Please allow our staff to make a copy your driver’s license and insurance details. All information you supply is confidential. We comply with all federal privacy standards. Please print clearly.

Today’s Date (MM/DD/YYYY) Whom may we thank for referring you?

Last Name First Middle(or Initial)

Street Address

City State/Province ZIP/Postal Code

Home Phone Cell Email Address

Gender MaleFemale

Birth Date (MM/DD/YYYY) Other Family Members

Occupation

Employer Phone

Preferred method of contact Home PhoneCell PhoneWork PhoneEmail

Primary Care Physician Phone

Emergency Contact Phone Number

Insurance Carrier Policy Number

Group ID # Carried by selfsposeparent

Insured’s Last Name First Middle Initial)

Insured’s Birth Date (MM/DD/YYYY)

Insured’s Employer Phone

Street Address

City State/Province ZIP/Postal Code

Have you seen a Chiropractic Physician before? yes no

Who? When?

Reason for Visit at that time:

How did you respond?

Name: Date:

The symptom(s) that have prompted me to seek care include:

And are the result of: work injury auto accident wellness other

Intensity: On a scale from 0-10 (10 being severe) how much pain does it cause?

Duration and timing: How often do you feel your symptoms? constant comes and goes

How often?

Symptoms: What does it feel like?
numbness tingling stiffness dull aching cramps nagging sharp buring shooting throbbing stabbing

Other:

Location: Were does it hurt?

What areas, if any, does the pain radiate, shoot or travel?

Aggravating/relieving factors: What makes it better or worse? time of day movements certain activities other

What makes the pain worse?

What makes the pain better?

What previous treatments have you done for this condition?

What else should the Doctor know about your current condition?

Activity Pain

Sitting: no mild moderate severe

Rising out of chair: no mild moderate severe

Standing: no mild moderate severe

Walking: no mild moderate severe

Lying down: no mild moderate severe

Bending over: no mild moderate severe

Climbing stairs: no mild moderate severe

Using a computer: no mild moderate severe

Getting out of car: no mild moderate severe

Driving car: no mild moderate severe

Looking over shoulder: no mild moderate severe

Caring for family: no mild moderate severe

Grocery shopping: no mild moderate severe

Household chores: no mild moderate severe

Light lifting: no mild moderate severe

Reaching overhead: no mild moderate severe

Showering/bathing: no mild moderate severe

Dressing self: no mild moderate severe

Getting to sleep: no mild moderate severe

Concentrating: no mild moderate severe

Exercise: no mild moderate severe

Yard work: no mild moderate severe

Intimacy: no mild moderate severe

Mother:

State of health good poor

Age Illnesses Age of death Cause of death

Father:

State of health good poor

Age Illnesses Age of death Cause of death

Sister 1:

State of health good poor

Age Illnesses Age of death Cause of death

Sister 2:

State of health good poor

Age Illnesses Age of death Cause of death

Brother 1:

State of health good poor

Age Illnesses Age of death Cause of death

Brother 2:

State of health good poor

Age Illnesses Age of death Cause of death

Other:

State of health goodpoor

Age Illnesses Age of Death Cause of Death

Are there any other hereditary health issues of which you are aware?

For each of the conditions listed below, place a check in the "past" box if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" box.

