Intake Form FORMS Application for Chiropractic Treatment Step 1 of 9 11% Patient's Name* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient's gender*Please SelectMaleFemaleHome PhoneCell PhoneNumber of ChildrenIs patient a minor?*Please SelectYesNoDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Referred to our clinic by Relationship Status*Please SelectSingleMarriedDivorcedWidowedSeparatedParent or Guardian* First MI Last Email Enter Email Confirm Email Are you employed?*Please SelectYesNoDoes your pain relate to a Workers Comp claim?*Please SelectYesNoWhere are you employed?* Employer's Name* First Last Employment Phone*Employment Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Does your pain relate to a motor vehicle accident?*Please SelectYesNoEmergency ContactName First MI Last Relationship Primary PhoneSecondary PhoneAuthorization for Release of Your Patient Information: (optional)Name First MI Last Relationship Please mark the exact location of your pain or symptoms on the diagrams below*Click or tap the X to reset Please mark the exact location of your pain or symptoms on the diagrams below*Click or tap the X to reset Workers Comp Claim FormWe are very pleased you have chosen our doctors to get you back on the path to wellness after your Workers Comp injury. We will be glad to forward your treatment plan and billing to your employer’s insurance carrier. For us to do this it will be necessary to provide us with the following information in order to be seen on your appointment date. Notify your employer that you will be seeing our doctors. Employer HR Contact Name* First Last HR Contact Phone*Name of the insurance company.* Address of your insurance company* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Phone*Name of the person handling your claim* First Last Their phone number*6) Claim Number* Motor Vehicle Treatment Form We are very pleased you have chosen our doctors to get you back on the path to wellness after your automobile accident. It is not our clinic policy to file automobile medical claims on a third-party policy, regardless of which party is at fault. We will be glad to forward your treatment plan and billing to YOUR automobile insurance company. For us to do this it will be necessary to provide us with the following information in order to be seen on your appointment date Name of your insurance company* Medical claim number you were given when you filed your medical claim with your automobile insurance company* Name of the person handling your medical claim* First Last Phone number of the person handling your claim to whom claims and bills will be sent by our clinic* Major Complaint(s):*Please describe your major complaint(s) and describe the frequency and nature of your pain. For example: dull, sharp, constant, off and on, when standing, when sitting, etc.When did your condition first begin?* How did your condition develop?*What caused it?*Have you ever had this problem or similar problem before?*Please SelectYesNoIf yes, please explain*Have you seen another chiropractic physician for this complaint?*Please SelectYesNoIf yes, who?* What was their diagnosis?*Have you seen another medical physician for this complaint?*Please SelectYesNoIf yes, who?* What was their diagnosis?*Is your condition getting better, worse, or staying the same?*Please SelectBetterWorseSameWhat makes your condition worse?What makes your condition better?Have you ever been involved in an automobile accident?*Please SelectYesNoIf yes, when and where?*What surgeries have you had? Include Date:*Please list drugs you now take:Please list vitamins, minerals, supplements, and/or herbs you now take:Other conditions or additional comments:Signature of Patient* I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I understand and agree that the health and accident insurance policies are an arrangement between me and my insurance company. I understand that this clinic will file insurance forms to assist me in obtaining payment from the insurance company and that any amount authorized to be paid directly to this clinic will be credited to my account on receipt. I also authorize the release of any needed information. I understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable within 30 days. I also understand that I am giving my consent to be treated. Scheduled appointments that are not kept by the patient with no prior notification of cancellation may be subject to a $25 charge. Returned checks for insufficient funds may be charged $30 per incident. Signature of Parent or Guardian* I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I understand and agree that the health and accident insurance policies are an arrangement between me and my insurance company. I understand that this clinic will file insurance forms to assist me in obtaining payment from