New Patient Intake Form

This form is used to give us your basic information, like name, address and phone number. It also provides a place for you to give a brief overview of your condition (you will have an opportunity to go into more detail on another form). There is also a page about our Privacy Practices (HIPAA) and acceptance of terms. The last page is Financial Consent and Authorization, this allows us to bill your insurance and is an agreement to pay if you do not have insurance or if your insurance does not pay all or part of your bill. Please be sure to sign the bottom of the last 3 pages.

Review of Systems – Past Health History

This form is a place to give us information on any current conditions you may have or have had in the past. This is also a place to list current/past doctors, medications and allergies. Please fill this out as thoroughly as possible. All this information helps Dr. Chapman better understand your condition and ensures he will be able to treat you.

ADL and Recreation Forms

This form is going to help Dr. Chapman understand what type of activities you do on a regular basis, and how those activities affect your condition. (This is where you have the opportunity to go into more detail of your condition.) There are also questionnaires about the severity of your neck, low back and headache pain. This all ensures that Dr. Chapman has a full understanding of you and your condition to facilitate proper treatment.

Keep Good Record

is a form to use if you are ever in a car accident. It is always in your best interest to keep an accurate account of any accident you are in. There may be additional brief forms based on your situation. (ie: Worker’s Comp, Motor Vehicle Accident or Medicare)

Common Symptoms of Following Car Accidents

MVA Incident Form

Type of Pain Form