Headaches pastpresent

Neck Pain pastpresent

Upper Back Pain pastpresent

Mid Back Pain pastpresnt

Low Back Pain pastpresent

Shoulder Pain pastpresent

Elbow/Upper Arm Pain pastpresent

Wrist Pain pastpresent

Hand Pain pastpresent

Hip Pain pastpresent

Upper Leg Pain pastpresent

Knee Pain pastpresent

Loss of Appetite pastpresent

Joint Pain/Stiffness pastpresent

Hepatitis pastpresent

Cancer pastpresent

Muscular Incoordination pastpresent

Chronic Sinusitis pastpresent

High Blood Pressure pastpresent

Heart Attack pastpresent

Chest Pains pastpresent

Stoke pastpresent

Angina pastpresent

Kidney Stones pastpresent

Kidney Disorders pastpresent

Bladder Infection pastpresent

Painful Urination pastpresent

Loss of Bladder Control pastpresent

Prostate Problems pastpresent

Abnormal Weight Gain/Loss pastpresent

Jaw Pain pastpresent

Ulcer pastpresent

Rheumatoid Arthritis pastpresent

General Fatigue pastpresent

Asthma pastpresent

Dizziness pastpresent

Diabetes pastpresent

Excessive Thirst pastpresent

Frequent Urination pastpresent

Smoking/Tobacco Use pastpresent

Drug/Alcohol Dependency pastpresent

Allergies pastpresent

Depression pastpresent

Systemic Lupus pastpresent

Epilepsy pastpresent

Dermatitis/Eczema/Rash pastpresent

HIV/AIDS pastpresent

Ankle/Foot Pain pastpresent

Abdominal Pain pastpresent

Arthritis pastpresent

Liver/Gall Bladder Disorder pastpresent

Tumor pastpresent

Visual Disturbances pastpresent

Other pastpresent

For Females Only: birth control pillshormonal replacementpregnancy

List all prescription medications you are currently taking

List all the over-the-counter medications you are currently taking

List all Supplements and Herbs

List all surgical procedures you have had

Alcohol Use dailyweeklyoccasional

How much?

Coffee Use dailyweeklyoccasional

How much?

Tobacco Use dailyweeklyoccasional

How much?

Exercising dailyweeklyoccasional

How much?

Pain Relievers dailyweeklyoccasional

How much?

Water Intake dailyweeklyoccasional

How much?

Hobbies:

Mercury Filling yesno

Recreational Drugs yesno

How much sleep are you getting per night? Hours

Preferred Sleeping Position: backsidestomach

Typical Eating Habits:

In addition to the main reason for your visit, what are your other health goals?

In order to set clear expectations, improve communication and help you attain the best results, please read each statement and initial your agreement.

I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered at Duchene Chiropractic is based on evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art form from medicine and does not proclaim to cure any named disease or entity. yes

I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.yes

I realize that an X-ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not pregnant. yes

Date of last menstrual period (MM/DD/YYYY)

I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards letters, emails or health information, as an extension of my care in this office.yes

I acknowledge that any insurance I may have is an agreement between the carrier and myself and that I am responsible for the payment of any covered or non-covered services that I receive.yes

To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.yes

If the patient is a minor child, print child’s full name:

Insurance Policy and Fee Schedules

Consultation includes practice member history. This is a complimentary service.
Examination (new patient and established patient) includes one or more of the following: range of motion, motion and/or static palpation, muscle testing, dermatome testing, and leg check.
Chiropractic Adjustment, this is the actual realignment of the vertebra, a manual or specific instrument spinal adjustment will be delivered to help re-align the vertebra.
X-rays may be taken with specific views of your spine to determine a misalignment/subluxation of your vertebrae. These can also be used to help indicate progress after a period of care.

Release of Authorization/Assignment of Benefits

I authorize the release of any information necessary to process my insurance claims. I authorize and request payment of insurance benefits directly to Duchene Chiropractic. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for the service when rendered unless other arrangements have been made in advance. I understand that I am Financially responsible for any charges not covered by this assignment.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

December 23, 2020 10:48 am CDT

New Patient Intake Form Uploaded by Jeffrey Duchene - drjeff@duchenechiropractic.com IP 24.192.162.13

March 23, 2021 10:43 am CDT

Jeffrey Duchene - jeffreyduchene@yahoo.com added by Bruce Hakala - fred@tppwebsolutions.com as a CC'd Recipient Ip: 24.192.177.123

March 23, 2021 10:47 am CDT

Jeffrey Duchene - jeffreyduchene@yahoo.com added by Bruce Hakala - fred@tppwebsolutions.com as a CC'd Recipient Ip: 24.192.177.123

September 21, 2021 1:05 pm CDT

Jeffrey Duchene - jeffreyduchene@yahoo.com added by Bruce Hakala - fred@tppwebsolutions.com as a CC'd Recipient Ip: 24.192.162.13

September 21, 2021 1:05 pm CDT

Jeffrey Duchene - jeffreyduchene@yahoo.com added by Bruce Hakala - fred@tppwebsolutions.com as a CC'd Recipient Ip: 24.192.162.13

September 21, 2021 1:12 pm CDT

Document owner fred@tppwebsolutions.com has handed over this document to jeffreyduchene@yahoo.com 2021-09-21 13:12:02 - 24.192.162.13

September 21, 2021 1:12 pm CDT

Jeffrey Duchene - jeffreyduchene@yahoo.com added by Jeffrey Duchene - jeffreyduchene@yahoo.com as a CC'd Recipient Ip: 24.192.162.13

October 14, 2021 11:06 am CDT