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New Patient Center
About Us
- Meet Our Team
- Office Tour
Services
Testimonials
Contact Us

Home

LIPO Intake Form

LIPO Intake Form

Patient Intake Form

Patient Name

Date

Street

City / State / Zip

Cell Phone

Age

Date of Birth

Occupation

Marital Status

Single Married Divorced Widowed

Spouse Name

Ages of Children

Referred by

Family Physician

Concurrent Health Therapies or Regimens

Height

Weight

Ideal

Previous Weight Programs

Results

Do you consider your health an investment or an expense?

Do you have tattoos?

Yes No

If yes, How many?

Any on your stomach or back?

Yes No

Are you pregnant?

Yes No

Are you nursing?

Yes No

HSA(Health Savings) and FSA(Flex Spending) cover our services, do you have one?

Yes No

Medical History

(check all that apply)

HIV Cancer Hepatitis High cholesterol Significant Trauma High Blood Pressure Heart Disease Diabetes Epilepsy/Seizures Thyroid Disease Kidney Disease Cardiovascular Varicose veins Autoimmune Disorder Pregnant/Nursing Insulin Dependent Skin disease/disorder Liver Disease Leukemia Hemophilia Endocrine System condition Surgically implanted Electro-stimulation devices Medications that cause photosensitivity (in the 12 months)

List medications/prescriptions

Pain Indicators

Please select

Headaches Mid back pain Neck pain Shoulder pain Knee pain Hip pain Upper back pain Low back pain Radiating leg pain Wrist pain Ankle pain Radiating arm pain

Body Composition

Problem areas you would like addressed

Love Handles Turkey Neck Cellulite Wrinkles/ Age Spots Thighs Stretch Marks Flabby arms Back fat Mommy tummy Other

If others

Lifestyle

Please select

Stress Caffeine Under / Overeat Pain Skipping meals Sugar / Bad Carbs No exercise Poor Sleep Nerves Alcohol Poor liver Get Hungry Poor Snacks

List vitamins/minerals/supplements

Would you like to learn which supplements can improve your health?

Yes No

How committed are you to living a healthy life on a scale from 1-10, with 10 being the healthiest?

How would your life change if you didn’t have the problems listed on this form?

How are these problems affecting your family life? Work life? Recreational activities? Mindset?

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Office Hours

Our Regular Schedule

Monday

8:00 am - 6:00 pm

Tuesday

8:00 am - 6:00 pm

Wednesday

8:00 am - 6:00 pm

Thursday

8:00 am - 6:00 pm

Friday

8:00 am - 5:00 pm

Saturday

Closed

Sunday

Closed

Location

Find us on the map

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RiverCrest Chiropractic

Address

W177 N9856 Rivercrest Drive #102
Germantown, WI 53022, US

Contact Information (262) 251-7711

262-251-4821

[email protected]

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