New Patient Intake Form

Welcome to Our Office!

Hanley Chiropractic HealthCare • 955 Factory Road • Beavercreek, OH 45434 • PH# 937-426-4545 • Fax# 937-426-4548

Patient Information

Please select one option

* If insurance is through someone other than yourself, complete the below information:

Primary Insurance Card Holder

Check which applies

Secondary Insurance Card Holder

Assignment and Release of Primary Insurance Benefits

If you want benefits to be sent to Hanley Chiropractic Health Care directly, please read and then sign the following.

and assign directly to Hanley Chiropractic HealthCare all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I understand and agree that all charges that are denied which may include any insurance, workers compensation and personal injury claims are my responsibility and are to be paid in full. I hereby authorize Hanley Chiropractic HealthCare to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all insurance submissions.

Consent to Treat and Financial Responsibility (initial each section, sign and date)

Consent to Treat a Minor (if patient is under 18) If Patient is under 18, parent or guardian must complete this portion

do hereby authorize, request and direct Dr. Stuart D. Hanley D.C. and whomever he designates as his assistants and/or associates to perform examinations, diagnostic procedures including x-rays, laboratory tests and any treatment that in their judgement is deemed advisable or required. It is the understanding of the undersigned that the doctor and their staff will have full authority from me as legal parent/guardian to continue with examination diagnostic procedures and tests and treatments as will be needed while said minot showed above is under care in this office until legal age is obtained. As legal parent/guardian I realize full responsibility for all charges and payments due.

ATTENTION: If question does not apply put N/A in the space

Is your condition related to:

Complaints: Mark area of complaints on the figure to the right with an x also, if pain radiates, please mark where it radiates with arrow.

Mark your Pain Point


Mark a # (1 Least-10 Most)

Mid Back
Low Back
Are You Pregnant?
Pain/condition is
Also have:
Condition is:
What makes condition better:
What makes condition worse:
It feels:
How often do you get headaches?
Social habits: Smoking
Alcohol Use
Current drugs (prescription and OTC)
Surgeries/hospitalizations for:
Past or present illnesses
Recent tests (within 2 yrs. Body part and mo/yr):
History: Check if YOU have now or have had any of the following:
Family History: Any immediate Family with:
Work activities
Current work status due to condition:

Patient Quality of Life Survey

Please take several minutes to answer these questions so we can help you get better.

(Please mark as many that apply)

1. How have you taken care of your health in the past?
2. How did the previous method(s) work out for you?
3. How have others been affected by your health condition?
4. What are you afraid this might be (or beginning) to affect (or will affect)?
5. Are there health conditions you are afraid this might turn into?

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

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