Mailing Address:______________________________________________________________

City:________________________ State:____ Zip:__________

Date:_____/_____/_____

Patient’s Full Name __________________________________________

E-Mail: _______________________________________________________

Home Phone: ______________________ Cell: _______________________

____Male ___Female Age:_______ Date of Birth:_____/____/______

__Married ___Single ___Widowed ___Separated ___Divorced

Emergency Contact:____________________________________________________ Relationship:_______________________ Phone: __________________ Address:_______________________________________City:_____________________________ State:______ Zip: _____________

Referred By:

(Next Page)

New Patient Intake Form

Insurance Yes No

PATIENT INTAKE FORM

___________________________________________________________________________________

□ Neurologist□ Orthopedist□ Physical Therapist

□ Primary Care Physician □ Other:_____________ □ No one

□ Extremely□ □ A little bit □ Moderately Quite a bit

8. How much has the problem interfered with your social activities?

□ Extremely□ Quite a bit□ Moderately□ A little bit 7. How much has the problem interfered with your work?

□ Getting Better

□ Numb□ Tingly□ Sharp with motion□ Shooting with motion□ Stabbing with motion□ Electric like with motion□ Other:___________________

4. How would you describe the type of pain?□ Sharp□ Dull□ Diffuse □ Achy□ Burning □ Shooting □ Stiff

□ Occasionally (26-50% of the time) □ Intermittently (1-25% of the time)

□ Workers Compension Other:_________________________________

Auto Accident□ □

□ Chiropractor□ ER physician□ Massage Therapist

10. How long have you had this problem/when did it begin?

9. Who else have you seen for your problem?

NAME:_______________________

1. Is today’s problem caused by:

2. Indicate on the drawings below where you have pain/symptoms:

6. Using a scale from 0-10 (10 being the worst), how would you rate your problem? 0 1 2 3 4 5 6 7 8 9 10 (Please circle)

3. How often do you experience your symptoms? □ Constantly (76-100% of the time) □ Frequently (51-75% of the time)

5. How are your symptoms changing with time? □ Getting Worse □ No change

□ Not at all

□ Not at all

Present Past PresentHigh Blood PressureHeart AttackChest PainsStrokeAnginaKidney Stones/Disorders Bladder InfectionsPainful UrinationLoss of Bladder Control Prostate Problems Abnormal Weight Gain/Loss Loss of AppetiteAbdominal PainUlcerHepatitisLiver/Gall Bladder Disorder General FatigueVisual Disturbances DizzinessDiabetesExcessive ThirstFrequent UrinationSmoking/Tobacco UseHIV/AIDSSystemic Lupus

For Females OnlyBirth Control Pills Hormonal Replacement Pregnancy Breast Implants

□ Strenuous □ None□ Moderate □ Light

□ Excellent □ Very Good □ Good □ Fair □ Poor

A:___________________________________________

Past

11. Do you consider this problem to be severe? □ Yes □ Yes, at times □ No

12. A: What aggravates your problem? B: What makes it better?

13. What concerns you the most about your problem? What does it prevent you from doing? _______________________________________________________________________________

15. What type of exercise do you do?

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

B:_____________________________________________

14. How would you rate your overall health?

HeadachesNeck PainUpper Back PainMid Back PainLow Back Pain Shoulder PainElbow/Upper Arm Pain Wrist PainHand PainHip PainUpper Leg PainKnee PainAnkle/Foot PainJaw PainJoint Pain/ Stiffness ArthritisRheumatoid Arthritis CancerTumorAsthmaAllergiesChronic Sinusitis DepressionEpilepsy/SeizuresDermatitis/Eczema/Rash

□ Most of the day □ Most of the day □ Most of the day □ Most of the day

□ A little of the day □ A little of the day □ A little of the day □ A little of the day

□ Sit:

□ Computer work: □ On the phone:

□ Stand:□ Half the day □ Half the day □ Half the day □ Half the day

□ Yes□ No

if yes, explain _______________________________________________________________________

___________________________________________________________________________________

□ Yes□ No

Patient Signature___________________________________ Date:____________________

19. List all surgical procedures you have had: ________________________________________________________________________________

20. What activities do you do at work?

21. What activities do you do outside of work? _________________________________________________________________________________

22. Have you ever been hospitalized?

if yes, why __________________________________________________________________________ ___________________________________________________________________________________

18. List all of the over-the-counter medications you are currently taking: ________________________________________________________________________________

17. List all prescription medications you are currently taking: _______________________________________________________________________________

23. Have you had significant past trauma? Auto accident, slip, fall, etc.

24. Anything else pertinent to your visit today?__________________________________________ __________________________________________________________________________________

