Online Forms

Confidential Patient Information

Marital Status*
Please select one option
Ethnicity
Communication Preference: Please Choose One
Do you want text and/or email reminders?

About the Spouse 

Emergency Contact

Insurance Information

(Please give you insurance card(s) to the front desk.)

Do you have health insurance?

Primary

Secondary

Payment is expected at time of service

I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself. Furthermore, I understand that Rasmussen Chiropractic Llc will prepare any necessary reports and forms to assist me in collection from the insurance company and that any amount authorized to be paid directly to Rasmussen Chiropractic Llc will be credited to my account upon receipt. However, I clearly understand and agree that any services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fee for professional services rendered me will be due immediately and payable

Health History

Have you been seen in this office for this problems before?
Which activities are difficult to perform?
Type of pain:
Is the pain constant?
Does the pain come or go?
What treatment have you already received for your condition?
Women only: Are you pregnant?
Are you nursing?
Do you take birth control pills?
Have you had any surgeries?

Family History

Heart Disease
Cancer
Diabetes
Hypertension
Stroke
High Cholesterol
Migraines

Daily Habits

Do you perform exercises on a daily basis?
Do you smoke?
Have you ever smoked?
Do you consume liquor?
Do you consume caffeine on a daily basis?

Review of Systems

INSTRUCTIONS: Please fill out all of the sections. If none of the conditions apply, select "None."
Constitutional
Eyes/Vision
Ears, Nose, and Throat
Cardiovascular
Gastrointestinal
Respiration
Endocrine
Skin
Nervous system
Allergy
Hematology
Psychological
Female
Male

Oswestry Low Back Pain Questionnaire

This questionnaire is designed to enable us to understand how much your low back pain has affected your ability to manage everyday activities. Please answer each Section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just click the one choice which closely describes your problem right now.

Section 1: Pain Intensity*
Please select at least one option
SECTION 2--Personal Care (Washing, Dressing etc.)*
Please select at least one option
SECTION 3--Lifting*
Please select at least one option
SECTION 4 --Walking*
Please select at least one option
SECTION 5--Sitting*
Please select at least one option
SECTION 6 -- Standing*
Please select at least one option
SECTION 7--Sleeping*
Please select at least one option
SECTION 8--Social Life*
Please select at least one option
SECTION 9--Traveling*
Please select at least one option
SECTION 10--Changing Degree of Pain*
Please select at least one option

Neck Disability Index Questionnaire

This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. Please answer each Section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just click the one choice which closely describes your problem right now.

Section 1: Pain Intensity*
Please select at least one option
SECTION 2--Personal Care (Washing, Dressing etc.)*
Please select at least one option
SECTION 3--Lifting*
Please select at least one option
SECTION 4 --Reading*
Please select at least one option
SECTION 5--Headache*
Please select at least one option
SECTION 6 -- Concentration*
Please select at least one option
SECTION 7--Work*
Please select at least one option
SECTION 8--Driving*
Please select at least one option
SECTION 9--Sleeping*
Please select at least one option
SECTION 10--Recreation*
Please select at least one option

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point

Goals for my Care

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.


Ownership of X-ray Films


It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office.

Rasmussen Chiropractic Llc

CONSENT FOR X-RAYS

I,(named above), do here by give my consent to allow the doctors and staff to take the x-rays they deem necessary. I hereby declare that to my knowledge I am not pregnant.

CONSENT TO TREAT A MINOR

I hereby authorize the doctors at Rasmussen Chiropractic Llc and whomever they may designate as his/her assistants to administer chiropractic care as he/she deems necessary to my minor son/daughter:

This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the doctor's discretion.

As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorizations, the consent of a spouse/former spouse or other parent is not required. If my authority to select and authorize this care should be revoked or modified in any way, I will immediately notify this office.

ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to the organization listed below for any equipment or services provided to me by that organization.

I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, the Health Care Financing Administration, my insurance carrier or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company or other entity if requested. The original authorization will be kept on file by the organization.

I understand that I am financially responsible to the organization for any charges not covered by health care benefits. It is my responsibility to notify the organization of any changes in my health care coverage. In some cases exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by the organization and/or my health care insurer if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products received.

By signing this document, I also acknowledge that I have received a copy of the organization's Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.

Nutrition and self-care are just two of the components in obtaining optimal wellness.

Please let us know what you are currently doing for your health.

Things I do currently to support my health include:
Please indicate which of these you do/have on a consistent basis:

Initial Consultation Form


Overall frequency of complaint (Please check only one)
Overall intensity of complaint (Please check only one)
If yes, please select the amount below that you feel your symptoms increase at work:

Missed Appointments


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.


Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Today's payment will be made by:

Insurance:


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately.

Authorization for Care:

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Agreement:


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

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

Location

Find us on the map

HOURS OF OPERATION

New Albany Office

Monday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Wednesday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

Closed

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Sunday

Closed

New Albany Office

Monday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Tuesday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Wednesday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Thursday
Closed 2:00 pm - 6:00 pm
Friday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Saturday
Closed
Sunday
Closed