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Confidential Patient Intake Form

Information contained in this form is considered strictly confidential. Your responses are important to better understand the health issues you face and ensure the delivery of the best possible treatment. When complete, click on the yellow SUBMIT button. This will send your health information in a secure manner to New Heights Chiropractic and Rehabilitation.

Please tell us about yourself
Your name:   Date of Birth:                Age: Sex:
Address:                     City:            State:    Zip:
Cell Phone: Home Phone: Work Phone:    
Email: Marital Status:

Height:     Weight:     Name you prefer to be called:    
Social Security #:     Occupation:     Employer:    
Emergency Contact Name:     Phone:     Relationship:    

How did you hear about us?
May we contact you via email regarding appointments?  
May we send you our online newsletter?  

Please tell us about your health concern
Give a brief, detailed description of the problem you are currently experiencing:
What seemed to be the initial cause?
When did this condition begin:
Is this condition:?  
Is this condition interfering with:   Work   Sleep   Daily Routine   Other  
Have you had this or similar conditions in the past?  

Check the activities that aggravate your symptoms:
  Sitting     Getting in/out of car     Reading  
  Standing     Driving car     Recreation  
  Walking     Reaching overhead     Putting on socks/shoes  
  Stair climbing     Reaching behind back     Athletics  
  Squatting     Putting on shirt     Coughing/Sneezing  
  Running     Buttoning shirt     Bending  
  Lifting     Putting on pants     Carrying >10 lbs  

Please comment on any other activity that makes your pain worse:
What seems to make this problem better?
Please describe where you are experiencing pain:

Using a scale of 1-10 with 10 being the worst pain you have ever had and 0 being no pain at all, rate your current level of pain.
When my pain is the worst:
When my pain is the least:

Please check the word/words that best describe the nature of your symptoms/pain:
  Aching     Burning   Numbness   Pins & Needles      Radiating   Stabbing     Tingling     

Have any of the following diagnostic studies or testing been completed for your injury? Please indicate below.
Arthrogram           Myelogram          
MRI           Diskogram          
DEXA scan           EMG/nerve conduction        
Bone scan           Plain x-ray        
CT scan           Other        

Other doctors or therapists that have treated this condition

Name of current Primary Care Physician:      Date of last physical exam:  

May we contact your physician regarding your care at this office?  

Was this a result of a work related or auto injury?       Comments: 


Please check the corresponding boxes if you have the condition now or have had it in the past:
GeneralNow      Past           SkinNow      Past
Weakness  Color Changes
Fatigue  Hair/Nail Changes
Fever  Moles
Chills  Rashes
Night Sweats  Eczema
Fainting  Psoriasis
HeadNow      Past           NeckNow      Past
Headache  Stiffness
Injuries  Soreness
TMJ Dysfunction  Lumps/Masses
EyesNow      Past           EarsNow      Past
Glasses/Contact Lenses  Deafness
Cataracts  Ringing
Glaucoma  Ear Ache
Change in Vision  Dizziness
NoseNow      Past           MouthNow      Past
Decreased Smell  Bleeding Gums
Bleeding  Sores
Runny Nose  Loss of Taste
Sinus Congestion  Dry Mouth
ThroatNow      Past           CardiovascularNow      Past
Soreness  Palpitation
Hoarseness  Rapid Pulse
Trouble Swallowing  Swollen Ankles
Recurrent Infection  Cold Hands/Feet
   Blood Clots
GastrointestinalNow      Past           High Blood Pressure
Abdominal Pain  Low Blood Pressure
Food Intolerance GenitourinaryNow      Past           
Heartburn  Urgency
Indigestion  Incontinence
Constipation  Frequent Voiding
Diarrhea  Blood in Urine
Hemorrhoids  Kidney Stones
Bloody Stool  Painful Urination
Black/Tarry Stool     
Diverticulitis  RespiratoryNow      Past           
Vomiting Chronic Cough
Ulcers  Cough Up Blood
NeurologicalNow      Past           Short of Breath
Seizures  Wheezing
Tremors  Difficult Breathing
Loss of Sensation  Chest Pain
Tingling BloodNow      Past           
MusculoskeletalNow      Past           Low Iron
Muscle Pain  Bruise Easily
Muscle Cramps  Bleeding Disorder
Muscle Weakness     
Joint Stiffness EndocrineNow      Past           
Arthritis  Weight Loss
Low Back Pain  Weight Gain
Middle Back Pain  Hyperthyroidism
Neck Pain  Hypothyroidism
Upper Extremity Pain     
Lower Extremity Pain PsychiatricNow      Past           
Foot Trouble/Pain  Depression
Women OnlyNow      Past           Anxiety
Lumps in Breast  Nervousness
Hot Flashes    
Menopause  Men Only                         
Irregular Periods  Date of Last Prostate Exam:   
                         Normal Abnormal   Not Applicable  
Birth Control Type  
Number of Births:  
Are You Pregnant?           Yes     No    
Trying to Get Pregnant?   Yes     No     
Date of Last PAP:         
        Normal     Abnormal     Not Applicable
Date of Last Mammogram:  
        Normal     Abnormal     Not Applicable

Please check the corresponding box if you have had any of the following conditions:
  Measles     Hypertension     Asthma     Appendicitis     Multiple Sclerosis  
  Mumps     Heart Disease     Tuberculosis     Gall Stones     Syphilis  
  Chicken Pox     Arteriosclerosis     Pneumonia     Mental Illness     Malaria  
  Cancer     High Cholesterol     Migraine     Hepatitis     Gonorrhea  
  Tumor     Stroke     Gout     Liver Trouble     HIV / AIDS  
  Angina     Blood Disease     Diabetes     Osteoporosis     Herpes  