the insurance company and that any amount authorized to be paid directly to this clinic will be credited to my account on receipt. I also authorize the release of any needed information. I understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable within 30 days. I also understand that I am giving my consent to be treated. Scheduled appointments that are not kept by the patient with no prior notification of cancellation may be subject to a $25 charge. Returned checks for insufficient funds may be charged $30 per incident. Insurance Benefit InformationInsurance Information: Please upload a FRONT AND BACK copy of your medical health insurance card(s) in addition to a copy of your driver's license. OR, please provide the following information: A copy of your insurance card (s) and driver's license will be made when you arrive for your appointment. File(s) Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB. Please remember to scan the front and back of your insurance card!! You can scan or photograph your driver's license and insurance card(s) and upload them here. jpg, gif, png, pdf file types only please. OR, please provide the following information: A copy of your insurance card (s) and driver's license will be made when you arrive for your appointment.Insurance Company Name Provider Customer Service PhoneMember ID Number Group Number Secondary Insurance Provider's InformationInsurance Company Name Provider Customer Service PhoneMember ID Number Group Number Family and Social History: Your History1. Any history of lung disease?*Please SelectYesNoExplain:*2. Any history of bowel problems?*Please SelectYesNoExplain:*3. Any history of genito/urinary problems?*Please SelectYesNoExplain:*4. Any history of cardiovascular disease?*Please SelectYesNoExplain:*5. Any history of neurological diseases?*Please SelectYesNoExplain:*6. Any history of cancer?*Please SelectYesNoWhere:*7. Do you use tobacco products?*Please SelectYesNoHow much?*8. Do you drink alcohol?*Please SelectYesNoHow much?*9. Any history of accident other than automobile?*Please SelectYesNoExplain*10. Any drug, vitamin or herbal allergies?*Please SelectYesNoExplain*Family and Social History: Your Family History1. History of diabetes in your family?*Please SelectYesNoExplain*2. History of heart disease in your family?*Please SelectYesNoExplain*3. History of cancer in your family?*Please SelectYesNoExplain*4. History of arthritis in your family?*Please SelectYesNoExplain* System Review and Past Medical HistoryFrom the following list, please check any symptoms or conditions that apply to you.SKIN* Rashes, psoriasis or dermatitis History of skin cancer New skin growth or mole None of the above EYES* Wear glasses Wear contact lenses Permanent blindness in either eye Cataracts Glaucoma None of the above EARS / NOSE / THROAT* Loss of hearing Ringing in the ears Discharge from the ear Frequent sinus infections Nasal blockage Frequent sneezing Frequent sore throat Loud snoring Recent change in voice quality Sleep apnea Difficulty in swallowing Frequent headache Nose bleeds Exposure to loud noise None of the above Hearing Aids?*Please SelectYesNoRESPIRATORY* Asthma or wheezing Recent bronchitis or chest cold Cough for over the past 2 months Coughing up blood Shortness of breath None of the above HEART & CIRCULATION* Heart attack Hypertension (high blood pressure) Chest discomfort (angina) with physical activity Heart failure or fluid on the lungs Palpitations, racing or pounding heart beat Stroke Blood clot in artery or vein "Mini-strokes" or TIA's "Black out spells" Aneurysm of any blood vessel Frequent ankle swelling at bedtime Heart surgery None of the above STOMACH / INTESTINES* Stomach ulcer of peptic ulcer Frequent heartburn or indigestion Hiatal hernia and or acid reflux Poor appetite Gall bladder attacks Frequent diarrhea Chronic constipation Bright blood from bowels or rectum Dark, tarry stools Liver disease or jaundice None of the above ENDOCRINE / METABOLISM* Thyroid disorder Recent weight gain or loss (More than 10 lbs.) Diabetes None of the above KIDNEYS / URINARY TRACT* Kidney disease or failure History of kidney dialysis Kidney stones or infection Pain or burning with urination Trouble starting urinary stream Dribbling or incontinence Multiple trips to the bathroom to urinate at night Bladder infections during past year Blood in urine during past year Prostate disease None of the above MUSCLES / BONES / JOINTS* Arthritis or other joint disease Chronic back trouble Bone or joint surgery in past year None of the above NERVOUS SYSTEM* Migraine headaches Epilepsy or seizures Depression Other nervous disorder None of the above Specify your other nervous disorder* Date of last seizure* Month Day Year BLOOD* Bleeding or bruising tendency Previous blood transfusion History of hepatitis None of the above REPRODUCTIVE (Women only) Are you or might you be pregnant?