3055 W. Ina Road Suite 195

Tucson, AZ 85741 US

New Patient Intake Form

Welcome to our office!


Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 




About this Patient 

Male
Female
Other
Married
Single

Employer Information

Emergency Contact

Experience with Chiropractic 

Yes
No

My Health Insurance

Past Health History

Family Health History

                                                                                              

Cancer
Stroke/TIA'S
Headaches
Heart Disease
Neurological Diseases
Adopted/Unknown
Cardiac Disease Below Age 40
Psychiatric Disease
Diabetes
None Of The Above

Social and Occupational History

Severe or Frequent Headaches
Sinus Problems
Dizziness
Cancer
Loss of Sleep
Hepatitis
Pain Between the Shoulders
Frequent Neck Pain
Numbness or Pain in Arms/Legs/Hands
Lower Back Problems
Digestive Problems
Ulcers/Colitis
Heart Attack/Stroke
Thyroid Problems
Kidney Problems
Congenital Heart Detect
Heart Surgery/Pacemaker
High/Low Blood Pressure
Psychiatric Problems
Difficulty Breathing
Rheumatic Fever
Asthma
Arthritis
Alcohol/Drug Abuse
Venereal Disease
HIV/AIDS
Diabetes
Tuberculosis
Shingles
Chemotherapy
Anemia

Review of Systems

Asthma/difficulty breathing
COPD
Emphysema
None of the above
other
Heart surgeries
Congestive heart failure
Murmurs or valvular disease
Heart attacks/MIS
Heart disease/problems
Hypertension
Pacemaker
Angina/chest pain
Irregular heart beat
None of the above
Other
Visual changes/loss of vision
One-sided weakness of body or face
History of seizures
One-sided decreased feeling in the face or body
Headaches
Memory loss
Tremors
Vertigo
Loss of sense of smell
Strokes/TIAs
None of the above
Other
Thyroid disease
Hormone replacement therapy
Injectable steroid replacements
Diabetes
None of the above
Other
Renal calculi/stones
Hematuria (blood in urine)
Incontinence (can't control)
Bladder infections
Difficulty urinating
Kidney disease
Dialysis
None of the above
Other
Nausea
Difficulty swallowing
Ulcerative disease
Frequent abdominal pain
Hiatal hernia
Constipation
Pancreatic disease
Irritable bowel/colitis
Hepatitis or liver disease
Bloody or black tarry stools
Vomiting blood
Bowel incontinence
Gastroesophageal reflux/heartburn
None of the above
Other
Anemia
Regular anti-inflammatory use (Motrin/Ibuprofen/Naproxen/Naprosyn/Aleve
HIV positive
Abnormal bleeding/bruising
Sickle-cell anemia
Enlarged lymph nodes
Hemophilia
Hypercoagulation or deep venous thrombosis/history of blood clots
Anticoagulant therapy
Regular aspirin use
None of the above
Other
Significant burns
significant rashes
Skin grafts
Psoriatic disorders
None of the above
Other
Rheumatoid arthritis
Gout
Osteoarthritis
Broken bones
Spinal fracture
Spinal surgery
Joint surgery
Arthritis (unknown type)
Scoliosis
Metal Implants
None of the above
Other
Psychiatric diagnosis
Depression
Suicidal ideations
Bipolar disorder
Homicidal ideations
Schizophrenia
Psychiatric hospitalizations
None of the above
Other
 HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy describes how we may use and disclose your protected health information (PHI) to carry our treatment, payment or health care operations (TPO) for other purposes that are permitted or required by law. “Protected Health Information” is information about you, including demographic information that may identify you and that related to your past, present, or future physical or mental health or condition and related care services.

 Use and Disclosures of Protected Health Information:Your protected health information may be used and disclosed by your physician, our staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, pay your health care bills, to support the operations of the physician’s practice, and any other use required by law. 

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your health care information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

 Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing, and fundraising activities, and conduction or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. 

We may use or disclose your protected health information in the following situations without your authorization. These situations included as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and organ donation. Required uses and disclosures under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section164.500.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT,AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW. 

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of chiropractic to provide me with chiropractic care, in accordance with this state's statutes. If my insurance will be billed, I authorize payment of medical benefits to Jim Westerman DC/Chiropractic Northwest for services performed.

