New Patient Form

New KCPCR Intake V1

"*" indicates required fields

Personal Information

Full Legal Name*

Preferred name/ Nickname

Date of Birth*

Age*

Sex*

Male

Female

Other

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Email*

Emergency Contact

Name

Relationship

Phone

Health Insurance Information

Primary Insurance

Insurance Company

Member ID #

Secondary Insurance (if applicable)

Company

Member ID #

Chief Complaint

(Primary reason for coming in today)

Primary Area(s) of Concern (check all that apply)

Date Primary Symptom Began

Onset

Sudden / Injury

Gradual / Overuse

Unknown/ No apparent reason

Pain & Symptoms

Location(s)

Symptom Type

Sharp

Dull

Aching

Tightness

Stiffness

Numbness

Tingling

Other

Pain Rating (0–10):

Current

Best

Worst

Symptoms get worse with

Symptoms get better with

What do your symptoms affect? What’s hard or impossible to do because of your symptoms?

Training

Competition

Work duties

Daily activities

Sleep

Other

Past Health & Injury History

Previous chiropractic care?

Yes

Previous injury to same area?

Yes

Surgeries (location & year)

Prior imaging (X-ray / MRI / CT)?

Yes

If yes, where & when

Current or previous history of cancer?

Medications & Supplements

All of Your Current Medications (including over the counter)

Supplements

Safety Screening

General Health

Yes

No | Unexplained weight loss

General Health

Yes

No | Fever, chills, or night sweats

General Health

Yes

No | History of cancer

General Health

Yes

No | Persistent fatigue without explanation

Neurological

Yes

No | Progressive weakness in arms or legs

Neurological

Yes

No | Worsening numbness or tingling

Neurological

Yes

No | Difficulty with balance or coordination

Neurological

Yes

No | Changes in bowel or bladder control

Spine / Trauma

Yes

No | Recent significant trauma (fall, collision, accident)

Spine / Trauma

Yes

No | Severe pain after minor trauma

Spine / Trauma

Yes

No | Pain that does not improve with rest

Spine / Trauma

Yes

No | Night pain that wakes you from sleep

Vascular / Cardiovascular

Yes

No | Chest pain or pressure

Vascular / Cardiovascular

Yes

No | Dizziness, fainting, or blackouts

Vascular / Cardiovascular

Yes

No | Sudden shortness of breath

Vascular / Cardiovascular

Yes

No | Calf pain, swelling, or redness; or previous diagnosis of deep vein thrombosis (DVT)

Inflammatory / Other

Yes

No | Hot, swollen joint with fever

Inflammatory / Other

Yes

No | Known inflammatory arthritis

Inflammatory / Other

Yes

No | Long-term steroid use (i.e. prednisone)

Inflammatory / Other

Yes

No | Blood thinner use

Goals of Chiropractic Care

What are your goals?

Pain reduction

Improved mobility

Return to sport

Injury prevention

Performance optimization

Describe your ideal outcome if you’re looking back to this day 3 months from now

Other health information:

How’s your daily water intake? (please specify)

Are you following any specific diet or eating habits?

How’s your fruit and vegetable intake?

On average, how much sleep do you get per night?

Missouri Informed Consent for Chiropractic Care

I understand that chiropractic care in Missouri includes evaluation, spinal and extremity manipulation, manual therapy, and rehabilitative procedures related to the neuromusculoskeletal system.

I understand:

Chiropractic care does not include prescribing medication or performing surgery.

No guarantee of results has been made.

Referral to another healthcare provider may be recommended if findings fall outside the scope of chiropractic practice.

I have disclosed all relevant health information truthfully.

Patient / Guardian Signature

Date

Minor Consent (If Applicable)

I am the parent or legal guardian of the above minor and authorize chiropractic evaluation and treatment.

Guardian Name

Signature

Date

Payment & Scheduling Policies

Payment is due at the time of service unless prior arrangements have been made. Charges vary based on insurance coverage, self-pay status, or third-party administrator involvement.

We will verify insurance benefits before your first visit; however, quoted benefits are not a guarantee of payment. Any balance remaining after insurance is processed is the patient’s responsibility. Insurance does not cover missed appointments or late cancellations.

You will receive three appointment reminders as a courtesy. If you need to cancel or reschedule, you may reply to a reminder or call/text (816) 988-0185. We kindly ask for at least 2 hours’ notice so we can offer the time to another patient.

If you are running late, please let us know as soon as possible. We will do our best to accommodate you, depending on the schedule. Arrivals more than 8 minutes late may need to reschedule, and appointment times may be shortened.

Missed or late-canceled appointments will be charged a $65 fee, which is not covered by insurance. Fees are waived if the appointment is rescheduled and attended.

Please notify us if you would like a copy of these policies.

Please notify us if you would like a copy of these policies. If applicable, your intake form and copy of your insurance card (if you're using health insurance) are required 24 hours ahead of your appointment to secure your new patient appointment.

What People Says About Us.

Dr. Alex was recommended to me by a trusted physical therapist. I had recent back surgery and was left with much post-surgical pain. Dr. Alex did a complete assessment. He was thorough and gentle. He gave me hope. It was justified by a treatment that relieved my pain more thoroughly than it had been for months. When I got home, I laid down to rest. Never had my rest been complete, due to pain. That afternoon, it was. I phoned a grateful and admittedly tearful thank you to Dr. Alex.

– L.C.

KC Performance Chiro and Rehab will forever be my go-to for all my chiropractic needs! I have struggled with chronic low back/hip pain as well as tight neck and shoulders from a previous injury in my youth. Dr. Alex was able to get me to a point where I no longer needed self-support to tip my head all the way back! He has also been able to keep my back and hips loose enough to continue running and lifting weights 4-5 times per week! I am always excited for my visits with Dr. Alex because I know that when I leave I will be moving with more ease and less pain after he gets "cracking"!

– J.H.

He’s particularly good with the whiniest of patients who don’t want to listen.

– D.K.