Let’s work together Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Phone * (###) ### #### Email * How do you prefer we contact you to schedule your consultation and examination? * Phone Text Email Primary Care Physician First Name Last Name Occupation Employer Marital Status * Single Married Divorced Widowed Spouse's Name (if applicable) Emergency Contact's Name Emergency Contact's Phone Number Names of Children (if applicable) Are you a veteran or active military? * Yes No How did you hear about our office (please check all that apply)? * Family Friend Google Facebook Instagram TikTok Evolved CrossFit Insurance Other Whom may we thank for referring you to the office? First Name Last Name Medical History Sex * Male Female Height (inches) Weight (pounds) Have you been hospitalized within the past six months? * Yes No If yes please explain reason for hospitalization Have you had a complete spinal examination (including x-rays) within the past year? * Yes No If yes, please explain who performed the exam and what was done. Have you ever been to a chiropractor before? * Yes No If you answered yes, how was your experience? * Good Bad Indifferent Are you nervous about seeing a chiropractor? * Yes No Do you have a preference of which doctor you see? * No preference Dr. Lynn Dr. Matt Reason for initial visit * Wellness and improved health/function Health challenge/concern Is your reason/injury/condition related to an auto accident or work related injury? * Work Injury Auto Accident Neither PLEASE NOTE: IF INJURIES ARE DIRECTLY RELATED TO AN AUTO ACCIDENT OR WORK INJURY AND ARE BEING SUBMITTED TO AUTO INSURANCE OR WORKER'S COMPENSATION, PLEASE REFER TO OUR CORRESPONDING PAPERWORK UNDER "START YOUR JOURNEY" PORTION OF OUR WEBSITE HOMEPAGE List all prescription medications that you are currently taking. And please give the reason for use (not all medications are prescribed for the symptom(s) or condition(s) they were approved for) and the length of time using: Check the box if you are not currently taking any medications I am not currently taking any prescription medications List any Over-The-Counter medications that you take (example: Tylenol) Check the box if you are not currently taking any OTC medications I am not currently taking any OTC medications History of Complaint First Complaint * Date of Onset (approximate) * MM DD YYYY In your words, how would you describe the pain? (examples: ache, burning, numbness) * On a scale from 0 to 10 with 10 being the worst pain you have ever felt and 0 being no pain, how would you rate your discomfort? * How often do you experience the pain? * Constant On/off throughout the day Comes and goes throughout the week What time of day is the problem the worst? * AM Mid-day PM Late PM No specific time of day Does the pain/discomfort radiate into your extremities? * Yes No If yes please explain (where does it radiate to?) Have you suffered with this pain/symptom/condition/injury/illness in the past? * Yes No Have you (in the past or currently) received care for this condition? * Yes No If you answered yes please explain: * Second Complaint Date of Onset (approximate) MM DD YYYY In your words, how would you describe the pain? (examples: ache, burning, numbness) On a scale from 0 to 10 with 10 being the worst pain you have ever felt and 0 being no pain, how would you rate your discomfort? How often do you experience the pain? Constant On/off throughout the day Comes and goes throughout the week What time of day is the problem the worst? AM Mid-day PM Late PM No specific time of day Does the pain/discomfort radiate into your extremities? Yes No If yes please explain (where does it radiate to?) Have you suffered with this pain/symptom/condition/injury/illness in the past? Yes No Have you (in the past or currently) received care for this condition? Yes No If you answered yes please explain: Do you have more than two complaints? * If you answered yes, we will discuss in-person with the doctor. Yes No Review of Systems In the past 6 months have you experienced any of the following health challenges? Please check all that apply. General Fatigue Fever(s) Unexplained weight loss Insomnia Ears, Eyes, Nose & Throat Visual changes Hearing loss Sore throat Trouble swallowing Nasal congestion Ear pain Respiratory Prolonged cough Unable to catch breath Wheezing Snoring Cardiovascular Issues Irregular heartbeat Racing heart Chest pain Swelling of legs or feet Shortness of breath (especially climbing up stairs) Musculoskeletal Joint pain Muscle pain Neurologic Headaches Dizziness Difficulty walking Numbness or tingling (in face, hands and or feet) Seizures Gastro-Intestinal Issues Abdominal pain Constipation Diarrhea Gas Heartburn Nausea Vomiting Genitourinary Painful urination Bloody urine Increased urination Leaking urine Females Only Section Ionizing radiation can be hazardous to an unborn child. * To the best of my knowledge I am not pregnant and the doctor has my permission to perform an x-ray evaluation. I am currently, pregnant and therefore I am unable to receive ionizing radiation at this time. Are you trying to become pregnant? * Yes No Do you suffer with any of the following? Check all that apply PMS Painful monthly cycle Absent monthly cycle Heavy menstrual cycle Abnormal vaginal discharge Polycystic Ovarian Syndrome If you are pregnant How many weeks pregnant are you? Have you been diagnosed with gestational diabetes? Yes No Have you been diagnosed with preeclampsia? Yes No Is your baby breech? Yes No Unsure Do you have a mid-wife? Yes No Where do you plan on having baby? * Home Birthing Center Hospital Mental Health History Are you currently under the care of a health care practitioner (therapist, psychologist, psychiatrist) * Yes No Have you been officially diagnosed with a mental health condition? * Yes No If you answer yes, please