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2 Patient Name Date Please answer the following questions below in as much detail as possible: What holistic or medical procedures have you taken to solve your bunions? Do your bunions make it difficult and/or to walk? Do you believe your bunions are causing you to have foot and/or back? If so, please rate your in each area on a sliding scale of (0 is no to 10 which is maximum ). Do your bunions prevent you from fun activities or exercising? Do you feel that your bunions are causing your feet to look deformed or unattractive? Are you self- conscious about showing your feet in public? Is it hard to find shoes that fit?
3 Foot and Ankle Questionnaire Instructions Please answer the following questions for the foot/ankle being treated or followed up. If it is BOTH feet/ankles, please answer the questions for your worse side. All questions are about how you have felt, on average, during the past week. If you are being treated for an injury that happened less than one week ago, please answer for the period since your injury. 1. During the past week, how stiff was your foot/ankle? (Circle one response.) 1 Not at all 2 Mildly 3 Moderately 4 Very 5 Extremely 2. During the past week, how swollen was your foot/ankle? (Circle one response.) 1 Not at all 2 Mildly 3 Moderately 4 Very 5 Extremely During the past week, please tell us about how your foot/ankle was during the following activities. (Circle ONE response on each line that best describes your average ability.) Not Mildly Moderately Very Extremely because of foot/ankle for other reasons 3. Walking on uneven surfaces? Walking on flat surfaces? Going up or down stairs? Lying in bed at night? During the past week, did your foot/ankle give way during the following activities. (Circle ONE response on each line that best describes you for each activity level.) 7. Strenuous activity, such as heavy physical work, skiing, tennis? 8. Moderate activity, such as moderate physical work, jogging, running? 9. Light activity, such as walking, house work, yard work? Did not give way at all Partially gave way, but I did not fall Completely gave way, so that I fell the activity because of foot/ankle giving way Could not do for other reasons Which of the following statements best describes your ability to get around most of the time during the past week? (Circle one response.) 1 I did not need support or assistance at all. 2 I mostly walked without support or assistance. 3 I mostly used one cane or crutch to help me get around 4 I mostly used two canes, two crutches or a walker to help me get around. 5 I used a wheelchair. 6 I mostly used other supports or someone else had to help me get around. 7 I was unable to get around at all. Foot and Ankle Outcomes Instrument: Page 4 of 6
4 Foot and Ankle Questionnaire 11. How much trouble did you have with balance during the past week? (Circle one response.) 1 No trouble at all 2 A little bit of trouble 3 A moderate amount of trouble 4 Quite a bit of trouble 5 A great amount of trouble 6 I cannot balance on my feet at all 12. How difficult was it for you to put on or take off socks/stockings during the past week? (Circle one response.) 1 Not at all difficult 2 A little bit difficult 3 Moderately difficult 4 Very difficult 5 Extremely difficult 6 Cannot do it at all All questions are about how you have felt on average during the past week. During the past week, please tell us about how your foot or ankle was when you were performing the following activities. (Circle ONE response on each line that best describes your average ability.) 13. Strenuous activity, such as heavy physical work, skiing, tennis 14. Moderate activity, such as moderate physical work, jogging, running 15. Light activity, such as walking, house work, yard work No Mild Moderate Severe Extreme because of foot/ankle for other reasons Standing for an hour Standing for a few minutes How much difficulty do you have walking on uneven surfaces (eg., small stones, rocks, sloping ground)? (Circle one response.) 1 No difficulty 2 Mild difficulty 3 Moderate difficulty 4 Severe difficulty 5 Extreme difficulty 6 Cannot do because of foot/ankle 7 Cannot do for other reasons Foot and Ankle Outcomes Instrument: Page 5 of 6
5 What types of shoes can you wear comfortably? (Circle one response on each line.) Foot and Ankle Questionnaire Yes No Not applicable 19. Any women's shoe (including high heels) OR any men's shoe (including fancy dress shoes) 20. Most women's dress shoes (except high heels) OR most means dress shoes Sneakers, walking, or casual shoes Orthopaedic or prescription shoes All shoes How much did your foot or ankle problem interfere with your normal work, including work both outside the home and house work? (Circle one response.) 1 Not at all 2 A little bit 3 Moderately 4 Quite a bit 5 Extremely 6 Unable to work due to foot and ankle problems 25. How much did your foot or ankle problem interfere with your life and your ability to do what you want? (Circle one response.) 1 Not at all 2 A little bit 3 Moderately 4 Quite a bit 5 Extremely 6 It ruins everything Foot and Ankle Outcomes Instrument: Page 6 of 6
