General Intake

Please fill out the following form in as much detail as possible.

Full Name

Date

Address

City

State

Country

Postal Code

E-mail address *

Drivers License No

Social Security No

Home Phone

Office Phone *

Age

Date of Birth Patient

Occupation

Gender

Weight

Employer Name

Employer's Address

Marital Status

Children names and ages

Name of Spouse/Parent

Spouse/Parent's Birthday

Have you ever had chiropractic care before?

Spouse/Parent's Employer

For what problem?

Were the results satisfactory?

Major complaints and symptoms - please be as specific as you can. Ask the doctor or nurse for help if you need assistance in filling out this section.

How do you believe your problem (pain) began?

When did you first notice this problem/pain?

Have you lost any work?

Day and date you last worked

Have you ever had this condition before or a similar condition?

When?

What positions or activities aggravate your condition?

What positions or activities relieve your condition?

Have you been treated by a medical physician for this ailment?

Where?

Describe the type of treatment

Diagnosis of previous physician

Length of time under care

Results

Family physician

Will this be covered by any insurance company? Major Medical

Major Medical

Auto

Blue Cross/Blue Shield

Workers' Compensation

Medicare

Other

Have you ever been in any accidents, auto, fall down stairs, fall from ladder, etc. (even as a child)?

Are you allergic to anything you are aware of ?

Are you presently taking any medication (aspirin included)?

If yes, name them

Have you ever broken any bones? (fractures)

Any dislocations?

What operations have you had?

Year

Provide date if you have had any of the following? (if exact date is unknown give approximate)

Blood tests

Urinalysis

X-Ray examination

Other special treatment

At what hospital or office were these tests taken?

Name of doctor who ordered tests

Date of last menstrual period

Do you have any reason to believe that you may be pregnant?

Do you have any health problems not listed above?

Do you faint easily?

Do you take vitamins?

If Yes, please list them

Habits: (please check)

Cigarettes

Cigarettes Quantity

Coffee

Coffee Quantity

Alcohol

Alcohol Quantity

Tea

Tea Qunatity

Hobbies

Have you been treated for any health condition by a physician in the past year?

If yes, what condition?

Have you lost or gained weight in the past year?

Use this space for any additional information you wish to discuss

Samuel G Charles DC DACNB
Elkton Neurology Chiropractic Center
139 East Main Street
Elkton MD 21921
410-398-2108

PATIENT OR AUTHORIZED PERSON'S SIGNATUREa

I authorize payment of medical benefits to S G Charles DC DACNB of the Elkton Chiropractic Neurology Center for Services Rendered.

X
Date

AUTHORIZATION TO RELEASE INFORMATION

I authorize the release of any medical information necessary to process insurance claims submitted by S G Charles DC DACNB of the Elkton Chiropractic Neurology Center for services rendered.

X
Date

Elkton Chiropractic Neurology Center
Samuel G. Charles, DC, DACNB
139 East Main Street Elkton, MD 21921
(410) 398-2108

PRACTICE REOUIREMENTS

The Practice:
(a) Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI.

(b) Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided under federal law.

(c) Is required to abide by the terms of this Privacy Notice. (d) Reserves the right to change the terms of this Privacy Notice.

(e) Will distribute any revised Privacy Notice to you prior to implementation.

(f) Will not retaliate against you for filing a complaint.

EFFECTIVE DATE
This notice is in effect as of 04/15/2003
PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

Ready to Begin Your Healing Journey?

Start with a consultation and get the answers your brain and body need.

Image of a chiropractic office with a welcoming environment, featuring a treatment table, anatomical models, and healthcare materials, relevant to Elkton Chiropractic Neurology's patient care and evaluation process.

COMPANY

CUSTOMER CARE

TERM OF SERVICES

POLICY

CUSTOMER CARE

CONTACT US

General Intake

Please fill out the following form in as much detail as possible.

Provide date if you have had any of the following? (if exact date is unknown give approximate)

Habits: (please check)

Samuel G Charles DC DACNBElkton Neurology Chiropractic Center139 East Main Street Elkton MD 21921410-398-2108

PATIENT OR AUTHORIZED PERSON'S SIGNATUREa

AUTHORIZATION TO RELEASE INFORMATION

Elkton Chiropractic Neurology CenterSamuel G. Charles, DC, DACNB139 East Main Street Elkton, MD 21921 (410) 398-2108

PRACTICE REOUIREMENTS

EFFECTIVE DATE This notice is in effect as of 04/15/2003 PATIENT ACKNOWLEDGEMENT By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.

Ready to Begin Your Healing Journey?

COMPANY

CUSTOMER CARE

CUSTOMER CARE

Samuel G Charles DC DACNB
Elkton Neurology Chiropractic Center
139 East Main Street
Elkton MD 21921
410-398-2108

Elkton Chiropractic Neurology Center
Samuel G. Charles, DC, DACNB
139 East Main Street Elkton, MD 21921
(410) 398-2108

EFFECTIVE DATE
This notice is in effect as of 04/15/2003
PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms.