Chiropractic Intake Form

Chiropractic Intake Form 

Tell Us About You 

Preferred Phone Contact:
In which format do you prefer appointment reminders?
Marital Status:
Employment Status:
Student Status:
Emergency Contact is your:

Tell Us Why You're Here 

Is this due to a :
The Overall Severity of your Complaints/Concerns is:
The Overall Frequency is:
On a Scale of 0 to 10, how would you Rate your Pain/Symptoms today?
If your symptoms change, when are they worse:
Are your Symptoms/Pain getting:
Have you had recent treatment for this condition?
Have you had the same or similar problems in the past?
Do you have any additional complaints/concerns/health problems?

Use the following key to mark your complaints on the diagram: 

Pain = P        Soreness = O       Burning = B        Numbness = N      Stiffness = X       Tingling = T Weakness = W        Swelling = S 

Mark on the Diagram:
If your complaints include pain, how would you describe it? Please check all that apply:
Since your symptoms began, have you noticed any function changes:
Do work activities aggravate your present complaints?

Please mark whether you NOW HAVE or had IN THE PAST any of the following conditions/illnesses: 

Your Lifestyle 

Which is your dominant hand:
Which of the following best describes your stress level:
Do you have weight issues?
Are you currently taking any Vitamins or Nutritional Supplements?

Using a Scale from 0 to 10, where 0 equals "awful" and 10 equals "amazing". 

How would you Rate your Overall Health?
WOMEN ONLY: To your knowledge are you Pregnant?

Other Health Care Providers 

Have you ever been to a doctor of chiropractic before?

Communication is Key to a Positive Relationship

Which health subjects most interest you for our E-Newsletters:
Is there anything else you would like us to know?

To the best of my knowledge the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be detrimental to my health. It is my responsibility to inform Jurgens Chiropractic of any changes in my health status. 

Informed Consent to Care 

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. 

We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. 

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being. 

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, gractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. 

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. 

The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events per one million persons per year and risk of death has been estimated as 104 per one million users. 

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. 

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office. 

Notice: Patient Privacy 

At Jurgens Chiropractic, we are committed to preserving the privacy of your health information. In fact, we are required by law to protect the Privacy of your health information and to provide you with a notice describing how health information about you may be used and disclosed and how you can access this information. 

We may be required or permitted by certain laws to use or disclose your health information for other purposes without your consent or authorization. 

As our patient, you have important right relating to inspecting and copying your health information that we maintain, amending or correcting that information, obtaining and accounting of our disclosures of your health information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information and complaining if your rights have been violated. 

We have provided you with this notice a detailed Notice of Privacy Practices, which fully explains your rights and our obligations under the law. We may revise our notice from time to time. The effective date at the top right corner of this page indicates the date of the most current notice in effect. 

You have the right to receive a copy of our most current notice at any time; please notify our front desk if you would like a copy, and they will provide you with one. 

If you have any questions, concerns or complaints about the Notice or your health information, please contact Drs. Flores/Jurgens, our privacy officers at our office at: 

9855 Erma Road Ste #104

San Diego, CA 92121

(858) 547-8913 / Fax: (858) 547-8914

Acknowledgement of Receipt of Notice of Privacy Practices 

I acknowledge that Jurgens Chiropractic's Notice of Privacy Practices has been provided to me. I understand that I have a right to review Jurgens Chiropractic's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills, or in performance of health care operations of Jurgens Chiropractic. The Notice of Privacy Practices of Jurgens Chiropractic is also provided on request at the main administration desk (front desk) of the practice. 

This Notice of Privacy Practices also describes my rights and Jurgens Chiropractic's duties with respect to my protected health information. Jurgens Chiropractic reserves the right to change the privacy practices at any time. I understand that I may request a copy of the revised policy at any time by requesting a revised copy be sent by mail, or asking for one at the time of my next appointment. 

Thank you for taking the time to fill out this form.

Our Location

Hours of Operation

Chiropractic Office Hours

Monday

9:00 am - 7:00 pm

Tuesday

9:00 am - 7:00 pm

Wednesday

9:00 am - 7:00 pm

Thursday

9:00 am - 7:00 pm

Friday

9:00 am - 7:00 pm

Saturday

10:00 am - 1:00 pm

Sunday

Closed

Chiropractic Office Hours

Monday
9:00 am - 7:00 pm
Tuesday
9:00 am - 7:00 pm
Wednesday
9:00 am - 7:00 pm
Thursday
9:00 am - 7:00 pm
Friday
9:00 am - 7:00 pm
Saturday
10:00 am - 1:00 pm
Sunday
Closed