Please note any other health conditions in your past:

Please complete the sections below to the best of your knowledge:
Please list all previous surgeries:        
Type Date Type Date Type Date

Please list all medications, supplements, and herbals you use:        
Name Dosage Name Dosage Name Dosage

Please list any allergies (Medications, Latex, Food, Chemicals, Inhalants, Etc):         

Please fill in the following information. If no illnesses, type None.
Relative   Age (If Living)   Age at Death   Cause of Death    Illnesses
Maternal Grandfather                           
Maternal Grandmother                           
Paternal Grandfather                           
Paternal Grandmother                           

Please check the box that most accurately represents you or fill in the blanks:
Sleep:     Quality:           
Difficulty falling asleep?
Frequent waking?
Exercise:     Days per week:
Employment:     Briefly describe your duties:
Drug Use:     Do you use illegal or recreational drugs?  
Tobacco Use:     Do you smoke or chew tobacco?        
Have you smoked in the past?            
                            If yes, Cigarettes: packs/day for years
Diet:     Which best describes your diet?
            Quantities you consume:
             Water:      per day
             Tea: cups per  
             Soda: drinks per
             Alcohol:   drinks per

Please review the following Informed Consent and Office Financial Policy at this time. You will not be able to sign these forms online, but you will be provided paper copies of these forms and asked to sign them at your first visit.

I hereby request and consent to the performance of physical examinations, chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and physiotherapy, on myself (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at this office.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to sprains, strains, fractures, disc injuries, dislocation, and stroke. I do not expect the doctor to be able to anticipate and explain all risks and complications, as I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures along with any therapeutic procedures performed that are within the scope of the treating doctor of chiropractic’s license. I intend this consent form to cover the entire course of examination and treatment for my present condition and for any future condition(s) for which I seek treatment.
Kayla Bennett, DC
Daniel Polizzi, DC

New Heights Chiropractic and Rehabilitation, Inc.

New Heights Chiropractic and Rehabilitation wants to provide the most efficient and affordable health care services, so it is necessary for us to have a financial policy stating our requirements for timely payment of services and products provided by our office. We welcome the opportunity to discuss any aspect of our financial policy.

To help us help you, please:
  1. Provide us with accurate and updated information on yourself and your insurance company.
  2. Pay at the time of service for your entire balance.
If you have health insurance:
We are happy to file claims for services provided at New Heights Chiropractic and Rehabilitation to your insurance company as a courtesy to you. As stated by your insurance company: Verification of benefits is not a guarantee of payment. If you have insurance and we file with your carrier for you, you will be responsible for all charges not paid by the insurance company. The balance due is your responsibility if we have not received payment from your insurance company within 60 days.

New Heights Chiropractic and Rehabilitation sends claims with procedure codes to the insurance companies. Your insurance company then chooses the reasonable and customary amount to apply to your visit. Your insurance plan is a contract between you and your insurance company, therefore any amount applied toward your deductible, copays and coinsurances must be paid in full.

By signing this financial policy:
  1. You are authorizing New Heights Chiropractic and Rehabilitation, its providers, and its employees to release any necessary information related to this visit and all future visits to your insurance company for the purpose of claim(s) payment.
  2. You are authorizing your insurance company and your medical provider to release your medical records at New Heights Chiropractic and Rehabilitation for the purpose of claim(s) payment.
  3. You are authorizing your insurance company to pay any medical benefits and all future claims for services provided by our office directly to New Heights Chiropractic and Rehabilitation. In the event that your insurance company directly pays benefits to you, the patient, you agree to authorize those payments, in full, to New Heights Chiropractic and Rehabilitation.
  4. You are giving New Heights Chiropractic and Rehabilitation the right to speak with your insurance company, any third party insurance company, and your attorney regarding your claims and bills.
  5. You agree that a photocopy of any document is as valid and effective as the original.
New Heights Chiropractic and Rehabilitation and its providers accept worker’s compensation and auto accident insurance. We require that a lien signed by the patient and any attorneys is on file when applicable. If Med-Pay is unavailable, it remains the responsibility of the patient to pay for any services rendered at the time of service.
If you prefer that we do not file insurance claims for you, you may pay cash at time of service and send the claim to your insurance carrier. If you choose to submit your own claims, we will provide you with a superbill, but cannot assist you in filing your claims.

If You Do Not Have Health Insurance:
If you do not have insurance or your insurance company does not cover our services, you will be considered a self-pay patient. All payments will be due at time of service/s, or according to the payment schedule based on an authorized payment plan. Payment plans are available to make treatment an affordable part of your budget.

Cancellation Policy:
In order to provide you with the best possible care, please arrive 5 minutes prior to your appointment. A late arrival may result in cancellation. We require 24 hours notice of cancellation or you will be subject to a $25 fee. Please remember that failure to appear for your appointment prevents others from receiving care.

Financial Charges:
Failure to pay for services and products provided by New Heights Chiropractic and Rehabilitation will result in a finance charge. If we need to forward your account over to a collections agency for further legal action, you will be responsible for the entire balance on your account plus any collection fees.

Payment Options
For your convenience, we are happy to keep your credit card on file and secured for payment of all services and products.

Non-Sufficient Funds Charges:
We charge a NSF charge if any payment is returned due to insufficient funds. If payment is returned, then we are authorized to charge your credit card on file for the balance owed plus the NSF Charge.

*Signing below also acknowledges receipt of our Privacy Notice, which can be provided upon request or accessed online at

Notes of explanation or clarification on any of the above: 


Thank you for taking the time to review your health history.


The New Heights Team