Welcome to World Class Chiropractic
Welcome to our office! Rest assured that you will be provided the most appropriate and professional healthcare possible. The information we collect on the following pages is really important for us to properly assess your symptoms, function, health care challenges and health care goals.
Please fill out our history forms completely and to the best of your ability so that we can quickly get you on the road to health. We look forward to a healthy relationship with you and your family.
Date: ______Social Security #______Email: ______
Name: ______
Last First M.I
Address/City/Zip:______
Cell Phone: ______Home Phone: ______
Preferred method of communication: (Check one) Email___ Text___ + Carrier Name ______
Sex: ______Male ______Female Age: ______Birthdate: ______
___Married ____Separated ____Widowed ____Divorced ____Single ____Partnered for ___Yrs ____Minor
Preferred Language: ______Ethnicity (Circle): Hispanic or Latino / Not Hispanic or Latino/ Decline
Race (Circle): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) /
Native Hawaiian or Pacific Islander / Other / I Decline to Answer
Patient Employer/School ______
Address: ______
Phone: ______Occupation: ______
Spouse’s Name: ______SS#______- ______- ______Phone: ______
Birthdate: ______Spouse’s Employer: ______
Emergency Contact: ______Relationship: ______Phone______
ACCIDENT INFORMATION: Is condition due to an accident? Yes____ No____ Date of Accident ______
Type of Accident: Auto ____ Work ____ Home____ Other ____
INSURANCE INFORMATION:
I certify that I, and/or my dependent(s), have insurance coverage with ______and I understand that I am financially responsible for all charges. World Class Chiropractic provides its services directly to you, not to your insurance company. You are ultimately liable for your bill. If you are billing your own claims, we will provide you with an itemized bill. However, as a courtesy to you, we will bill your insurance company for services rendered up to medical necessity care. I have read and understood all the above information. This clinic doctor may use my health care information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I authorize the use of my signature on all insurance submissions.
______
Signature of Patient, Parent, Guardian or Personal Representative Date
______Please print name of above signature Relationship to Patient
Patient Name: ______DOB: ______
We are happy to verify your insurance coverage, meaning that we will verify your benefits and have that information prepared for you.
Who is responsible for this account? ______Relationship to patient: ______
Insurance Co:______Provider Phone #: ______
Subscriber Name ______Subscriber Birthdate: ______ID #: ______
INFORMED CONSENT:
REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures:
I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.
Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at World Class Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.
______/____/____Witness Initials
Patient or Authorized person’s Signature Date
REGARDING: X-rays/ Imaging Studies
FEMALES ONLY please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation.
The first day of my last menstrual cycle was on ____-____-____Date
I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant.
By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
______/____/____ Witness Initials
Patient orAuthorized person’s Signature Date
Patient Name: ______DOB: ______
We appreciate you choosing our office. Is there anyone that we can thank for referring you? ______
Please indicate the main reason you are seeing us today: ______
If you are seeing us for a pain related issue, USE THE SYMBOLS to show the type of pain you feel in each location.
Using the pain scale below, CIRCLE the pain level you experience when your problem is at its very worst:
.
Is there any radiating pain into the arms or legs? ______Is there any numbness or tingling? ______
How often do you experience your problem? (Please indicate for each of the body location if applicable)
Constant (75 – 100% of the time) ______
Frequent (50 – 75% of the time) ______
Occasional (25 – 50% of the time) ______
Intermittent (0 – 25% of the time) ______
Patient Name: ______DOB: ______
List any MD’s or Chiropractors you’ve already seen for this problem:
______
What tests have you already had for this problem?X-rays MRI C.T. Scan Myelogram EMG/NCV
None Other ______
What have you already tried for this problem?Anti-inflammatory Pain Meds Muscle Relaxers
Injections Physical Therapy Chiropractic Massage Exercise Other ______
What makes your problem worse?Sitting Standing Changing Position Walking Bending Lifting Twisting
Reaching Driving Sleeping Sneeze/Cough Computer Work Telephone Going From Sit To Stand Other______
PAST MEDICAL HISTORY
Please list any significant conditions that you’ve been diagnosed with or been treated for over the course of your life: ______
______
Please list any surgeries you have had over the course of your life:______
______
MEDICATIONS & ALLERGIES
Are you allergic to any medications?Yes No If yes, please list:______
List any medications, herbs or supplements you are taking and the reason for their use: ______
FAMILY HISTORY
Mother:Living Deceased List any medical problems: ______
Father:Living Deceased List any medical problems: ______
