Bircher Chiropractic & Wellness Clinic
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Our Commitment: To be the best at delivering wellness care by measuring where a persons current level of health is and designing specific programs to help them gain the level of health they desire.
Patient Information In Case of Emergency Contact
Date_________________________________________ Name__________________________________________
Patient Name _________________________________ Relationship_____________________________________
Last Name
Home # (____) ___________ Work # (____) ___________
_____________________________________________
First Name Middle Name Employment/School Information
Address ______________________________________ Occupation _____________________________________
City ______________________ State ______________ Patient Employer/School ___________________________
Zip_________ Email ___________________________ Employer/School Address __________________________
Sex □ M □ F Date of Birth ___________________ Employer/School Phone ___________________________
□ Married □ Divorced □ Widowed □ Single □ Minor Spouse/Guardian Information
Phone Numbers Name_________________________________________
Home # (____) __________ Cell # (____) ___________ Date of Birth ____________________________________
Cell Carrier________________ (for text messages) Employer _____________________________________
In case of a medical emergency, if the patient is a
Best time/Way to reach you_______________________ minor, it is ok to treat in my absence.
_________________________________________________
We WILL be calling after your first appt. to see how your visit went Parent/Guardian Signature
Insurance Information Accident Information
Who is responsible for account? __________________ Is condition due to an accident? □ Yes □ No Date ______
Relationship to Patient __________________________ Type of Accident □ Auto □ Work □ Home □ Other
Insurance Co. _________________________________ To whom have you reported your accident?
ID # _________________ Group # ________________ □ Auto Insurance □ Employer □ Work Comp □ Other
Subscribers Name ______________________________ Attorney Name (if applicable) ______________________
Date of Birth____________ SS# __________________ Attorney Address _______________________________
Relationship to Patient __________________________ _____________________________________________
Assignment and Release
I certify that I, and/or my dependent(s), have insurance coverage with ______________________________ and assign directly to Optima Health & Vitality Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named clinic may use my health care information and may disclose such information to the above-named insurance company and ______________________ their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
______________________________________ ____________________________________________
Signature of Patient, Parent or Guardian Print Name of Patient, Parent or Guardian
______________________________________ ____________________________________________ Date Signed Relationship to Patient
OFFICE POLICY
We believe that REGAINING AND MAINTAINING YOUR HEALTH is our main priority and a clear definition
of our office policies will allow both you the patient, and us the doctor, to concentrate on just that.
M:\Forms - Masters\New Patient Forms\New patient intake forms over 2 years old\Patient Intake Form - complete for printing.doc
What is your main health concern:___________________________________
______________________________________________________________________________
1a. Where is your PRIMARY problem area located: _____________________
Cervical (neck): ____left side ___ right side ___upper neck ___lower neck
Thoracic (mid back): ____left side ___ right side ___between shoulders
Lumbar (lower back): ____left side ___ right side ___tailbone area
Upper Extremity Problem: ____shoulder- left / right ___ elbow- left / right
____wrist- left / right ____ hand- left / right ___ hip- left / right
____ knee- left / right ____ ankle- left / right ___ foot- left / right
b. When did the PRIMARY problem start: _________________________________
Describe onset of problem: ___ acute (new) ___chronic (always there) ____gradual
What is the cause of the problem: ___unknown ___accident ___other
Have you had prior problem here: ___ none ____on & off for yrs ___ yes, but not for yrs
c. Description of PRIMARY problem: _______________________________
Describe your problem: ____improving ____getting worse ____no change
If the problem has changed, how: ____gradually ____slowly ____slightly
Quality of pain: ___achy ____burning ____dull ____sharp ____stiff ___throbbing Description of problem: ____mild ____moderate ____severe
On scale from 1-10, with 1 being mild and 10 being severe, what is your pain? ________
Is problem: ___constant ____frequent ____intermittent ____occasional
How often do you have the problem: ____daily ___weekly ___comes & goes ___always
Does the pain radiate? If yes, where: ___head __neck ___shoulder/arm- left / right
When is problem the worse: ___morning ____afternoon ____evening ____night
When is problem better: ___morning ____afternoon ____evening ____night
What makes the problem worse: _____________________________________________
