Electronic Health Records intake form:
Verification Question: (Choose one question and complete the answer)
o What is the name of your favorite pet?
o What was your first car?
o In what city were you born?
o What high school did you attend?
o What is your favorite movie?
o On what street did you grow up?
o What is your mother’s maiden name?
o What is your favorite color?
o When is your anniversary?
Verification Answer to the Chosen Question: (must be at least six characters) _________________
Smoking Status (Circle One): Every day Smoker/ Occasional Smoker/ Former Smoker/ Never Smoked
If yes, what is your level of interest in quitting smoking?
(Circle One): { No Interest --- 0 1 2 3 4 5 6 7 8 9 10---- Very Interested }
CMS requires providers to report race, ethnicity, and preferred language.
Preferred Language: ________________________
Race (Circle One): Native American or Alaskan Native/ Asian/ Black or African American/ White
(Caucasian)/ Native Hawaiian or Pacific Islander/ Other/ Decline to answer
Ethnicity (Circle One): Hispanic or Latino/ Not Hispanic or Latino/ Decline to answer
Are you currently taking any medications? (Please include regularly used over the counter
medications)
Medication Name
Dosage (i.e. 5 mg.)
Frequency (per hour, day, week)
*If more than 3 medications, please continue list on the back of the page.
Do you have any medication allergies?
Medication Name
Reaction
Onset Date
Additional Comments
I choose to decline receipt of my clinical summary after each visit. (These summaries are often
blank as a result of the nature and frequency of chiropractic care.)
Patient Signature: _____________________________________ Date: _________________________
For office use only.
Height: ________________ Weight: ________________ Temp: ________________
Blood Pressure: ________/ ________ Heart Rate: ________________