explain Are you currently experiencing any of the following Check all that apply Eating related concerns (example: intense fear of gaining weight)) Overwhelming sadness Worry and fear affecting your ability to function Unusual or extreme shifts in mood or energy Issues with attention or behaviors Feel like your brain is playing tricks on you Bothered by a traumatic life event Do you currently or have you ever harmed yourself? * Yes No Have you ever had thoughts of suicide? * Yes No Have you ever attempted suicide? * Yes No Past Medical History Please List any surgeries you have had in the past (or present) * If no surgeries in past say "none" Have you broken any bones in the past (please list)? * If no broken bones say "none" Have you suffered with any major illnesses or are you currently suffering with (for example: diabetes) * If no major illnesses say "none" Family History Has anyone in your family suffer with or is currently suffering with similar condition(s)? * Yes No If yes whom? * Mother Father Sister Brother Grandparents Husband Wife Are there any hereditary conditions that the doctor should be made aware of? * Yes No If yes, please list Social History Do you smoke (cigarettes, cigars, pipe)? * Daily Weekends Occasionally Never Do you consume alcoholic beverages? * Daily Weekends Occasionally Never Do you use marijuana? * Daily Weekends Occasionally Never Do you use drugs recreationally (Example: cocaine, methamphetamines)? * Daily Weekends Occasionally Never If yes, please list which drugs you use and how often. Exercise level (number of times per week 0 - 7) * What position do you typically sleep in? * Back Stomach Side Unsure Life Goals * Possibly being held back by your current condition Do you wish to use health insurance for your visit(s)? * Yes No If you wish for our office to verify your insurance benefits, please provide us with the following information. Primary Insurance Identification Number Secondary Insurance Identification Number Out of Network Health Insurance If we are not in-network with your health insurance, understand that this decision was made after careful consideration. The demands from the insurance companies have became unrealistic. They were requiring PCP referrals, pre-authorizations and forms to be filled out at every visit which didn’t necessarily ensure that patients would have access to their full insurance benefits. Third party management groups were hired by the insurance companies to save the insurance company money by denying care. These management groups ended up dictating how many visits our patients could/could not utilize. Our office is focused on getting you well with the best results possible and we feel that we cannot provide you with the best results if a for-profit insurance company is dictating the care. Additionally, when we did an assessment of the insurance reimbursements we found that the average copayments, for our insurance patients, were within $5-$10 of our regular fees without insurance and in some cases our regular fees offered a savings to our patients. We understand that money can be an issue and a road block to receiving care. We encourage you to reach out to your insurance company and ask them for your chiropractic benefits (for an in-network provider). Compare the rates with our cash plans (which our staff will provide) and then make a decision that is right for you. Don’t just blindly go to another office because they are in your network without knowing the facts. Thank you. * I have read and fully understand the above statements. Standard Waiver of Liability I understand that I am financially responsible for any charges incurred at this office. For those patients using insurance, this would include co-pays, deductibles, and charges denied or not covered by the insurance company. The insurance company will review any and all documentation submitted by New Beginnings Chiropractic and I understand that final determination is based upon the insurance company’s medical guidelines. Insurance policy limitations are per individual insurance policy plans, as are co-payments, co-insurance, deductibles, referrals, etc. I understand this office agrees to notify me as soon as possible whether my care is approved or denied by the insurance company. I understand my initial visits may be denied and this may be beyond the office’s ability to notify me prior to rendering acute care, while waiting for insurance coverage approval. These charges will be my responsibility if denied by the insurance company. * I hereby authorize my insurance benefits to be paid directly to New Beginnings Chiropractic. I have read this document and understand my obligations for payment in the absence of insurance coverage. Informed Consent Chiropractic is a art, science, and philosophy which concerns itself with the relationship between the spinal structure and the health of the central nervous system. Any disturbance to the CNS will create sickness and disease. One such disturbance to the nervous system is known as a vertebral subluxation. If during the course of care we encounter a non-chiropractic issue we will refer you out to the appropriate health care provider. I have the right, as a patient/guardian, to be informed about the condition and the recommended care to be provided so that I can make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives. I have read and fully understand the above statements and therefore accept chiropractic care on this basis. By checking the box, I am consenting to care. Submit Goal of Care If the doctor finds the cause of your problem, how committed are you toward fixing it? * "Only want what my insurance covers" Pain relief only Pain relief and correction to reduce likelihood of problem returning Pain relief, correction, lifetime wellness Other If "other" please explain Thank you!
