Thrive Family Chiropractic. Vitality Questionnaire
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- Brent Jefferson
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1 Thrive Family Chiropractic 1121 S Bowman, Suite C-3 Little Rock, AR Vitality Questionnaire Name: Date: Address: City: Zip: *: Phone: Date of Birth: *Your will be used only by our office in order to contact you or to send you our monthly newsletter. Method of Contact Preference: 0 0 Phone 0 Either Would you like future appointment reminders? 0 Yes via text message 0 Yes via 0 No Marital Status: 0 Single 0 Married 0 Divorced 0 Widowed Spouse s Name: Do you have children? Children s names and ages: Have you gotten them checked for spinal misalignments? Have you been to a chiropractor before? If yes, how long has it been since your last adjustment? Who can we thank for referring you or how did you hear about Thrive Family Chiropractic? When a patient seeks chiropractic care and we accept a patient for such care, it is essential for both to be working for the same objective. The intent of our practice is to remove the interference in the nervous system (subluxation), allowing the expression of the body s innate wisdom and optimal function. Chiropractic is a science and an art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may affect the restoration and preservation of health. We believe the greatest ability to heal is within each patient and our use of specific adjustments to correct the subluxations, without the use of drugs or surgeries, allows the maximum ability of the body to be expressed. In certain situations we may use other procedures to help your body hold those adjustments. Our priority at this office is to help you meet your health goals!
2 Health Information What are your chief complaints in consulting our office? What are your health goals once your chief goals have been met? What other wellness professionals are currently part of your health care team? 0 Massage Therapist 0 Acupuncturist 0 Naturopath 0 Homeopath 0 Other How many medical doctor visits did you and your family have last year? 0 None 0 Less than 5 0 More than 5 0 More than 10 Please list your history of traumas (Surgeries/Injuries/Accidents) What activities does your current health condition affect? 0 Work 0 Daily Activities 0 Sleep 0 Exercise 0 Quality of Life 0 Other: FOR DOCTOR S USE ONLY Patient s Health Objective Temporary symptom relief only Symptom relief and correction for prevention of reoccurrence Health maintenance Health development
3 Do you exercise? If so, what type and how often? Lifestyle Habits What is your daily water intake? What is average time of rest/sleep each night? Are you taking any supplements or medications? If so, please list what for. Where would you rate your current level of health and where would you like to be? (10=perfect) Stress History Please indicate whether you have ever experienced stress in any of the following areas. Your answers will enable us to determine which factors have contributed to your present health concerns. Repeated antibiotic use Car accident Coffee drinker Drug use/abuse Fall/Jump from a height Head trauma Home environment stress Inhaler use Prescription medications Smoker Surgery Contact sports Extreme sports Workplace stress Other:
4 Please Circle any problems you are currently experiencing or have experienced in the past Tissues & Organs Functions Possible Symptoms Vagus Nerve Autonomic Nervous Sys. Inner/Middle Ear Balance & Coordination Face, Jaw, & Teeth Digestive System Brainstem Immune System Sinuses ENT System Eyes Speech Inner Ear, Tonsils, Throat Nerve Supply to Shoulders Neck & Shoulder Muscles Nerve Supply to Arms Nerves to Arms & Hands Metabolism ENT System Vocal Cords Thyroid Upper Back & Shoulders Esophagus & Upper GI Lungs & Respiratory Chest/Sternum Cardiac/Heart Middle Back & Shoulders Gallbladder Pancreas Stomach Spleen Liver Reproductive Organs Adrenal Glands Small Intestines Kidneys Ureters Parasympathetic Plexus Nerves to Legs & Feet Lower Back Muscles Lymph Circulation Ovaries & Uterus Large Intestines Prostate Gland Pelvic Muscles Bladder Upper Gastrointestinal Respiratory System Cardiac Function GI Absorption & Motility Major Hormonal Control Gut/Immune System ADD Allergies Sinus problems Focus Dizziness Headaches & Migraines Anxiety Ear Infections Sensory & Spectrum Balance Depression High Blood Pressure Seizures Insomnia Frequent Sickness Memory Reflux Chronic Fatigue Allergies Numb/Tingling In Arms Croup & Cough Sore Throat & Strep Ear/Sinus Infections Speech Issues Headaches & Migraines Stiff Neck & Shoulders Pain/Weakness into Arms Swollen Tonsils Asthma Reflux / GERD Bronchitis Stiff Neck & Shoulders Chronic Colds & Cough Functional Heart Conditions Major Digestive Center Blood Sugar Problems Gallbladder Issues Detox & Immunity Fever Jaundice Frequent Sickness Stomach Pains Immune Deficiency Ulcers Indigestion Filtration & Elimination Hormonal Control Gut & Digestion Stress Response Allergies & Eczema Bedwetting Hyperactivity & Anxiety Behavior Issues Infertility Chronic Fatigue Kidney Problems/Stones Excessive Stress Poor Metabolism Cramps/Menstrual Problems Bedwetting Hemorrhoids Bladder Problems Cold Feet Cramps Cysts & Endometriosis Difficult/Painful Urination Diarrhea Disc Degeneration Gluten Intolerance Hamstring Tightness Gas Pain & Bloating Hip Pain Immune Deficiency Impotency Infertility IT Band Tightness Knee, Ankle, & Foot Pain Leg Cramps Low Back/SI Joint Pain Sciatica/Radiating Pain Thank you for taking this time for yourself, we look forward to serving you!
5 Informed Consent to Care You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as informed consent and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an arterial dissection that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users. It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend
6 this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office. Patient Name: Signature: Date: Parent or Guardian: Signature: Date: I understand and agree to the following: The statements made on this form are accurate to the best of my knowledge and I agree to allow this office to examine me for further evaluation. I accept, if eligible, chiropractic care on this basis. I consent to the use of my protected health information by Dr. Kaitlin for the purpose of analyzing or providing treatment to me, obtaining payment for my health care bills or conduct health care operations. HIPAA Compliance. There is no guarantee that my health insurance will pay for all or any part of my care health and accident insurance policies are an arrangement between an insurance company and myself. Thrive Family Chiropractic does not bill insurance directly, but will provide the necessary documentation for me to use in filing claims with my insurance company. If applicable: I, being the parent or legal guardian of the prospective patient listed above, have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive an examination and chiropractic care. All payments are due at the time services are rendered and I am responsible for all payment of fees charged in this office. X Printed Name Signature Date I am aware that a copy of the Privacy Practices of this office is available at the front desk for my review. I may ask to review them at any time. Signed: Date:
Thrive Family Chiropractic
Thrive Family Chiropractic Dr. Kaitlin Parker, DC 1121 S. Bowman, Suite C-3 Little Rock, AR 72211 501.712.1022 Pediatric Vitality Questionnaire Name: Date: Birth Date: Gender: Male Female Parent s phone
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INFORMATION/APPLICATION FOR CARE
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AHI - New Patient Information
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Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
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New Practice Member Application
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PERSONAL INFORMATION. First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip:
ADULT INTAKE FORM Date: PERSONAL INFORMATION First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip: Cell Phone: ( ) Alternate Phone: ( Text Reminders: Y N Before
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
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PATIENT FEE SCHEDULE As of January 1, 2017
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New Practice Member Application
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FRAME CHIROPRACTIC South Price Road, Suite D-110 Tempe, Arizona Phone: Fax:
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Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
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