Intake Form

InMotion Spine Muscle Joint

Dr. Meryl Miller, Dr. Jared Shoemaker

Patient Information

Patient (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Sex (required)

 Male Female

Age (required)

Birthdate (MM/DD/YYYY) (required)

Marital Status (required)

 Single Married Widowed Separated Divorced

Occupation (required)

Employer (required)

Employer Address (required)

Student at

Full-time or Part-time Student

 Full-time Part-time N/A

Spouse's Name

Spouse's Birthdate

Spouse's Occupation

Spouse's Employer

Whom may we thank for referring you?

Contact Information

Home Phone

Cell Phone

Work Phone

Email Address (required)

Best time and place to reach you: (required)

In Case of Emergency, Contact
Name (required)

Relationship (required)

Home Phone (required)

Work Phone (required)

Insurance

Who is responsible for this account? (required)

Relationship to Patient (required)

Insurance Co. (required)

ID # (required)

Is Patient covered by additional Insurance? (required)
 Yes No

Subscriber's Name (required)

Subscriber's Birthdate (required)

Subscriber's SS# (required)

Subscriber's Relationship to Patient (required)

Insurance Company (required)

Subscriber's ID # (required)

ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) have insurance coverage with
and assign directly to InMotion SMJ 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature:

Relationship:

Date (MM/DD/YYYY):

Accident Information

Is condition due to an accident? (required)
 Yes No

Date of Accident (MM/DD/YYYY)

Type of Accident
 Auto Home Work Other

To whom have you made a report of your accident?
 Auto Insurance Employer Worker Comp Other

Attorney Name

Attorney Address

Attorney Phone #

Patient Condition

Reason for visit:

When did your symptoms appear?

What do you think caused the symptoms?

Is this condition progressively getting worse?
 Yes No Unknown

Has this occurred before?
 Yes No

When

Areas where you have pain, numbness, or tingling:

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain):
12345678910

Type of pain (Select all that apply):

*If Other, please describe:

What time of day do the symptoms often occur?

Is the pain constant or does it come and go?

Does it interfere with your (Select all that apply):
 Work Sleep Daily Routine Recreation

Number of days lost from Work or School

Activities you'd like to be able to do again:

Activities or movements that are painful to perform (Select all that apply):
 Sitting Standing Walking Bending Lying Down Lifting Stretching Other
*If Other, please describe:

Pain is reduced by (Select all that apply):
 Rest Exercise Medicine Adjustments Therapy

Health History

What treatment have you already received for your condtion? (Select all that apply):
 Medications Surgery Physical Therapy Chiropractic Services None Other
*If Other, please describe:

Outcomes of these treatments:

Name and Address of other doctor(s) who have treated you for your condtion:

Is there anyone you would like us to keep informed regarding your treatment at the office?
 Yes No

Please specify name and address:

Date of Last (MM/DD/YYYY):
Physical Exam:
Spinal X-ray:
MRI, CT-Scan, Bone Scan:
Chest X-ray:

Any related symptoms/conditions:

Any recent infections?
 Yes No

Any fever or chills?
 Yes No

Any dizziness?
 Yes No

Any change in bowel or bladder habits?
 Yes No

Have you ever suffered from:

*If Other, please describe:

Has a physician treated you for any other condition(s) in the past 12 months? (If yes, please explain):
 No Yes

*Women Only* Is there any change you may be pregnant?
 No Uncertain Yes Due date:

Exercise

 None Moderate Daily Vigorous

Activities:

Work Activity

 Sitting Standing Light Labor Heavy Labor Other
*If Other, please describe:

Habits

*1 being lowest, 10 being highest levels of stress

Stress Management Techniques Used:

Please describe for us any hospitalizations, serious illnesses, falls, broken bones, or surgeries you have had:

Please list your prescribed medications, over-the-counter medications, herbs, vitamins/supplements, and inhalers

Please provide details of any known allergies (eg. Latex, foods, medications, etc.)

Family History

Please help us to identify your potential health risks by placing a check in any column that applies to you or your blood relatives.