Online Intake Form | Bloom Family Chiropractic

Section 1 of 7

Patient Information

Please complete all fields below. If the patient is under 18, include a parent or guardian's information.

Full Name

Date of Birth

Address

Gender

Phone

Best Email

Occupation

How Did You Hear About Us?

Guardian Name (if patient is under 18)

Relationship to Patient

Guardian Phone

Emergency Contact Name

Relationship

Emergency Phone

Section 2 of 7

Pain Areas

Select all areas where you're currently experiencing pain or discomfort.

Section 3 of 7

Chief Complaint

What is the reason for today's visit?

When did this incident begin?

Was your pain completely resolved last time?

Have you experienced this pain or injury before? If so, please elaborate.

Have you seen anyone else for this pain?

What have you tried to make the pain better?

What aggravates the pain?

Is there a time of day the pain worsens? If so, when?

Is your pain constant or does it come and go?

Constant Intermittent (comes and goes)

Are you experiencing pain anywhere else, and/or does the pain travel anywhere? If so, where?

Section 4 of 7

Medical History

Have you been diagnosed with any illnesses or conditions? If so, please list them here.

Are you currently being treated for these conditions? If so, which ones?

Please list out all of the medications you are currently taking and the reason(s) for each.

Have you had any surgeries? If so, please list them below and the year in which they were performed.

Have you ever been hospitalized? If so, why and when?

Do you have a history of broken bones? If so, please list with the year(s) of the injury.

Do you have any known allergies? (to medications, foods, environment, latex, etc.)

Section 5 of 7

Lifestyle

How many hours a day do you sit?

How many hours a day do you stand?

Do you smoke? If so, how many a day?

Do you drink alcohol? If so, how much a week?

Do you take recreational drugs? If so, how often?

Is there anything else you would like to share with me?

Section 6 of 7

Review of Systems

Please check any symptoms you currently have or have experienced recently.

Cardiovascular

Respiratory

Ears / Nose / Throat

Genitourinary

Hematologic / Lymphatic

Easy bleeding Swollen lymph nodes History of anemia

Allergic / Immunologic

Seasonal allergies Food allergies Medication allergies Frequent infections Autoimmune disease

Endocrine

Psychiatric

Section 7 of 7

HIPAA Acknowledgment

Under HIPAA, you have the right to privacy regarding your protected health information. We use your health information to provide treatment, bill for services, and run the everyday operations of our practice — and we won't use or share it for any other purpose without your written authorization, except where required by law. Signing below only confirms you've received, or had the opportunity to receive, our full Notice of Privacy Practices, available at our office upon request.

I acknowledge receipt of, or the opportunity to receive, the Notice of Privacy Practices.

Patient (or Guardian) Signature (type full name)

Date