We Believe that you are Designed to be Extraordinary. (Office Use) Care Provider: Name: Date of birth (MM/DD/YY): Apt# City: Prov: PC:
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1 (Office Use) Care Provider: Name: Date of birth (MM/DD/YY): Mailing address: Apt# City: Prov: PC: Phone: h) c) Do we have your permission to send you our weekly health newsletter? Y N **You can withdraw your consent at any time. Gender: M F Marital status: Spouse s name: Do you have any children? Y N Names and ages of children: Occupation: Employer: Work phone: _ext: Benefit period: Total amount: How did you hear about our office?
2 Thank you for choosing Gainsborough Family Chiropractic. We want to assure you that we will provide you with the best in chiropractic service and recommendations in the most professional and honest manner. To do this we will be conducting a chiropractic analysis of your spine. This may include some non-invasive procedures that are not familiar to you. The doctor will not perform any part of the analysis without your consent. Please feel free to ask if you have any questions. Once the analysis is complete we present our recommendations to you. This will require some basic knowledge that may be new to you even if you have been to chiropractors in the past. Remember our findings are strictly chiropractic in nature and do not involve any other areas of your health. We would like to begin this process with some more information about you. Please answer the following questions to the best of your ability. Health History: If we were meeting here 3 years from today and you were to look back over those three years to today what has to happen during that period, for you to feel happy about how your life has progressed? Do you have any present complaints or persistent health challenges? Please explain: When did this begin? Have you had this problem before? Have been to see anyone for this complaint? If so, who and how did they manage your complaint? _
3 Past Health History Who is your family physician? Have you seen your family doctor in the past year? Y N Why? Have you had any surgeries? Include the year: Have you had any traumas, accidents, falls, or injuries in the past year? Have you ever been diagnosed with a serious disease or condition? Chemical Stress and Challenges List all prescription and non-prescription drugs. Drug: Purpose: Emotional Stress and Challenges List emotional/mental stressors presently in your life and previous stressors: How would you rate your current emotional state? Excellent Good Poor Other
4 General Health History How would you rate the following? Diet Poor Good Excellent Rest Poor Good Excellent Exercise Poor Good Excellent Have you ever been to a chiropractor? Y N If yes, how long ago? Are you healthier than you were 5 years ago? Do you believe you will be healthier in 5 years? I state that the above information is true to the best of my knowledge. Signature Date
5 Informed Consent to Chiropractic Adjustments and Care I hereby request and consent to receive chiropractic adjustments and other chiropractic procedures (if necessary), from the doctors of chiropractic in this clinic. I have had an opportunity to discuss with the doctors of chiropractic in this clinic the nature and purpose of chiropractic adjustments and care. I understand that results are not guaranteed. I further understand and am informed that, as in all health care, there are some very slight risks associated with chiropractic care. Doctors of chiropractic and other health care practitioners who use spinal adjustment techniques are required to advise their patients of the following: On rare occasions, some patients have reported rib fractures, muscle strains, ligament sprains, and disc injuries following spinal adjustments. However, no scientific study has ever verified such injuries. Spinal adjustments are rarely associated with vertebral artery injuries. Such injuries may cause stroke, sometimes with serious neurological impairment. The risk of injuries or complications from chiropractic care is very rare. I do not expect the doctor to be able to anticipate and explain all risks and complications. During the course of my care, I wish to rely on the doctor to exercise judgment in my best interest, based upon the facts known at the time. I have read the above consent. I have had an opportunity to ask questions about its content, and by signing below I agree to the above procedures. I intend this consent to apply to all my present and future care in this clinic. Print patient s full name Patient s (or guardian s) signature Witness to signature above Date signed
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