HOW WELL DO YOU REALLY EAT?

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1 HOW WELL DO YOU REALLY EAT? To find out, think HONESTLY about each question and circle your answer. Then add up your score. How many servings of fruit do you usually eat per day? 1 serving = 1 med. Piece, ½ cup fruit pieces, or 1 cup fruit juice 0 (-2) 1 (0) 2 to 3 (+2) 4 or more (+3) How many different kinds of fruit do you eat in an average month? 2 or less (-2) 3 to 4 (-1) 5 to 6 (+1) 9 or more (+3) How many servings of veggies do you usually eat per day? 1 serving = 1 cup leafy greens or 1/2 cup cooked or raw pieces, including legumes 0 (-3) 1 (0) 2 (+1) 3 or more (+3) How often do you eat whole grain foods: brown rice, quinoa, whole grain bread? Many wheat breads are made from refined flour. I don t eat them (-3) 2 or fewer times/wk (-2) Few times per week (0) Several times/week (+1) At least one per day (+3) How often do you eat calciumrich foods: green leafy veggies, Greek yogurt, almonds? I don t eat them (-3) 2 or fewer times/week (-2) Few times per week (0) Several times per week (+1) At least once per day (+3) How many times do you eat red meat each week? 6 or more (-3) 3 to 5 (-2) 1 or 2 (0) I often go a week without it (+1) I do not eat red meat (+3) What do you use most often as a sandwich spread? Mayonnaise (-3) Butter substitute (-3) Real butter (-1) Mustard (+1) Hummus, salsa, nothing (+2) How often do you eat cakes, cookies, ice cream or pastries? Daily (-3) 3 to 6 times/week (-2) Twice/week (-1) Once a week (0) Couples times/month (+1) Rarely or never (+3) Which would you most likely choose as a snack? Cake, pie, pastry, cookies, candy or ice cream (-3) Snack chips (-3) No fat sweets, gingersnaps or hard candy (-1) Sports bar (0) Non-fat treats such as unbuttered popcorn (+1) Fruit or raw veggies (+3) What do you drink most often throughout the day? Soft drinks, sports drinks (-3) Caffeinated tea or coffee (-3) Decaf coffee or tea (-1) Milk (0) Herbal tea or fruit juice (+1) Water (+3) How much coffee, tea and sodas do you drink? 5 or more cups /day (-3) 3 to 4 cups/day (-2) 1 or 2 cups/day (-1) Only decaf, 1 or more/day (0) I drink only herbal tea (+1) None (+3) Your Total Score How You Scored: 28 TO 35: Excellent Great job! You know healthful food can taste great. You have good food habits and you will add years onto your life. 17 to 27: Good Way to go! You work hard to eat a diet high in fiber and antioxidants and moderate in fat. Determine which areas still need work and continue to let your good habits evolve. 6 to 15: Fair Not bad, but you can do even better! You know how. Eat more fiber, more fresh produce, more whole grains, and less fat, sugar, salt and caffeine. Try writing down your goals and plan meals in advance 5 or less: Bad But don t despair! Pick one change you would like to make this month, then, add another each month after that. Take this survey again in 6 months. You will be surprised to see making changes to your diet isn t hard.

2 FILE # OFFICE USE ONLY Waccamaw Chiropractic & Wellness Center Dr. John Evans Dr. Jeff Evans 658 Wachesaw Road Murrells Inlet, SC Phone (843) Fax (843) Date: Last Name: First Name: Street Address: City/ State: Zip: Billing Address: City/ State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Occupation: Employer: Age: Date of Birth: Sex: M F Marital Status: Married Single Number of Children: Spouse s Name: Employer: Name of person responsible for payment (if different from applicant): Would you like us to file your insurance? (circle one) YES NO In case of emergency, please contact (include phone #) Previous Chiropractic care: YES NO If yes, previous Chiropractors name When was your last chiropractic evaluation/ treatment? Primary Care Physician: Who may we thank for referring you to our office? Goals For Your Care: Please check the type of care desired to help us when considering your care plan Relief Care Corrective Care Comprehensive Care I would like Symptomatic Relief of Correcting & Relieving Care designed to improve the doctor to Pain or Discomfort the cause of the problem as overall health and maximize select the type well as the symptom body function. of care that is best for me I am interested in: Massage Nutrition/ Detox Weight Loss Wellness Classes Blood work TO LEARN MORE, PLEASE VISIT US AT:

3 CURRENT CONDITION CONTINUED Major Complaint or reason for visit When did this/ these conditions begin? What is the cause of your condition? Symptoms are aggravated by? Symptoms are relieved by? Any previous treatment for the current condition (s)? Medical History Medical conditions: Diabetes Cancer Back Pain Stroke Heart Disease Other Family History: Diabetes Cancer Back Pain Stroke Heart Disease Other Social History: Smoking Alcohol Caffeine If yes Packs per day Exercise Recent Tests Performed (within the last year) MRI X-Ray Blood Work Medication(s): List ALL current or CIRCLE NONE Vitamin(s): List ALL current or CIRCLE NONE Allergies: List ALL or CIRCLE NONE Past Surgeries: List ALL or CIRCLE NONE TO LEARN MORE, PLEASE VISIT US AT:

4 The following questions are regarding you current condition: Please indicate on the diagram below where you are experiencing the following symptoms: A= Ache B= Burning N= Numbness P= Pain S= Stabbing O= Other Please check any symptoms that apply: Arm pain Right or Left Hand pain Right or Left Neck pain Right or Left Neck stiffness Right or Left Chest Right or Left Shoulder pain Right or Left Upper back pain Right or Left Mid back pain Right or Left Low back pain Right or Left Leg pain Right or Left Foot pain Right or Left Hip pain Right or Left Buttocks pain Right or Left Numb/ tingling Dizziness Please check any of the conditions you are experiencing or have been diagnosed with: Allergies Arthritis Bursitis Cancer Constipation Diarrhea Diabetes Difficult breathing Disc problems Ear noises Emphysema Epilepsy Frequent Urination Headaches Heart/ Circulatory High blood pressure Infertility Insomnia Kidney trouble Life trouble Multiple sclerosis Nervousness Neuritis Pinched nerve Prostate problems Rosacea Scoliosis Sinus infection Stomach trouble Stroke Vision problem I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. Patient Signature: Date:

5 CONSENT FOR TREATMENT I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, diagnostic x-rays, and nutritional products on me (or on the patient named below, for whom I am legally responsible) by the licensed doctors at Waccamaw Chiropractic and Wellness Center. I understand that nutritional information or suggestions are not intended to diagnose, cure, or prevent disease. Nutritional supplement are used to support normal body function. I have had the opportunity to discuss with the doctor and/ or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to exam and treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctors to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then knowing, is in my best interest. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover entire course of treatment. I authorize payment directly to the doctor from my insurance company and I clearly understand that I am responsible for payment should my insurance company deny payment or make payments directly to me. I understand the initial visit fees are due and payable at the time of service. To be completed by patient: Print Your Name X Signature Date If patient is a minor or physically or legally incapacitated. To be completed by patient s representative: Print Name of Patient Print Name of Patient s Representative As: Relationship or authority of Patient s Representative Signature of Patient s Representative Date TO LEARN MORE, PLEASE VISIT US AT:

6 Medical Records Request Patient: Date of Request: DOB: SSN#: Patient Address: This authorization will expire in one year from the date of signature unless an alternate is requested and noted herewith: Expiration Date: I hereby authorize (name of previous medical facilities/physicians and telephone fax) To use and/or disclose to Waccamaw Chiropractic & Wellness Center Description of information to be disclosed: Complete Chart Other, if so please specify dates as well as visits, tests, labs, etc I understand that: 1. I may refuse to sign this authorization and that doing so is strictly voluntary. 2. I may revoke this authorization at any time in writing, but if I do not it will not have any effect on any actions prior to relieving the revocation. 3. If the requestor or receiver is not a health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed. I have read the above and authorize the disclosure of the protected health information stated. Signature of Patient: Signature of Witness: Date: Date: 658 Wachesaw Road Murrells Inlet, SC Phone (843) Fax (843)

7 Appointment Cancellation Policy We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled massage appointments to be cancelled at least 24 hours in advance. Our doctors & massage therapists want to be available for your needs and the needs of all our patients. When a patient does not show up for a scheduled massage appointment, another patient loses an opportunity to be seen. Although we have always had a cancellation policy, circumstances have caused us to enforce a policy of charging for no-show appointments, and those appointments not cancelled within 24 hours. As of May 1, 2015 there will be a fee of $15.00 assessed if we do not receive a call to cancel an appointment. Thank you for being a valued patient and for your understanding and cooperation as we institute this policy. This policy will enable us to open otherwise unused appointments to better serve the needs of all patients. Signature Date 658 Wachesaw Road Murrells Inlet, SC Phone (843) Fax (843)