Mode of Onset: Pain Frequency:Intermittent FrequentOccasional Constant

Migraine Left Dull AcheHeadache Right Sharp Throbbing

Bilateral StabbingPAIN SCALE out of 10

Neck Pain Left Dull AcheRight Sharp Throbbing

Bilateral Stabbing

PAIN SCALE out of 10

Shoulder Pain Left Dull Ache

Right Sharp

Bilateral

PAIN SCALE out of 10

Upper Extremity Left Hand LeftRight Fingers Right

Bilateral Wrist Pain BilateralPAIN SCALE out of 10 Elbow

Mid Back Pain Pain Between Hand Numbness & Left

Shoulder Blades Fingers Tingling RightWrist Pain Bilateral

PAIN SCALE out of 10 Elbow

Low Back Pain Left Buttock Left

Right Right

Bilateral Bilateral

PAIN SCALE out of 10

Lower Extremity Left Hip Pain Ankle Pain

Right Knee Pain Foot PainBilateral

PAIN SCALE out of 10

Burning

Burning

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Burning

()*+$$%&'

!"#$%&'' ()*%+,*%+

  

I hereby consent to the performance of chiropractic adjustments and other chiropractic procedures, on myself (or on the patient named below, for whom I am legally responsible) by Richard L. Austin, D.C., and/or other licensed doctors of chiropractic who now or in the future provide chiropractic adjustments and other procedures for me. This consent includes other doctors of chiropractic that are employed by, associated with, or serve backup for Richard L. Austin, D.C., whether or not their names are listed on this form. I understand and consent to the following procedures:

• EXAMINATION • MASSAGE • MOBILIZATION • EXTREMITY EXERCISE INSTRUCTION • SPINAL EXERCISE INSTRUCTION • ADJUSTMENTS • X-RAYS • REHAB EXERCISE

I have had the opportunity to discuss, with Richard L. Austin, D.C., the various types of treatment, including neck and spinal/extremity adjustments, which have been proposed to me for my condition, and the purpose and objectives of these chiropractic procedures. I understand that the results from the chiropractic treatment are not guaranteed for my condition. I have been informed about the risks and benefits of the chiropractic adjustments and other chiropractic procedures, and understand that, there are some uncommon potential serious risk to chiropractic adjustments and procedures, including, but not limited to, sprains, fractures, disc injuries, dislocations, nerve injuries and strokes, specifically from neck adjustments. I understand and have had the opportunity to ask about risks and benefits of the proposed treatment and of other alternative types of treatments for my condition. I have had the opportunity to read this form and I understand the above statements, accept the risks mentioned, and hereby consent and agree to chiropractic treatment over the entire course of treatment for my present condition and any future conditions for which I seek treatment.

___________________________________________ ________________________ PATIENT SIGNATURE or LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT (Please indicate your name and relationship to the patient, if the patient is under the age of 18)

___________________________________________ ________________________ PRINTED NAME DATE

456 78 9&%."% (.):;.'/ <! =>>?46@5A BBCA5455

  

OUR PRIVACY PLEDGE   

We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information.

● We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.

● We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.

● We may need to use your health information within the practice for quality control or other operational purposes.

YOUR RIGHT TO LIMIT USES OR DISCLOSURES

You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions; however, if we agree with your restrictions, the restriction is binding on us.

YOUR RIGHT TO REVOKE YOUR AUTHORIZATION

You may revoke your consent to us at any time; however, your revocation must be in writing. WE will not be able to honor your revocation request if we have already released your health information prior to receiving your request to revoke your authorization. If we were required to give your authorization as a condition of obtaining insurance, the insurance company may have the right to your health information if they decide to contest any of your claims.

___________________________________________ ________________________ PATIENT SIGNATURE or LEGAL REPRESENTATIVE RELATIONSHIP TO PATIENT (Please indicate your name and relationship to the patient, if the patient is under the age of 18) ___________________________________________ ________________________ PRINTED NAME DATE

We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form (164.520). We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy notices.

456 78 9&%."% (.):;.'/ <! =>>?46@5A BBCA5455

215 SE Urania Ln Bend, OR 97702

(541) 668-1211

List of Charges

Treatment (CPT Code) Insurance Billed Pricing Time of Service Pricing New Patient Initial Exam (99202): 1-2 Region Manipulation (98940): 3-4 Region Manipulation (98941): 1 Unit of Massage (97124): 4 Units of Massage (97124): Time of Service Pricing is the price associated with paying for treatment the same day of your appointment. This is offered to both patients and insurance companies. Price is lower due to the convenience of immediate payment and not having to send off an insurance claim. Billing insurance is not a guarantee of payment. Insurance payments are determined based off of patient plan coverages, deductible and coinsurance responsibility. I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any and all professional services rendered. Signature: __________________________________________ Date: ________________

$120

$55

$70

$30

$120

$65

$40

$40

$25

$65