Professional Documents
Culture Documents
New Patient Intake Form
New Patient Intake Form
African American
Hispanic
Japanese
Korean
Chinese
Filipino
Preferred Language:
English
Chinese
Other _______________
Spouse Data
Marital Status Single Married Other
Emergency Contact
Contact Name: ___________________________ Phone: (______) _______-____________
Employer Data
Employment Status: Employed Full Time Student Part Time Student Other
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Insurance Information
SKIP THIS SECTION UNLESS YOU ARE INSURED BY SOMEONE OTHER THAN YOURSELF
Relationship to Insured: Spouse Child
Referral Information
How did you hear about our clinic?
Family/Friend ______________ Physician ____________ Online ___________ Other ____________
Primary Physician
Please list your primary physicians name here: _______________________________________________
Medical Conditions
Review of Body Symptoms:
Musculoskeletal:
Have
Had
None
Neurological:
Have
Had
None
Cardiovascular:
Have
Had
None
Respiratory:
Have
Had
None
Digestive:
Have
Had
None
Sensory:
Have
Had
None
Integumentary/Skin:
Have
Had
None
Endocrine:
Have
Had
None
Genitourinary:
Have
Had
None
Constitutional:
Have
Had
None
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Joint Replacement
Laminectomies
Allergies: None
Eggs
Fish or shellfish
Milk or Lactose
Peanut
Soy
Sulfites
Wheat/Gluten
Medications _____________
Symptoms: _____________________________________
Smoking History:
Smoke Tobacco: Never Occasionally Often
If often, how much? 1 pack or less per day 1 pack or more daily
What is your interest in quitting smoking? No interest Some interest Very interested
Social History:
Drink alcohol: Never Occasionally Often
Coffee Used: Never Occasionally Often
Soda Pop Used: Never Occasionally Often
Recreational Drug Use: Never Occasionally Often If yes, please specify ________________________
Your health eating habits:
Excellent
Very Good
Good
Fair
Poor
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No
Symptoms
What describes the nature of your symptoms?
Sharp
Dull ache
Numb
Shooting
Burning
Yes
No
Tingling Stabbing
If you have seen treatment for the past for the same or similar symptoms, who did you see?
Other Chiropractor
Medical Doctor
Physical Therapist
Other ________________
By using the key below, indicate on the body diagram where you are experiencing the following symptoms:
# = Numbness
X = Burning
/ = Stabbing
+ = Dull Ache
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Frequently
(51-75% of the day)
Occasionally
(26-50% of the day)
Intermittently
(0-25% of the day)
Getting worse
Not changing
Other Chiropractor
Medical Doctor
Physical Therapist
Physical Therapy
Medication
Surgery
3 6 months ago
5 10 years ago
CT Scan
Other
3 6 months ago
5 10 years ago
2 3 months ago
2 5 years ago
MRI
2 3 months ago
2 5 years ago
During the past 4 weeks, indicate the average intensity of your symptoms: (0 = None to 10 =
Unbearable)
0 None
1-2
7-8
9-10 Unbearable
3-4
5-6
During the past 4 weeks, how much has pain interfered with your normal work (including both work outside the
home and housework):
Not at all
A little bit
Moderately
Quite a bit
Extremely
During the past 4 weeks, how much of the time has your condition interfered with your social
activities?
All of the time
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PAYMENT is due at the time of service, unless other arrangements have been made.
AN INSURANCE CONTRACT is between the patient and the patients insurance company; therefore it is the
responsibility of the patient to keep the account current.
The patient is responsible for keeping track of his/her medical visits, especially when visiting other clinics; in
relation to plan benefits.
Patients involved in LITIGATION (lawsuits) are, as are others, responsible for their service here at the clinic.
Personal cleanliness is requested due to the close interpersonal nature of this work.
ATTENDANCE
1.
2.
Patient must arrive on time; otherwise the appointment will be reduced or rescheduled.
It is the patients responsibility to notify the office, at least 24 hours in advance, if the appointment will be
cancelled or rescheduled.
3.
We reserve the right to BILL FOR MISSED APPOINTMENTS. There will be a $25 charge per appointment.
4.
Failure to comply with attendance policies can affect, and possibly terminate, your future treatments at the
center.
My signature is an acknowledgement that I have read the policy above and agree to abide by the same and
authorize the office of Hong Zeng Yuen-Schat (Dr. Zen), D.C. to treat and/or release any medical information
necessary to process this claim and request payment of benefits to either to myself or to the party who
accepts assignment below.
_____________________________________________________
Signature of Patient
________________________
Date
If youve been injured in an auto or work accident please fill out Auto/Workers Comp Form.
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