What makes the problem better: _____________________________________________
Do you have any: __numbness __spasms __weakness If yes, where: ______________
2a. Where is your SECOND problem area located: _____________________
Cervical (neck): ____left side ___ right side ___upper neck ___lower neck
Thoracic (mid back): ____left side ___ right side ___between shoulders
Lumbar (lower back): ____left side ___ right side ___tailbone area
Upper Extremity Problem: ____shoulder- left / right ___ elbow- left / right
____wrist- left / right ____ hand- left / right ___ hip- left / right
____ knee- left / right ____ ankle- left / right ___ foot- left / right
b. When did the SECOND problem start: ___________________________________
Describe onset of problem: ___ acute (new) ___chronic (always there) ____gradual
What is the cause of the problem: ___unknown ___accident ___other
Have you had prior problem here: ___ none ____on & off for yrs ___ yes, but not for yrs
Doctor's Use
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________
c. Description of SECOND problem: ________________________________
Describe your problem: ____improving ____getting worse ____no change
If the problem has changed, how: ____gradually ____slowly ____slightly
Quality of pain: ___achy ____burning ____dull ____sharp ____stiff ___throbbing Description of problem: ____mild ____moderate ____severe
On scale from 1-10, with 1 being mild and 10 being severe, what is your pain? ________
Is problem: ___constant ____frequent ____intermittent ____occasional
How often do you have the problem: ____daily ___weekly ___comes & goes ___always
Does the pain radiate? If yes, where: ___head __neck ___shoulder/arm- left / right
When is problem the worse: ___morning ____afternoon ____evening ____night
When is problem better: ___morning ____afternoon ____evening ____night
What makes the problem worse: _____________________________________________
What makes the problem better: _____________________________________________
Do you have any: __numbness __spasms __weakness If yes, where: ______________
3a. Where is your THIRD problem area located: _________________________
Cervical (neck): ____left side ___ right side ___upper neck ___lower neck
Thoracic (mid back): ____left side ___ right side ___between shoulders
Lumbar (lower back): ____left side ___ right side ___tailbone area
Upper Extremity Problem: ____shoulder- left / right ___ elbow- left / right
____wrist- left / right ____ hand- left / right ___ hip- left / right
____ knee- left / right ____ ankle- left / right ___ foot- left / right
b. When did the THIRD problem start: _________________________________
Describe onset of problem: ___ acute (new) ___chronic (always there) ____gradual
What is the cause of the problem: ___unknown ___accident ___other
Have you had prior problem here: ___ none ____on & off for yrs ___ yes, but not for yrs
c. Description of THIRD problem: ___________________________________
Describe your problem: ____improving ____getting worse ____no change
If the problem has changed, how: ____gradually ____slowly ____slightly
Quality of pain: ___achy ____burning ____dull ____sharp ____stiff ___throbbing Description of problem: ____mild ____moderate ____severe
On scale from 1-10, with 1 being mild and 10 being severe, what is your pain? ________
Is problem: ___constant ____frequent ____intermittent ____occasional
How often do you have the problem: ____daily ___weekly ___comes & goes ___always
Does the pain radiate? If yes, where: ___head __neck ___shoulder/arm- left / right
When is problem the worse: ___morning ____afternoon ____evening ____night
When is problem better: ___morning ____afternoon ____evening ____night
What makes the problem worse: _____________________________________________
What makes the problem better: _____________________________________________
Doctor's Use
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________
IF YOU HAVE MORE THAN THREE PROBLEM AREAS
ASK THE FRONT DESK FOR AN ADDITIONAL SHEET
Allergies/Lifestyle/Additional Information
Please list any medications: __________________________________________________________________________
Please list any medications you are allergic to: __________________________________________________________
Please list any foods or chemicals you are allergic to: ____________________________________________________
Do you currently smoke?____ If yes, how many per day:_____ Type: cigarettes / cigars Alcohol use: (Circle One) Never Rarely Moderate Daily Recreational Drug use: Type: _________ Never or Frequency___________
Have you had chiropractic care in the past? ________ If female- Are you currently pregnant?____ If yes, due date______
Systems Review: List any issues you are experiencing with the following systems:
Ears: _____________________________ Eyes: ________________________________ Nose: ____________________ Mouth: _________________________Throat: ____________________________ Lungs/Breathing: _________________
Heart Health: _______________________ Bowels: ________________________ Bladder/Kidneys: ______________________
Number of times you urinate during the day: ___ During the night: ___ How often do you have a bowel movement: _____
Health History- Please circle "Y" for a condition that you currently have,
and "P" for a condition that you have had in the past.
