On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below:
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- Iris Cox
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1 Healthcare History
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3 djp Pure-Health wellness centre Wellness Profile General Health On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below: Physical Health (pain, flexibility, strength) : Weight/Diet/Chemical Health: Emotional Health/Stress: On a scale of 1 10, indicate how important is is to you to take action to improve these areas ("10" being very motivated): physical health (pain, flexibility, strength) : emotional health/stress: weight/diet/chemical health: Are you seeing chiropractic care today for: Relief Care - Symptom relief of pain or discomfort Corrective Care - Correcting, relieving and stabilizing spinal, joint and postural issues Wellness Care - Maximizing the body's ability for optimal healing and function Do you have other concerns we should know about? Goals and Consent What is your primary goal for consulting our clinid Our goals are to provide a detailed assessment of your current health status and provide to you the resources for a highly engaged and healthy body which is functioning at its absolute peak potential. Essential is a healthy nervous system functioning free from interference called subluxations. You've taken an important step for your health through a chiropractic evaluation! Consent to Evaluation hereby grant permission to receive a chiropractic evaluation including history, spinal scan and examination. Any findings will be communicated before consenting to commencement of treatment, if appropriate. Consenting Adult's Signature Date 2014 Wellness Media Resource Materials Inc. wellnessmediaresources.com Page 3
4 Pure-Health Insurance Form In order to ensure that we can answer all of your question please bring the following information to your first appointment. What is your maximum coverage? Are you the primary insured member? Is there a maximum per adjustment (visit)? Do you have a deductible? What is your year end? Do I need a prescription? If yes, from who? Are you covered by your spouse s insurance as well? Insurance provider: Policy#: Member#: Spouse s name if spouse is the primary: Thank you!
5 Pure-Health wellness centre </? of Systems Function of Spinal Nerves SPINAL NERVE Cl C2 Cl C4 cs C6 C7 CB Tl T2 Tl T4 TS T6 T7 ORGANS & GLANDS The organs and glands listed below are linked to the corresponding sections of the spine and it's spinal nerves. Parotid Gland Scalp Base of Skull Eyes Lacrimal Gland Sinuses Inner, Middle & Outer Ear Nose Mouth lntracranial Blood Vessels Sympathetic Nervous System Neck Muscles Diaphragm Shoulders Elbows Arms Wrists Hands & Fingers Tonsils Vocal Cords Esophagus Heart Lungs Chest Thyroid ASSOCIATED SYMPTOMS Please indicate below any symptoms you are currently experiencing as well as any you have previously experienced... :::, 0 II, Sinus & Ear Pain/Infection Runny Nose &Allergies Frequent Head Colds Sore Throat & Tonsilitis Strep Throat Chronic Cough & Croup Difficulty Breathing Poor Immunity Dizziness & Vertigo Tinnitus & Ear Fullness Vision Problems Watery/Dry Eyes Chronic Fatigue Poor Concentration Depression.. :::, 0 II, Anxiety & Stress Seizures ADD/ADHD Thyroid Dysfunction Metabolic Dysfunction Insomnia High/Low Blood Pressure Enlarged Lymph Glands Migraines & Headache TMJ Pain Stiff Neck Arm Pain Hand/Finger Numbness Loss of Grip Strength TB T9 TIO Arms Wrists Esophagus Chest Heart Lungs Trachea Larynx Diaphragm Stomach Asthma Bronchitis & Pneumonia Congestion Reflux&GERD Indigestion & Heartburn Kidney Stones Gall Bladder Attacks Skin Conditions & Rashes Menstrual Cramps/PMS Infertility TII Tl2 LI Gallbladder Liver Pancreas Small Intestine Spleen Kidneys Appendix Adrenals Colon Buttocks Uterus Ovaries Testes Stomach Pains Ulcers Gas & Bloating Jaundice Liver Conditions Blood Sugar Dysregulation Menstrual Dysfunction Rashes & Eczema Hyperactivity Shoulder Pain Midback Pain Rib Pain L2 Ll L4 LS Large Intestine Colon Thighs Buttocks Groin Knees Legs Feet Reproductive Organs Irritable Bowel, Colitis, Crohn's Gas Pain & Constipation Diarrhea Hemorrhoids Bladder Infections Bladder Incontinence & Bedwetting Painful/Excessive Urination Prostate Dysfunction & Impotence Ovarian Cysts & Endometriosis Fertility Problems/ Loss of Menstruation Low Back Pain Hip Pain Thigh Pain Numbness & Tingles in Legs SI S2 Sl Buttocks Groin Legs Ankles Feet Toes Prostate Gland Bladder Reproductive Organs Varicose Veins Leg Cramping Restless Legs Poor Circulation & Cold Feet Sciatica Pelvic Pain Knee Pain Ankle Pain & Sprains Foot Pain &Weak Arches S4 ss 2014 Wellness Media Resource Materials Inc. wellnessmediaresources.com Page 5
Adult. Welcome. Personal Information. Today s Date (mm/dd/yy): / / Name (first/last): Age: Gender: M F Date of Birth (mm/dd/yy): / / Address:
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CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
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