About Pregnancy Pediatrics Conditions New Patients Blog Supplements Contact Schedule your appointment HFW Intake Forms Name(Required) First Last Date of birth(Required) Month Day Year Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail(Required) Gender Male Female Non-Binary Marital Status Married Single Occupation Family Doctor/Primary Physician Family Doctor's Phone # Reason Last Seen? May we contact your doctor? Yes No Whom may we thank for referring you to our office? Your Health InformationWhat is your primary complaint? Check all symptoms you have ever had even if they do not seem related to your primary complaint:* Headaches Pins and needles in arms Ringing in ears Neck Pain Sleeping Problems * Numbness in Fingers Tension Depression Anxiety Loss of balance * Dizziness Back Pain Sensory Challenges Shoulder Pain Vertigo * Fatigue Cold Feet Numbness in toes Pins and needles in legs Digestive problems Other - please explain Please list any medications you are taking: Any past surgeries or hospitalizations? Your condition has been getting: Better Worse Staying the same Was your condition due to an injury or auto accident? Yes No Not sure What activities make your condition worse? What have you tried that makes your condition better? Have you seen a Chiropractor in the past? Yes No Not Sure If yes, when? Insurance InformationDo you have insurance? Yes No Are you the primary policy holder? Yes No If "No" please provide the policy holder's name and date of birth: Self Pay? Yes No HSA Account? Yes No Authorization/Consent/Assignment of Benefits/HIPAA/PregnancyExam AuthorizationI hereby grant permission to receive a chiropractic evaluation including history, posture evaluation, examination and x-rays if warranted. Any findings will be communicated before consenting to starting treatment, if appropriate. I agreeContact AuthorizationI authorize Health From Within to contact me at all phone numbers / addresses listed on this intake form. If I do not wish to be contacted, I realize that I must notify Health From Within of this request. I agreeAssignment of Benefits*I hereby authorize payment to be made directly to Health From Within for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this form or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Health From Within for any and all services I receive at this office. (*Does not apply to Medicare) I agreeHIPAABy my signature below, I am acknowledging that Health From Within conforms with all current HIPAA guidelines and I may request a copy of the HIPAA policy from the front desk. I agreeFEMALES - I acknowledge that, as of today's date: YES - I am pregnant NO - I am not pregnant Unsure I certify that the statements made on this form are accurate to the best of my recollection(Required) Yes No Name of Patient OR Consenting Adult(Required) First Last FOR OFFICE USE ONLYDoctor's Signature Δ Home About New Patients Blog Contact 8128 W 143rd. St. Orland Park, IL | (708)-349-0040