List any problems common in your family:Cancer Diabetes Heart disease High blood pressure Stroke Arthritis
Scoliosis Thyroid disease Osteoporosis ______
SOCIAL HISTORY
Marital status:Married Single Divorced Common Law Engaged Widowed
Do you have any children?Yes No If yes, how many? ______
Do you drink alcohol?Yes No If yes, how much & how often? ______
Do you smoke?Yes No If yes, how much, how often & how long? ______
Are you currently employed?Yes No If yes, what is your occupation? ______
Who is your current employer? ______How long have you been at this job? ______
What do you do most of the day in your job postures, positions and repetitive movements: ______
On a scale of 0 to 10 with 0=Worst and 10=Best, rate how well you think you are doing with the following:
Exercise______Sleep ______Diet ______Stress Level ______Water Intake ______Energy Level______= ______
Patient Name: ______DOB: ______
REVIEW OF SYSTEMS
Please use the scale below (0 to 4) to rate each of the symptoms on this page according to your health status over the past 30 days: 0 = Never have this symptom
1 = Occasionally have this symptom, effect not severe
2 = Occasionally have this symptom, effect is severe
3 = Frequently have this symptom, effect not severe
4 = Frequently have this symptom, effect is severe
Head:______Headaches
______Faintness
______Dizziness
______Insomnia / Energy/Activity:
______Fatigue/Sluggishness
______Apapthy/Lethargy
______Hyperactivity
______Restlessness / Lungs:
______Chest Congestion
______Asthma, Bronchitis
______Shortness Of Breath
______Difficulty Breathing
Eyes:
______Watery or Itchy Eyes
______Swollen, Red or Sticky Eyelids
______Bags or Dark Circles Under Eyes
______Blurred or Tunnel Vision (not including near or far sightedness) / Weight:
______Binge Eating/Drinking
______Craving Certain Foods
______Excessive Weight
______Compulsive Eating
______Water Retention
______Underweight / Heart:
______Irregular or Skipped Heartbeat
______Rapid or Pounding Heartbeat
______Chest Pain
Ears:
______Itchy Ears
______Earaches, Ear Infections
______Drainage From Ear
______Ringing In Ears, Hearing Loss / Emotions:
______Mood Swings
______Anxiety/Fear/Nervousness
______Anger/Irritability/Aggressiveness
______Depression / Digestive Tract:
______Nausea, Vomiting
______Diarrhea
______Constipation
______Bloated Feeling
______Belching, Passing Gas
Nose:
______Stuffy Nose
______Sinus Problems
______Hay Fever
______Sneezing Attacks
______Excessive Mucus Formation / Mind:
______Poor Memory
______Confusion, Poor Comprehension
______Poor Concentration
______Poor Physical Condition
______Difficulty Making Decisions
______Stuttering or Stammering / ______Heartburn
______Intestinal/Stomach Pain
Mouth & Throat:
______Chronic Coughing
______Frequent Need to Clear Throat
______Sore Throat, Hoarseness
______Swollen or Discolored Tongue
______Canker Sores / ______Slurred speech / Other:
______Frequent Illness
______Frequent or Urgent Urination
______Genital Itch or Discharge
Skin:
______Acne
______Hives, Rashes, Dry Skin
______Hair Loss
______Flushing, Hot Flashes
______Excessive Sweating / Joints/Muscles:
______Pain or Aches in Joints
______Arthritis
______Stiffness or Limited Movement
______Pain or Aches in Muscles
______Weakness or Fatigued Muscles / Grand Total:
Patient Name: ______DOB: ______
Please answer the questions assuming that 1 = You DON’T AGREE with the statement and 10 = you AGREE with the statement whole heartedly without any doubt in your mind.
SECTION 1: Physical Health
- I am a physically fit person and formally exercise on a regular basis.
1 2 3 4 5 6 7 8 9 10
- I have a physically attractive body that I am proud to look at in the mirror.
1 2 3 4 5 6 7 8 9 10
- I have not had many traumas in my life (auto accident, broken bones, bad falls).
1 2 3 4 5 6 7 8 9 10
- I get at least 7 hours of sleep, 7 days a week
1 2 3 4 5 6 7 8 9 10
- I have gotten regular Chiropractic care within the past 5 years.
1 2 3 4 5 6 7 8 9 10
Total ______
SECTION 2: Mental/Emotion Health
6. I am a calm, peaceful person. I can shut my mind off and focus my mind at will.
1 2 3 4 5 6 7 8 9 10
7. I practice some form of mental relaxation (meditation, yoga, breathing exercises, prayer, etc.) on a
regular basis.
1 2 3 4 5 6 7 8 9 10
8. Most of the time, I am truly happy and feel a sense of purpose in my life.
1 2 3 4 5 6 7 8 9 10
9. I have healthy relationships and a rich social network of friends and activities.
1 2 3 4 5 6 7 8 9 10
10. I am organized, have time for myself, and can prioritize the important tasks in my life.
1 2 3 4 5 6 7 8 9 10
Total ______
SECTION 3: Chemical/Nutritional Health
11. I eat 4-6 small meals daily and properly combine my protein, carbs. and fats.
1 2 3 4 5 6 7 8 9 10
12. I supplement everyday with good supplements such as a vitamin/mineral complex, antioxidants, and
good fatty acids (fish oil, flax seeds).
1 2 3 4 5 6 7 8 9 10
13. I do not take medications for chronic medical problems such as digestive disorders; cardiovascular
problems; headaches; chronic pain; blood sugar problems; chronic fatigue; immune problems or chronic
infections; or any other chronic conditions.
1 2 3 4 5 6 7 8 9 10
14. I do not smoke cigarettes.
1 2 3 4 5 6 7 8 9 10
15. I drink water as my primary beverage and consume at least 30 ounces per day.
1 2 3 4 5 6 7 8 9 10
Total______
GRAND TOTAL OF ALL THREE SECTIONS: ______
1