AIDS/HIV Y P Diabetes Y P Multiple Sclerosis Y P
Alcoholism Y P Emphysema Y P Osteoporosis Y P
Allergies Y P Epilepsy Y P Pacemaker Y P
Anemia Y P Fibromyalgia Y P Parkinson’s Disease Y P
Appendicitis Y P Glaucoma Y P Pneumonia Y P
Arthritis Y P Gout Y P Prostate Problems Y P
Asthma Y P Heart Disease Y P Prosthesis Y P
Blood Clots Y P Hepatitis Y P Rheumatoid Y P
Breast Lump Y P Hernia Y P Scarlet Fever Y P
Bronchitis Y P Liver Disease Y P Stroke Y P
Cancer Y P Lupus Y P Thyroid Problems Y P
Cataracts Y P Lyme Y P Ulcers Y P
Chicken Pox Y P Migraines Y P Whooping Cough Y P
Depression Y P Mononucleosis Y P Yeast Infection Y P
Other Illness: _____________________________________________________________________________________
List any injuries or surgeries: _____________________________ List any broken bones:_______________________
Family History- Please list specific blood relatives who have had the following conditions: indicate either: mother, father, sister, brother, aunt, uncle and which side the grandparent is on maternal (M) or paternal (P)
Arthritis: _______________________ Blood Clots: _____________________ Cancer: ________________________ Memory Loss: ___________________ Diabetes: _______________________ Stroke: _________________________
Heart Disease: ______________________ High Blood Pressure: ________________
Other Significant Family Illness: __________________________________________
-----------------------
3321 A Golf Road
Eau Claire, WI 54701
Phone: 715-832-1953 · Fax: 715-832-0225
Website:
E-mail: contactus@
FINANCIAL AGREEMENT-NO INSURANCE
In consideration for the services rendered to me by Optima Health & Vitality Center, I agree to pay for all charges incurred on my behalf and my dependents behalf at time services are received.
FINANCIAL AGREEMENT-INSURANCE
For patients submitting services to insurance, Optima Health & Vitality Center will call to verify benefits, and will submit billable charges to your insurance company.
Verification of benefits is not a guarantee of payment. All deductibles, co-pays and co-insurances are due at the time services are rendered.
I understand it is my obligation to pay any and all balances regardless of any agreements between myself and my insurance companies. Non-payment by my insurance company after 45 days will result in a patient balance and will be due upon receipt of statement.
LAB WORK/BLOOD WORK POLICY
All lab and blood charges will be collected in full at time of service. We will be happy to submit to insurance for you and will refund you any amount paid by your insurance company.
NSF CHECKS / PAST DUE ACCOUNTS
There is a $30 NSF fee charged on all returned checks. Accounts over 90 days past due may be turned over to collections.
FOR YOUR CONVENIENCE WE OFFER MANY OPTIONS FOR PAYMENT, INCLUDING:
Cash / Personal Check / Visa / MasterCard / Discover /
American Express / Care Credit
APPOINTMENT POLICY
If you are currently on a care plan, it is important to reschedule your missed appointment as close to your original date as possible.
Once an appointment is made, that time is reserved specifically for you. If you are unable to keep an appointment for any reason, please call immediately to notify the office.
This office reserves the right to charge for missed appointments and those appointments cancelled without a 24 hour notification.
E-MAIL POLICY
Unsecure email communication containing sensitive health information can be sent between Optima and you. If this form is sign by you, and at a future date you request information to be emailed to you, then unsecure email communication about your medical care and treatment may be used to transmit information
X-RAY POLICY
The x-rays that are taken are the property of Optima Health & Vitality Center. Release for purposes of review can be arranged at your request.
WORKMEN’S COMP POLICY
Our office does accept workmen comp cases. However, it is not considered work comp until we have all insurance information, a claim number on file and liability is accepted. Until that time, all charges are the patient’s responsibility and are collected in full at time of service.
PERSONAL INJURY POLICY
Our office does accept personal injury cases. Optima Health will be happy to submit all services to your insurance company. However all charges are the patients responsibility and are collected in full at time of service unless other arrangements are made with the business office.
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aCJOJ[?]QJ[?]^J[?]aJhurhurOJ[?]QJ[?]^J[?])jhuBy signing below I acknowledge that I have read, understand and agree to the terms of the office and financial policies of Optima Health & Vitality Center. I hereby authorize the Doctor to treat my condition as he/she deems appropriate through treatment methods used. I also agree that I am responsible for all bills incurred in this office. I authorize release of all records, correspondence and all imaging studies to Optima Health & Vitality Center for my continued medical care.
The purpose of any functional medicine assessment and/or laboratory testing, if recommended, is to assist our doctors in finding the underlying causes of your condition. Functional medicine has evolved through the efforts of scientists and clinicians. Functional medicine evaluates the body as a whole, with special attention to the relationship of one body system to another and how nutrient imbalances and toxic overload may adversely affect these relationships. If you have any questions or concerns, please discuss them with our doctors.
Patient Signature _____________________________________ Date _____________________________
Parent/Guardian Signature ______________________________ Date _____________________________
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