Your Goals and Expectations:
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- Gloria Richards
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1 New Member Information: Aligned Health Chiropractic Dr. Jennifer Carauddo, D.C. 987 University Avenue, Suite 28 Los Gatos, CA (408) Fax (408) Today s Date / / Name Birth Date / / Phone (Home) (Work) (Cell) Address Number & Street City State Zip Address Single Married/Partnered Separated Widowed Divorced Spouse/Partner s Name: Names & ages of Children: HOW did you hear about Dr. Carauddo (friend, radio): Your Goals and Expectations: What are your Main Reasons for consulting with our office today? 1) 2) 3) 4) List treatments you have tried in the past that did NOT correct or fix your health: Surgeries, Medications, Herbs, Acupuncture, and/or others: ~ When did you first notice the issue and what do you believe caused your loss of Health? 1
2 ~ What do you believe CAUSED the loss of function leading to your complaints? Identifying YOUR Risk for SUBLUXATION (Nerve Interference): In order for the body to function properly, the brain sends messages through the spinal cord and nerves to every organ, tissue and cell. Physical interference to this communication in the nervous system can result from mis-alignments in the spine, this is called a subluxation. Interference to the normal brain to body messages can result in a lessening of the body s ability to function normally, putting your health at risk. There are literally thousands of events and lifestyle habits that can cause interference to the nerves or a subluxation to occur in your body. Subluxation (nerve stress) is caused by HOW we live each day, from birth until today, everything you have ever done has moved you TOWARDS health or AWAY from health and the life you desire for you and your family. Put a CHECK (X) by any stressors you have NOW or have had in the PAST. Physical Stress: Forceps Delivery C-Section Delivery Breech Vaginal Delivery Epidural / Meds in Labour Vacuum and/ or Forceps used Sleep on stomach Strenuous exercise Poor Ergonomic at work/ school Car Accident Falls Repetitive use of mouse/keyboard/ phone Texting PC/ Games (xbox. Game Boy, etc NO exercise Stand long hours Flat Feet Head Injuries Broken bones Serious Falls Drive/ Sit long hours Surgery / Stitches Cosmetic Surgery Other: Chemical Stress: Labour Induced Injections/ Epidural Steroids Prescription Drugs OTC pills Work with Chemicals Smoker Alcohol use Fast food Diet Sodas Sodas Processed foods (chemical additives, coloring, artificial flavours, etc Diet Pills Vaccines Antibiotics Medications Poor / Inadequate Diet/ Don t eat enough Splenda or other Artificial Sweeteners Other: 2
3 Emotional Stress: Hospitalized Divorce Death of loved one Financial Stress Career Change Newly Married Birth of Child Move away from home Depression ADD/ ADHD Bipolar High Personal Stress Severe Health Problems Other: Pregnancy/ Birthing Experience: Birth is traumatic for 80% of children, the twisting, pulling, C-sections, vacuums, inductions, etc. cause spine and nerve stress for newborns. Your Birth: C-Section: Forceps/ Vacuum, Induction used: Yes Premature / Overdue Complications No APGAR score: Did you have Nerve Block (Epidural): Yes No Your Childhood: Sickness: Broken bones: Hospitalizations: SPINE or Nerve System: Birth Stress, falling, learning to walk, bike accidents, car accidents, sports, life happens. Please let us know about your history of stress to your spine. Area of body: Event: Date of stress on spine: Example: neck and shoulders bike accident summer of ) 2) 3) 4) 5) (Use back of this page if more room is needed) Please list all: Surgeries, Pacemakers, Stents, Broken/ Dislocated Joints, etc. 1) 2) 3) (use back of this page if more room is needed) Current Quality of Nutrition: Fast food: 3
4 Vegan: Raw Diet: How many meals per day do you eat, and what times of day? Fluid Intake: What do you drink and how often? Water: Coffee/ Teas: Alcohol: Soda: Stimulant drinks/ weight loss shakes (slim fast, Ensure, etc): OTHER: Sleep and Rest: Do you have a sleep disorder? Insomnia:, Restless leg, Fibro Myalgia/ Chronic Fatigue Syndrome: Depression: OTHER: How s your quality of sleep? How many hours per night on average? Do you WAKE UP TIRED? Yes No Exercise: What types of movements and how often do you move your body (weights, yoga, jogging, etc)? Are you happy with your current level of activity/ exercise? Yes No What kind of work do you do? How long have you been in this field of work? Computer usage, indicate hours per week: Typing:, reading:, mouse: Are you right or left handed? Hours per DAY do you participate in: Bending: Walking: Standing: Sitting: Lifting: TV: Level of Satisfaction with Career: (1 to 10) 10= being very satisfied: What Activities do you enjoy OUTSIDE of work: Vacation: When was your last vacation, where did you visit and for how long? Medications: What are you taking, for how long, and for what complaint/diagnosis: Medications (list all over the counter and prescribed): Use Back side of page if needed: Please list ALL. 4