Reason for this Visit

Job
Sports
Auto
Fall
Chronic Discomfort
Home Injury
Other
Nothing
Any movement
Bending neck forward
Bending neck backward
Tilting head to the left
Tilting head to the right
Turning head to the left
Turning head to the right
Bending forward at waist
Bending backward at waist
Tilting left at waist
Tilting right at waist
Twisting left at waist
Twisting right at waist
Driving
Standing
Walking
Running
Lifting
Sitting
Getting up from seated position
Chewing
Changing positions
Lying down
Reading
Working
Exercising
Laying on side in bed
Other
Nothing
Resting
Ice
Heat
Stretching
Exercise
Walking
Pain medication
Muscle relaxers
Chiropractic adjustments
Massage
Other
Sharp
Dull
Achy
Burning
Throbbing
Piercing
Stabbing
Deep
Nagging
Shooting
Stinging
Stiff
Other
No difference
Morning
Afternoon
Evening
Night
Other
No
Anti-inflammatory meds
Pain medication
Muscle relaxers
Trigger point injections
Cortisone injections
Surgery
Massage
Physical Therapy
Chiropractic
Other
Nothing
Any movement
Bending neck forward
Bending neck backward
Tilting head to the left
Tilting head to the right
Turning head to the left
Turning head to the right
Bending forward at the waist
Bending backward at the waist
Tilting left at the waist
Tilting right at the waist
Twisting left at the waist
Twisting right at the waist
Driving
Standing
Walking
Running
Lifting
Sitting
Getting up from seated position
Chewing
Changing positions
Lying down
Reading
Working
Exercising
Laying on side in bed
Other
Nothing
Rest
Ice
Heat
Stretching
Exercise
Walking
Pain medication
Muscle relaxers
Chiropractic adjustments
Massage
Other
Sharp
Dull
Achy
Burning
Throbbing
Piercing
Stabbing
Deep
Nagging
Shooting
Stinging
Stiff
Other
No difference
Morning
Afternoon
Evening
Night
Other
No
Anti-inflammatory meds
Pain medication
Muscle relaxers
Trigger point injections
Cortisone injections
Surgery
Massage
Physical therapy
Chiropractic
Other
Nothing
Any movement
Bending neck forward
Bending neck backward
Tilting head to the left
Tilting head to the right
Turning head to the left
Turning head to the right
Bending forward at waist
Bending backward at waist
Tilting left at waist
Tilting right at waist
Twisting left at waist
twisting right at waist
Driving
Standing
Walking
Running
Lifting
Sitting
Getting up from seated position
Chewing
Changing positions
Lying down
Reading
Working
Exercising
Laying on side in bed
Other
Nothing
Resting
Ice
Heat
Stretching
Exercise
Walking
Pain medication
Muscle relaxers
Chiropractic adjustments
Massage
Other
Sharp
Dull
Achy
Burning
Throbbing
Piercing
Stabbing
Deep
Nagging
Shooting
Stinging
Stiff
Other
No difference
Morning
Afternoon
Evening
Night
Other
No
Anti-Inflammatory
Pain medication
Muscle relaxers
Trigger point injections
Cortisone injections
Surgery
Massage
Physical therapy
Chiropractic
Other
Nothing
Any movement
Bending neck forward
Bending neck backward
Tilting head to left
Tilting head to right
Turning head to left
Turning head to right
Bending forward at waist
Bending backward at waist
Tilting left at waist
Tilting right at waist
Twisting left at waist
Twisting right at waist
Driving
Standing
Walking
Running
Lifting
Sitting
Getting up from seated position
Chewing
Changing positions
Lying down
Reading
Working
Exercising
Laying on side in bed
Other
Nothing
Resting
Ice
Heat
Stretching
Exercise
Walking
Pain medication
Muscle relaxers
Chiropractic adjustments
Massage
Other
Sharp
Achy
Burning
Throbbing
Piercing
Stabbing
Deep
Nagging
Shooting
Stinging
Stiff
Other
No difference
Morning
Afternoon
Evening
Night
Other
No
Anti-inflammatory meds
Pain medication
Muscle relaxers
Trigger point injections
Cortisone injections
Surgery
Massage
Physical Therapy
Chiropractic
Other
Nothing
Any movement
Bending neck forward
Bending neck backward
Tilting head to the left
Tilting head to the right
Turning head to the left
Turning head to the right
Bending forward at waist
Bending backward at waist
Tilting left at waist
Tilting right at waist
Twisting left at waist
twisting right at waist
Driving
Standing
Walking
Running
Lifting
Sitting
Getting up from seated position
Chewing
Changing positions
Lying down
Reading
Working
Exercising
Laying on side in bed
Other
Nothing
Rest
Ice
Heat
Stretching
Exercise
Walking
Pain medication
Muscle relaxers
Chiropractic adjustments
Massage
Other
Sharp
Dull
Achy
Burning
Throbbing
Piercing
Stabbing
Deep
Nagging
Shooting
Stinging
Stiff
Other
No difference
Morning
Afternoon
Evening
Night
Other
No
Anti-Inflammatory
Pain medication
Muscle relaxers
Trigger point injections
Cortisone injections
Surgery
Massage
Physical therapy
Chiropractic
Other
Nothing
Any movement
Bending neck forward
Bending neck backward
Tilting head to the left
Tilting head to the right
Turning head to the left
Turning head to the right
Bending forward at waist
Bending backward at waist
Tilting left at waist
Tilting right at waist
Twisting left at waist
twisting right at waist
Driving
Standing
Walking
Running
Lifting
Sitting
Getting up from seated position
Chewing
Changing positions
Lying down
Reading
Working
Exercising
Laying on side in bed
Other
Nothing
Rest
Ice
Heat
Stretching
Exercise
Walking
Pain medication
Muscle relaxers
Chiropractic adjustments
Massage
Other
Sharp
Dull
Achy
Burning
Throbbing
Piercing
Stabbing
Deep
Nagging
Shooting
Stinging
Stiff
Other
No difference
Morning
Afternoon
Evening
Night
Other
No
Anti-Inflammatory
Pain medication
Muscle relaxers
Trigger point injections
Cortisone injections
Surgery
Massage
Physical therapy
Chiropractic
Other

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

Locations

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Office Hours

Our Regular Schedule

Monday:

7:00 am-12:00 pm

Tuesday:

1:00 pm-5:00 pm

Wednesday:

8:00 am-12:00 pm

Thursday:

1:00 pm-5:00 pm

Friday:

8:00 am-12:00 pm

Saturday:

Closed

Sunday:

Closed