PERSONAL INFORMATION WELCOME TO OUR OFFICE
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- Merryl Horton
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1 WELCOME TO OUR OFFICE PERSONAL INFORMATION We appreciate the opportunity to serve you. As we endeavour to ensure that your health outcomes are met, we ask you to assist us by completing the following information. Today s Date Last Name First Name Preferred Name If under 18: Mother s Name Father s Name Address City State Post Code H.Phone W.Phone Mob.Phone Address Preferred method of communication Date of Birth Age Relationship Status Occupation Partner s Name Partner s Occupation Names & Ages of children Referred By Have you ever received chiropractic care? Yes No If yes, from whom? Are you in a health fund? Name of Fund When? Emergency Contact Name Relationship Phone
2 YOUR HISTORY - YOUR JOURNEY OF LIFE - During the course of your life s journey you may have encountered many stressors. Whilst some of these stressors may have seemed small, they may have had an accumulating effect on your life. Please answer the questions on the following issues that commonly arise through the formative years. - PRE-PREGNANCY Did your Mum & Dad Plan and welcome the pregnancy? Prepare their bodies for pregnancy? - PREGNANCY Did your Mum Have chiropractic care during pregnancy? Exercise through pregnancy? Have a nutritious diet during pregnancy? Get injured during pregnancy? Smoke or drink alcohol during pregnancy? Endure stress during pregnancy? - BIRTH PROCESS Home birth? Hospital birth? Was your birth early/late (according to due date)? Induced labour? Drugs during delivery? Was the delivery long? Was the delivery difficult? Caesarean (Elective/Emergency)? Presentation position: Posterior, breech, correct, transverse, other - GROWTH AND DEVELOPMENT PHYSICAL Physical abuse by siblings/others? Violently pulled by the arm? Were you a head-banger? Did you fall on your head? Did you fall down stairs? Were you taught how to care for your spine? Did you have the chair pulled from under you? CHEMICAL Were you breast fed? If so for how long? Were you bottle-fed? If so for how long? Vaccines received
3 YOUR HISTORY PAGE 2 - MENTAL/EMOTIONAL - Was there communication breakdown in your household? Was there a loss of a close relative? Was there any stress in the family? If yes to any of the above, please give details - LIFESTYLE Do you smoke? Do you drink alcohol? Do you drink adequate water? Do you eat healthy foods? Do you sleep well? Are your teeth healthy? Do you exercise regularly? Are you physically stressed? Are you mentally stressed? Are you being, or have you been, exposed to chemicals? Are you taking, or have you ever taken, drugs? Sports: Hobbies: Accidents: Surgery: Drugs: Have you experienced a loss in the past 5 years? (.e.g. relationship, family, business, financial) - HEALTH OBJECTIVES People consult this office with one or more of the following health objectives. Please indicate which apply to you. Relief of my symptoms Correction of my underlying health problems To maximise my health To maximise myself, my family s and community health. You may have specific reasons for consulting this office. If this is the case what are they? How would you rate your overall health? /10 What would you like your health to be? /10
4 Informed Consent to Chiropractic Care Changes to the law now require all chiropractors to warn people of material risks. Chiropractic care is recognized as being an effective and safe method of care for many conditions. However, as in all health care, there are some very slight risks with chiropractic care. This includes, but is not limited to: - Your condition becoming worse; - Disc injuries, rib fracture, sprains/strains (1 in 139,000 in the neck and 1 in 62,000 in the low back) (1) ; - Stroke or stroke like symptoms (1 in 5.85 million neck adjustments) (2) (3). Put in context, chiropractic has been shown to be 250 times safer than anti- inflammatory drugs (4) and safer than driving a car (5). Some people may experience some mild soreness for hours after their adjustments, especially when their body is unwinding (6) (7). This is a normal sign of change, as may occur after exercise or stretching. Clinical experience consistently demonstrates unexpected improvement in people s life. One study indicated that 23% of people experience improvement in some other aspect of their health. (8) Of individuals who experience such improvements: - 26% experienced improvements in their respiratory system; - 25% in their digestive system; - 14% circulatory system/heart; - 14%: eyes/vision. Broken down into subcategories the benefits were reported as follows: - Easier to breathe: 21%, - Better circulation: 7% - Improved digestive function: 20%, - Changes in heart rhythm/blood pressure: 5%, - Clearer/better/sharper vision: 11%, - Less ringing in the ears/improved hearing: 4% (The references for the information quoted above are available upon request.) WorkCover and Veterans Affairs All matters involving WorkCover require the person to be referred to this office by a registered medical practitioner and have a current medical certificate to cover any chiropractic services provided. DVA patients are required to have a current request referral D904 from their GP. Agreement: I have read and understand the information above. I do not expect the chiropractor to be able to anticipate or explain all the risks and complications. I wish to rely on the chiropractor to exercise his/her judgment during the course of procedures which he/she feels at the time, based upon the facts known, is in my best interests. I have, to the best of my knowledge, provided the chiropractor with a complete and accurate health history. I have had the opportunity to discuss with the chiropractor the nature and purpose of chiropractic adjustments and other procedures as well as other concerns. I understand that results are not guaranteed. I intend this consent form to cover the entire course of my chiropractic care for this and any future presentation. I hereby request and consent to chiropractic examinations, adjustments and other chiropractic procedures, including scans, x- rays, and other imaging, wherever the chiropractor determines necessary. By signing below I agree to chiropractic care. Signature: (Parent /guardian if under 18 years) Chiropractor s signature: Print name: Child s name: Date: (1) Dvorak study in Principles and Practice of Chiropractic, Haldeman, 2nd Ed. (2) Arterial Dissections Following Cervical Manipulation: The Chiropractic Experience. Haldeman S et al. Canadian Medical Association Journal, Vol 165, No 7, , (3) The Mechanics of Neck Manipulation with Special Consideration of the Vertebral Artery. Herzog W, Symons B. J Can Chiropr Assoc 46(3): , (4) A Risk Assessment of Cervical Manipulation vs. NSAID s for the Treatment of Neck Pain. Dabbs V, Lauretti W. J Manipulative Physiol Ther 1995; 18(8);530-6 (5) What are the Risks of Chiropractic Neck Adjustments. Lauretti W. JACA 1999; 36(9); (6) Leboeuf-Yde C, Axen I, Ahlefeldt G, Lidefelt P, Rosenbaum A, Thurnherr T. The types of improved nonmusculoskeletal Side effects of chiropractic treatment: a prospective study. Leboeuf-Yde C. J Manipulative Physiol Ther Oct;20(8):511-5 (7) Frequency and characteristics of side effects of spinal manipulative therapy. Senstad O et al. Spine Feb 15;22(4):435-40; discussion (8) Symptoms reported after chiropractic spinal manipulative therapy. J Manipulative Physiol Ther 1999;22:
5 WHAT IS CHIROPRACTIC? Chiropractic is based on the natural law of homeostasis (balance), which simply states that a living organism (you) has an innate organisation/intelligence that causes it to always express its greatest potential for health and well- being. This organisation can be witnessed in the proper functioning of every cell, tissue, organ and system of your body. The brain and nerve system controls and monitors the proper function (organisation and expression) of your body. A lack of health can result when your nervous system is impaired or damaged by a misalignment, and/or malfunction of the bones that protect it. The practice of Chiropractic helps eliminate these malfunctioning areas so your body can work more effectively and, with appropriate health practices, allow you to regain/retain optimum health. - HEALTH - According to Dorland s Medical Dictionary, health is an optimum state of physical, mental and social wellbeing, and not merely the absence of disease and infirmity. - HEALTH POTENTIAL - We all have a potential for health based on our genetic information plus the situations and events that we have encountered so far in our life. - HEALTH FORMULA - W + F + T = Health Wholeness - you must have all your body organs and systems Function - all the parts are working at 100% capacity Time - the effects of yesterday, today and tomorrow - THE KEY TO HEALTH - You can t do anything about the parts that are missing, and time keeps marching on, therefore the key to health is function. If you can keep the parts that you have today functioning at 100% of their potential for the rest of your lifetime, you ll have your best chance for optimum health. While you must have proper nutrition, a clear mind, rest and exercise, the primary control of your body s function is the nervous system. - YOUR BODY - SKULL Eight major bones that are knitted together with movable joints. The skull protects the brain and assists in the movement of the spinal fluid. SPINE Twenty four moveable bones which surround and protect the spinal cord. From the side, four spinal curves are found. These curves are necessary for proper spinal function. DISCS Soft cushions of cartilage which separate spinal bones, allow movement and help create the weight- bearing spinal curves. CERVICAL The seven bones which make up the neck area.
6 THORACIC The twelve bones which comprise the mid- back area. LUMBAR The five bones forming the lower back. SACRUM/PELVIS Three large bones which form the tail bone and hips. - NERVOUS SYSTEM - The nervous system controls and coordinates all the cells, organs and systems of your body and adapts the organism (you) to the environment. The nervous system consists of: 1. Brain: Three highly developed modules which function as the computer control centre for the body. 2. Spinal Cord: An extension of the brain that carries information to and from the brain and the body. 3. Spinal Nerves: Bundles of nerves that branch from the spinal cord and then exit the spinal column. 4. Peripheral Nerves: The vast network of nerves that divide from the spinal nerves and connect with every cell of the body. 5. Organs and Cells: These have their own information processing abilities. Your heart and gut, are considered brains in their own right. - WHAT WOULD HAPPEN IF YOU INTERFERED WITH THE NERVOUS SYSTEM - Interference to the nervous system always results in malfunction of your body and reduces the expression of your health potential. - VERTEBRAL SUBLUXATION COMPLEX - Major interference can occur when there is misalignment and/or malfunction of the spinal bones and their movement. This is called the Vertebral Subluxation Complex (VSC) and is a very serious and disabling condition that affects the brain, spinal cord and the spinal nerves. - SPINAL DECAY - When the joints of the spin are not moving and functioning properly over time they begin to break down. The spinal decay that results from VSC progresses from a condition that is easily corrected to a permanent state that is unable to be corrected. - HOW IS NERVOUS SYSTEM INTERFERENCE PRODUCED? - The chain of movement from the top of our head to the tips of our toes is constantly adapting to the stressors of life. When your body meets a force that it can t deal with, something has to give. This is when we see vertebrae going into too much motion or not enough motion in order to adapt to the change. As your body attempts to correct this situation VSC can be established. These stressors come in three general categories: Physical birth trauma, falls, sports injuries, stressful activities that are done repeatedly or with one side of the body, car accidents, etc. Chemical water, foods, medications and environmental toxins Mental/Emotional thoughts and beliefs, relationships and work stress - CHIROPRACTIC ADJUSTMENT - A chiropractic adjustment is the physical means of correcting the VSC. There are numerous techniques in chiropractic. Your chiropractor will explain the technique that they use.
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New Practice Member Application
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Patient Health Record
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ADIO CHIROPRACTIC HEALTH PROFILE
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NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
PATIENT ENTRANCE FORM
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LIST YOUR HEALTH CONCERNS BELOW
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COMPREHENSIVE HEALTH & WELLNESS PROFILE
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AHI - New Patient Information
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