Howill Chiro — New Patient Form

Before you begin

Welcome to Howill Chiro

We're glad you're here. Please complete this health record as thoroughly and accurately as possible so our team can understand your history, your current concerns, and your goals for care. If anything is unclear, just ask a member of our team — we're happy to help.

I understand this is a legal agreement and intend to sign it. *

I agree to sign this agreement electronically. *

Are you filling this form out for yourself or your child? *

Myself My Child

Please complete the required fields above before continuing.

Patient details

About You

This helps us keep accurate records and reach you when needed.

First Name *

Last Name *

Birthday *

Cell Phone *

Email *

Gender *

Male Female Other

Referred By

Street Address *

City *

State

Zip Code *

Employer Information

Employer

Type of Work

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Your condition

Reason for This Visit

Is the purpose of this appointment related to: *

If job related, have you reported the accident to your employer?

Yes No

Please explain

When did this condition begin?

Has this condition:

Gotten worse Stayed constant Comes and goes

Has this condition occurred before?

Yes No

Does this condition interfere with:

Work Sleep Daily Routine Other activities

Overall intensity of complaint

Minimal Slight Moderate Severe

Overall frequency of complaint

Constant · 100% Frequent · 75% Intermittent · 50% Occasional · 25%

Have you seen other doctors for this condition?

Yes No

Doctor's Name(s)

Type of Treatment

Results

Mark Your Pain Points

Tap on the figures below where you feel pain, numbness, or tingling.

FRONT

BACK

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Goals & history

Health & Wellness

Beyond pain relief, which of these are important to you? *

Health Habits & Conditions

Medications I now take

Do you smoke? *

Yes No

Do you drink alcohol? *

Yes No

Do you drink coffee? *

Yes No

Do you exercise regularly? *

Daily Moderately No

Do you wear

Heel Lifts Sole Lifts Inner Soles Arch Supports

Health conditions (check all that apply)

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Consent to treat

Chiropractic & Dry Needling Consent

Please read the following consent carefully. It covers the nature of chiropractic adjustments, dry needling, and the associated risks.

Informed Consent to Treat

I hereby request and consent to chiropractic adjustments and other chiropractic procedures, including physical therapy modalities and diagnostic x-rays, and supportive therapies including Pulsed Electromagnetic Field Therapy, Low Level Light Therapy, Cold Laser, Decompression, Compression Recovery System, Myofascial Acoustic Compression Therapy, and Dry Needling, performed by Dr. Hung Cao and/or other licensed doctors of chiropractic and support staff at Howill Chiro (Richardson / Arlington), or any associated office, whether signatories to this form or not.

I understand that results are not guaranteed, and I rely on the doctor's judgment during the course of treatment.

Adjustment / Manipulation

An adjustment involves a controlled, quick thrust to a joint, which may produce a "popping" sound from gas release in the joint fluid. This is usually not painful. The doctor's hands may contact bony areas such as the back, hips, neck, or ribs while performing the adjustment.

Potential Risks

Stroke / Cardio-Vascular Accident is the most serious risk associated with cervical (neck) adjustments, though published research places the incidence at roughly 1 per several million upper cervical adjustments.

Rib Fracture may rarely occur in the thoracic spine, usually in patients with weakened bone structure such as osteoporosis.

Disc Herniation is frequently treated successfully by chiropractors; rarely, treatment may aggravate an existing weakened disc.

Soft Tissue Injury to muscles or ligaments is rare and typically resolves with temporary increased discomfort.

Burns may rarely result from heat/cold or electrical modalities such as e-stim, hot/ice packs, cupping, or ultrasound.

Soreness is common and temporary following adjustment, traction, or massage.

I understand alternatives to chiropractic care exist, including OTC medication and rest, prescription medication, physical therapy, injections, bracing, or surgery, and that I have the right to seek a second opinion.

Dry Needling Consent

Dry needling inserts a thin monofilament needle into muscle to release trigger points and reduce muscle tension. It is a medical treatment, not acupuncture. The most serious rare risk is accidental lung puncture (pneumothorax); other risks include bruising, infection, or minor nerve irritation, all uncommon.

Consent for Treatment of a Minor

If this form is completed for a minor, I authorize the doctors of Howill Chiro and/or their designated assistants to administer treatment as deemed necessary.

I have read (or had read to me) this consent, had the opportunity to ask questions, and agree to the procedures described above. *

Printed Name *

Email *

Date Signed *

Signature *

Sign with your finger, stylus, or mouse.

Please complete the required fields and sign above before continuing.

Privacy

HIPAA Notice of Privacy Practices

This notice describes how your medical information may be used and disclosed, and how you can access it. Effective 07/14/2026.

Your Rights

You have the right to get a copy of your medical record, ask us to correct it, request confidential communications, ask us to limit what we share, get a list of certain disclosures, get a paper copy of this notice, and choose someone to act on your behalf.

File a Complaint

You may contact our Privacy Officer at 214-484-2629 or info@howillclinic.com, or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

Your Choices

You may tell us how to share your information with family or friends involved in your care, in a disaster relief situation, or in a facility directory. We will never share information for marketing, sale of information, or psychotherapy notes without your written permission.

Our Uses & Disclosures

We use and share your health information to treat you, run our practice, and bill for services. We may also be required to share information for public health, research, legal, or safety purposes as permitted by law.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information, notify you of any breach, and follow the practices described in this notice. This notice applies to Howill Chiro — all locations (Richardson / Arlington).

My signature below only acknowledges that I have received this Notice of Privacy Practices. *

Printed Name *

Email *

Date Signed *

Signature *

Please complete the required fields and sign above before continuing.

Optional, but appreciated

Photo & Video Consent

I consent for photographs and/or video images to be taken of me by Howill Chiro or a representative, to be used as part of my medical record and for teaching, training, or marketing purposes (website, print, digital, or social media). I understand I will not be compensated, that images will be used without identifying information such as my name, and that my participation is voluntary. I may withdraw this consent at any time with a written request.

Consent *

Yes No

Printed Name *

Email *

Date Signed *

Signature *

Please complete the required fields and sign above before continuing.

Almost done

Review & Submit

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Thanks — you're all set

Your intake form has been received. We look forward to seeing you at Howill Chiro.