*Please SelectYesNo Patient Consent for Use and Disclosure Of Protected Health InformationI hereby give my consent for Little Rock Chiropractic Clinic, P.A. (hereinafter referred to as “LRCC”) to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). LRCC's Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. A copy of this Notice is available upon request to Dr. Richard L. Riley or Denise Moix, our Privacy Officers, or any other LRCC staff member. LRCC reserves the right to revise its Notice of Privacy Practices at any time and agrees to provide me a revised copy upon my request to LRCC. With this consent, the LRCC may call (or text message) my home or other designated phone number on file and leave a message on voice mail or in person in reference to any items that assist LRCC in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent, LRCC may mail to my home or other designated location on file any items that assist LRCC in carrying out TPO, such as patient statements. With this consent, LRCC may e-mail to my home or other designated location on file any items that assist LRCC in carrying out TPO, such as appointment reminders and patient statements. I have the right to request that LRCC restrict how it uses or discloses my PHI to carry out TPO. However, LRCC is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to LRCC's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that LRCC has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, LRCC may decline to provide treatment to me as permitted by Section 164.506 of the Code of Federal Regulations. Today's Date: 12/01/2023Print Patient’s Name* First MI Last Print Name of Legal Guardian, if applicable First MI Last Signature*Consent I have been given and am in receipt of LRCC’s Notice of Privacy Practices.(please initial)* Consent 2 I do not wish to receive a copy of LRCC’s Notice of Privacy Practices.(please initial)* Oswestry Disability QuestionnaireThis questionnaire has been designed to give us information as to how your pain is affecting your ability to manage in everyday life. Please answer by checking one option in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just check the box that indicates the statement which most clearly describes your problem. Section 1: Pain Intensity* I have no pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2: Personal Care (e.g.washing, dressing)* I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I need some help but can manage most of my personal care I need help every day in most aspects of self-care I do not get dressed, wash with difficulty and stay in bed Section 3: Lifting* I can lift heavy weights without extra pain I can lift heavy weights but it gives me extra pain Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed, e.g. on a table Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned I can only lift very light weights I cannot lift or carry anything Section 4: Walking* Pain does not prevent me walking any distance Pain prevents me from walking more than 1 ¼ miles Pain prevents me from walking more than 2/3 mile Pain prevents me from walking more than 1/3 mile I can only walk using a stick or crutches I am in bed most of the time Section 5: Sitting* I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me sitting more than one hour Pain prevents me from sitting more than 30 minutes Pain prevents me from sitting more than 10 minutes Pain prevents me from sitting Section 6: Standing* I can stand as long as I want without extra pain I can stand as long as I want but it gives me extra pain Pain prevents me from standing for more than 1 hour Pain prevents me from standing for more than 30 minutes Pain prevents me from standing for more than 10 minutes Pain prevents me from standing at all Section 7: Sleeping* My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all Section 8: Sex Life (if applicable)* N/A Not applicable My sex life is normal and causes no extra pain My sex life is normal but causes some extra pain My sex life is nearly normal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all Section 9: Social Life* My social life is normal and gives me no extra pain My social life is normal but increases the degree of pain Pain has no significant effect on my social life apart from limiting my more energetic interests e.g. sport Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain Section 10: Travelling* I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad but I manage journeys over two hours Pain restricts me to journeys of less than one hour Pain restricts me to short necessary journeys under 30 minutes Pain prevents me from travelling except to receive treatment Signature*Today's Date: 12/01/2023EmailThis field is for validation purposes and should be left unchanged. Δ