5 Herbs/ Homeopathic: SIDE EFFECTS: what side-effects have you noticed from the medications/ herbs: Have you ever been to a chiropractor before today? Yes No Doctor's name/ city Approximate date of last visit: Good experience? Yes No What did you like BEST about Chiropractic in the past: Any reason you would not be able to follow the Dr. Carauddo s recommendations? Yes No Please list your concerns: Check the areas you would like to see improvements: О Strength О Digestion О Driving О Libido О Endurance О Sitting О Sleeping О Focus О Walking О Immunity О Efficiency О Standing О Hormones О Ability to Relax О Lifting О Mood О Appetite О Other aspects of your Life or Health you d like to see BETTER: How committed are you to actively participating in moving yourself toward greater levels of Health and a lifetime of Wellness? (Circle One) 10 = 100% Committed Not at all How we help our patients: Care is provided through a specific and gentle Chiropractic Adjustment. This adjustment restores movement, shape, alignment of the spine, and results in optimal communication in the nervous system. Our Chiropractic adjustment method uses a variety of gentle techniques allowing newborns, children, adults, and women in all stages of pregnancy to enjoy the benefits of having optimum Nervous System Health. The fact is that everyone should have their spine carefully checked to make sure they have their Maximal Health Potential, and then that should be maintained for life! Terms of Patient Acceptance: Sign below to qualify for acceptance in our practice. Welcome to our Wellness Center! We are delighted you have taken the first necessary step towards improving your family s health and wellbeing. 5
6 Health is a state that we can create by living well and maintaining high levels of function within our bodies, for a lifetime. Treatment is a medical idea, that is based on management of symptoms, giving a diagnosis, and palliative care. We are DIFFERENT, I am a CHIROPRACTOR.We are NOT medical doctors nor do we practice medical philosophy. We do not diagnose or treat any disease or condition, however if during the course of a chiropractic evaluation, we encounter non-chiropractic or unusual findings, we will recommend that you seek the services of a provider who specializes in those findings. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. You CAN see your medical doctor, acupuncturist; massage therapist, etc while under our care. They don t do what we do, and we don t do what they do. Chiropractic is a vital part of a health care team, we are happy to speak with your other providers to best help you. Please let us know how we and facilitate communication with your other Doctors and Allied Health Professionals. All fees are due in full today that are necessary to evaluate and offer you Chiropractic advice. I agree to allow Aligned Health to perform the evaluation and pay in full today. Thank you for your confidence and trust in our office, we look forward to helping you. I, have read and fully understand the above statements. (Print Name) (Signature) (Date) 6
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Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
C o n f i d e n t i a l C a s e H i s t o r y
1 C o n f i d e n t i a l C a s e H i s t o r y Today's Date: Name: Phone: Cell phone: Email: Address: City: State: Zip Code: Occupation: Employer: Work phone: Address: City: State: Zip Code: Date of Birth:
Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION STREET ADDRESS CITY/STATE
EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION FIRST NAME LAST NAME EMAIL PHONE # STREET ADDRESS CITY/STATE ZIP GENDER: MALE FEMALE TRANSGENER MARITAL STATUS: MARRIED
PATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
Please Check the appropriate box: Single Divorced Married Widowed Number of Children & Ages:
Date: Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Primary Number: Secondary Number: Mobile Number: Home Email: Work Email: Date of Birth: Age: Gender: M F
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
A Total Wellness Center
800 Hwy 290 W./Building F Dripping Springs, TX 78620 (512)-858-9355 www.ffchiro.com Welcome To Family First Chiropractic! Welcome to our office! Rest assured that you will be provided the most appropriate
ADVANCED NUTRITIONAL CONSULTING
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Concussion or Mild Traumatic Brain Injury
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Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
Today s Date: APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC PATIENT DEMOGRAPHICS Name: Birth Date: / / Age: Male Female Address: City: State: Zip: E-mail Address: Home Phone: Cell Phone: Martial
Welcome To Our Office
Welcome To Our Office Mission Statement Our office is dedicated to educating and adjusting as many families as possible towards optimal health through natural chiropractic care. We believe the greatest
CLIENT INFORMATION. Brain Health Assessment PERSONAL INFORMATION
Brain Health Assessment PERSONAL INFORMATION Thank you for your interest in brain mapping and your inquiry regarding personal training for your brain. Please check your email inbox to confirm that you
BODY MECHANICS CMHA-CEI
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Depression Major Depressive Disorder Defined. by Yvonne Sinclair M.A.
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