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Philadelphia Chiropractor, Dr. Jeff Sklar LogoPhiladelphia Chiropractor, Dr. Jeff Sklar Logo

(215) 498-5825
Located in historic Chestnut Hill
at Wissahickon Spine Center

Philadelphia Chiropractor, Dr. Jeff Sklar LogoPhiladelphia Chiropractor, Dr. Jeff Sklar Logo

(215) 498-5825
Located in historic Chestnut Hill at Wissahickon Spine Center

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Intake Form

Intake FormKarie2022-03-28T11:15:30-06:00
1PATIENT INFO
2HEALTH INFO
3FAMILY INFO
4OTHER INFO
5INSURANCE INFO

CONFIDENTIAL PATIENT CASE HISTORY

Dear Patient:
Please complete this questionnaire. Your answers will help us to determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU.
Name(Required)
Address(Required)
MM slash DD slash YYYY
Gender(Required)
Marital Status(Required)
Pain Chart
How would you describe your pain?(Required)
Check more than one if necessary to describe your problem
1 = Best 10 = Worst
12345678910
What activities aggravate your condition? ((Required)
Check more than one if necessary to describe your problem
It interferes with:(Required)
What alleviates your condition?(Required)
Check more than one if necessary to describe your problem
Is Your Mattress
If unsure leave empty and select the next box
MM slash DD slash YYYY
Physical Exam Date
Drugs you now take:(Required)
Is there any chance that you may be pregnant?(Required)
At our office we are not only interested in your well being, but also the health and well being of your family and loved ones. Please mention below any health conditions or concerns you may have about your:
Family Health Information
Many health problems are the result of hereditary spinal weaknesses; thus information about your family members will give us a better picture of your total health
NAME
RELATION
PAST AND PRESENT HEALTH PROBLEMS
 
Have you been in an auto accident?(Required)
Have you had any personal injury or accident?(Required)

Childhood Years

Did you have any childhood illness?(Required)
Was there a prolonged use of medicine?(Required)
Did you have any falls from height Over 3 feet (i.e. crib, bunks)(Required)
Did you play youth sports?(Required)
Did you take/ use any drugs?(Required)

Adult Years (18-present)

Do/Did you smoke?(Required)
Do/ Did you drink alcohol?(Required)
Have you been in any accidents?(Required)
Do/Did you play adult/extreme sports?(Required)
Have you suffered from?(Required)
Is your condition due to an auto accident or job related injury?(Required)
Are you covered by Medicare?(Required)
Consent(Required)
I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this Chiropractic Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this Chiropractic office will be credited my account or receipt. However, I clearly understand and agree that all services rendered 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, any fees for professional services rendered me will be immediately due and payable.
MM slash DD slash YYYY
Reset signature Signature locked. Reset to sign again

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Dr. Jeff Sklar, Chiropractor
Philadelphia Chiropractor, Dr. Jeff Sklar LogoPhiladelphia Chiropractor, Dr. Jeff Sklar Logo
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(215) 498-5825
15 West Highland Ave, Suite F
Wissahickon Spine Center
Philadelphia, PA 19118

Chiropractor in Philadelphia, PA

Specializing in conservative, non-pharmacologic pain management treatment for oncology patients.

LOCAL LINKS

Chestnut Hill Business Association
Pennsylvania Chiropractic Association
Chestnut Hill Community Association

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