6 Consent To Treatment Health care providers are required to advise patients of the nature of the treatment to be provided, the risks and benefits of the treatment, and any alternatives to treatment. These are some inherent risks that may be associated with acupuncture or chiropractic treatment, including, but not limited to: While rare, some patients have experienced rib fractures or muscle and ligament sprains or strains following treatment. There have been rare reported cases of disc injuries following cervical and lumbar spinal adjustment although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal or soft tissue manipulation or treatment. There have been reported cases of injury to a vertebral artery following osseous spinal manipulation. Vertebral artery injuries have been known to cause stroke, sometimes with serious neurological impairment, and may, on rare occasion, result in paralysis or death. The possibility of such injuries resulting from cervical spine manipulation is extremely remote. Osseous and soft tissue manipulation has been the subject of government reports and multi- disciplinary studies conducted over many years and have demonstrated it to be highly effective treatment of spinal conditions including general and loss of mobility, headaches, and other related symptoms. Musculoskeletal care contributes to your overall well- being. The risk of injuries of complications from treatment is substantially lower than that associated with any medical or other treatments, medications, and procedures given for the same symptoms. I acknowledge I will have the opportunity to discuss the following with my healthcare provider: a. The condition that the treatment is to address; b. The nature of the treatment; c. The risks and benefits of the treatment; and d. Any alternatives to that treatment I will have the opportunity to ask questions and receive answers regarding the treatment. I do not expect the doctor to be able to anticipate and explain all the risks and complications, and wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I also understand that there are beneficial effects associated with these treatment procedures including decreased, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits. I realize that the practice of medicine, including chiropractic and the non- surgical bunion treatment procedure, is not an exact science and I acknowledge that no guarantee has been made to me regarding that outcome of these procedures. I consent to the treatments offered or recommended to me by my healthcare provider, including osseous and soft tissue manipulation. I intend this consent to apply to all my present and future care with Dr. Robert Levingston DC, FIAMA or other licensed doctors of chiropractic who now, or in the future, treat me while employed by, working for, or serving as a back- up for Dr Robert Levingston DC, FIAMA. Patient Signature: Date: Or Patient Representative Signature Relationship Office Signature Date:
7 Dr. Levingston DC, FIAMA.
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SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
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GENERAL INFORMATION HEALTH & LIFESTYLE PROFILE
GENERAL INFORMATION Name Today s Date // Address City/State/Zip Mobile Phone # _ Other Phone # Your Birthdate Occupation Employer Relationship: Single Married Partner Widow Children: Yes No How did you
Name: DOB: Age: Phone: Phone: Is this an injury related to a : (circle one) Other? Yes / No (Please Explain)
Family/Primary Doctor: Emergency Contact: Name Phone: Phone: Who referred you to our office? Who else have you seen for this condition? INSTRUCTIONS: Please provide the following information, in detail.
Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
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SPARROW FAMILY CHIROPRACTIC
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CONSULTATION ADMITTANCE FORM
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Patient Re-Examination Form
Harrisburg Family Chiropractic 220 S. Cliff Ave. Ste 106 Harrisburg SD 57032 (605) 767-7463 Name: Date: / / Patient Re-Examination Form Please fill out the information that has changed since your last
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
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