Welcome to Windmill Chiropractic! Address City State Zip

Transcription

1 Welcome to Windmill Chiropractic! Name Today's Date: Contact #s Home ( ) address: Work ( ) Cell ( ) Address City State Zip SSN Date of Birth Age Sex: M / F Occupation Marital Status: S M D W Spouse's Name: Who invited you to our office today? Have you ever experienced chiropractic before? Reason for consulting our office: List your health concerns in order of importance: Health Concern What have you tried to solve this concern? What are your health goals? If your health could be perfect, what would it look like? Are you moving toward or away from that picture of perfect health? When was the last time you felt your best?

2 On a daily basis we experience Physical, chemical and Emotional Stresses that can accumulate and result in the loss of Health. Most times the effects are gradual: not even felt until they become serious. Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime. This allows us to better assess the challenges to your health. The more we know, the better we can help YOU to design your perfect picture of health. List all Operations and their date: List all Medications you are currently taking and what they are for: List any significant physical traumas from birth to present: List any significant emotional traumas since birth: How stressful would you rate your life? (1 = No Stress / 10 = Extreme Stress) Occupational Personal What do you feel is your primary stress? Family Health Profile: At our office we are not only interested in YOUR health and well-being, but also the health and well-being of your family and loved ones. Please note below any health concerns you may have about your spouse, children, siblings, parents and friends: Spouse's Name / Age / Concern Children's Names / Ages / Concerns Other's Names / Ages / Concerns Chiropractic is the analysis of the spine, the identification and the correction of vertebral subluxations by specific adjustments of the spine. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. Our only practice objective is to eliminate a major interference to the expression of the body's innate wisdom. I hereby authorize the taking of x-ray films and spinal/nervous system scans. I further agree that Windmill Chiropractic shall be the sole owner and controller of these xrays and scans. I have fully read and clearly understand the above statement. All questions regarding the doctors' objective pertaining to my care in this office have been answered to my complete satisfaction. I certify that the information provided on this intake form is true and correct. Patient's (Parent or Guardian) Signature Date

3 Windmill Family Wellness Nutritional Assessment Questionnaire Name: Date: Address: City, State & Zip: Phone Number: Alternate Phone: Occupation: Birthdate: Age: What is: Your weight (without clothes) lbs. Your height (without shoes) ft. & in. In order of importance, please list your five major health problems or concerns, and the duration of each: Under what circumstances do you notice these problems improve? Under what circumstances do you notice these problems get worse? Have you had any other illnesses in the past ten years? If yes, what and when? What operations have you had? What is your normal blood pressure? (Do not worry if you do not know - we can test this in the office.) What is your resting pulse rate per minute? (We can test this too - if you want to calculate for yourself, you should be sitting down and as relaxed as possible, when you take your pulse. Your pulse can be found inside the bony protuberance on the thumb-side of your wrist. Count the number of beats per 60 seconds.)

4 PART 0 = Do not consume or use 2 = Consume or use weekly KEY: I 1 = Consume or use 2 to 3 times monthly 3 = Consume or use daily DIET Alcohol Luncheon meats Artificial Sweeteners Margarine Candy, desserts, refined sugar Milk products Carbonated beverages Radiation exposure (0=No 1=Yes) Chewing tobacco Refined flour / baked goods Cigarettes Vitamins and minerals Cigars / pipes Water - distilled Caffeinated beverages Water - tap Fast foods Water - well Fried foods Diet often for weight control LIFESTYLE Physical Exercise per week ( 0 = 2 or more times per week; 1 = 1 x week; 2 = 1 or 2 x per month; 3 = never or less than 1x per month) Changed job or profession; returned to work or lost job ( 0 = over 12 mo. Ago; 1 = within last 12 mo.; 2 = with last 6 mo.; 3 = within last 2 mo.) Divorced ( 0 = never or over two yrs ago; 1 = within last two years; 2 = within last years; 3 = within last 6 mo.) Work over 60 hrs per week ( 0 = Never; 1 = Occasionally; 2 = Usually; 3 = Always) * * * * Other major life/lifestyle change(s): MEDICATIONS 54 Indicate any medications you are currently taking or have taken within the last month ( 0 = No ; 1 = Yes) 0 1 Antacids 0 1 Estrogen or Progesterone 0 1 Antianxiety medications (pharmaceutical prescription) 0 1 Antibiotics 0 1 Estrogen or Progesterone 0 1 Anticonvulsants (natural) 0 1 Antidepressants 0 1 Heart Medications 0 1 Antifungals 0 1 High Blood Pressure Medications 0 1 Aspirin / Ibuprofen 0 1 Laxatives 0 1 Asthma Inhalers 0 1 Recreational Drugs 0 1 Beta Blockers 0 1 Relaxants/ Sleeping Pills 0 1 Birth Control pills or Implant Contraceptives 0 1 Testosterone ( Natural or Prescription) 0 1 Chemotherapy 0 1 Thyroid Medication 0 1 Cholesterol Lowering Medications 0 1 Topical Ointments 0 1 Cortisone/ Steroids 0 1 Acetaminophen ( Tylenol) 0 1 Diabetic Medication/ Insulin 0 1 Ulcer Medications 0 1 Diuretics 0 1 Sildenafal Citrate (Viagra) 0 1 Other: 0 1 Other: 0 1 Other: 0 1 Other:

5 PART 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (wkly) II KEY: 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom, occurs frequently (daily) Section 1 - Upper Gastrointestinal System Belching or gas within one hour after eating Feel like skipping breakfast Heartburn or Acid Reflux Feel better if you don't eat Bloating within one hour after eating Sleepy after meals Vegan Diet = No dairy, meat, fish or eggs Fingernails chip, peel or break easily (0 = No ; 1 = Yes) Anemia, unresponsive to iron Bad Breath (halitosis) Stomach pains or cramps Loss of taste for meat Diarrhea - chronic Sweat has a strong odor Diarrhea - shortly after meals Stomach upset by taking vitamins Black or tarry colored stools Sense of excess fullness after meals Undigested food in stool Section 2 - Liver and Gallbladder Pain between shoulder blades Easily hung over if you were to drink wine Stomach upset by greasy foods (0 = No; 1 = Yes) Greasy or shiny stools Alcohol per week (0=<3; 1=<7; 2=<14; 3=>14) Nausea Recovering alcoholic (0 = No; 1 = Yes) Sea, car, airplane or motion sickness History of drug or alcohol abuse (0=No; 1=Yes) History of morning sickness (0= No; 1= Yes) History of Hepatitis (0 = No; 1 = Yes) Light or clay colored stools Longterm use of prescription/recreational drugs Dry skin, itchy feet or skin peels on feet (0 = No; 1 = Yes) Headache over eyes Sensitive to chemicals Gallbladder attacks (0=Never; 1=years ago; (perfume, cleaning agents, etc.) =within last year; 3=within past 3 mo.) Sensitive to tobacco smoke Gallbladder removed (0= No; 1= Yes) Exposure to diesel fumes Bitter taste in mouth, especially after meals Pain under right side of rib cage Become sick if you were to drink wine Hemorrhoids or varicose veins (0 = No; 1 = Yes) NutraSweet (aspartame) consumption Easily intoxicated if you were to drink wine Sensitive to NutraSweet (aspartame) (0 = No; 1 = Yes) Chronic fatigue or fibromyalgia Section 3 - Small Intestine Food Allergies Crohn's Disease (0 = No; 1 = Yes, in the Abdominal bloating 1-2 hours after eating past; 2 = Currently mild cond.; 3 = Severe) Specific foods make you tired or bloated Wheat or Grain Sensitivity (0 = No; 1 = Yes) Dairy Sensitivity Pulse speeds after eating Are there food that you could not give up? Airborne Allergies ( 0 = No; 1 = Yes ) Experience Hives Asthma, Sinus infections, stuffy nose Sinus congestion "stuffy head" Bizarre vivid dreams or nightmares Crave bread or noodles Use over-the-counter pain medications Alternating constipation and diarrhea Feel spacey or unreal Section 4 - Large Intestine Anus itches Stools have corners or edge, or are flat or Coated Tongue ribbon-shaped Feel worse in moldy or musty place Stools are not well-formed (loose) Taken antibiotic for a total accumulated time of: Irritable bowel or mucus colitis (0= Never; 1= <1mo; 2= <3mo; 3= >3mo) Blood in stool Fungus or yeast infections Mucus in stool Ring worm; jock itch, athletes foot; nail fungus Excessive foul smelling lower bowel gas Yeast symptoms increase with sugar, starch or Bad breath or strong body odors alcohol Painful to press on outer sides of thighs Stools hard or difficult to pass (Iliotibial band) History of parasites ( 0 = No; 1 = Yes) Cramping in lower abdominal region

6 Less than one bowel movement per day Dark circles under eyes KEY: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom. Occurs frequently (daily) Section 5 - Mineral Needs History of Carpal Tunnel Syndrome (0=No;1=Yes) History of Bone spurs (0 = No; 1 = Yes) History of lower RIGHT abdonimal pains or Morning stiffness Ileocecal valve problems Nausea with vomitting History of Stress Fracture Crave chocolate Bone loss (reduced density on bone scan) Feet have a strong odor Are you shorter than you used to be (0=No; 1=Yes) History of Anemia Calf, foot or toe cramps at rest Whites of eyes (sclera) are blue tinted Cold sores, fever blisters or Herpes lesions Hoarseness Frequent fevers Difficulty swallowing Frequent skin rashes and/or hives Lump in throat Herniated disc (0 = No; 1= Yes) Dry mouth, eyes and/or nose Excessively flexible joints, "double jointed" Gag easily Joints pop or click White spots on fingetnails Pain or swelling in joints Cuts heal slowly and/or scar easily Bursitis ot tendonitis Decreased sense of taste or smell Section 6 - Vitamin Needs Muscles become easily fatigued Can hear heart pound on pillow at night Feel exhausted or sore after moderate exercise Whole body or limb jerk as falling asleep Vulnerable to insect bites Night sweats Loss of muscle tone, heaviness in arms or legs Restless leg syndrome Enlarged heart or congestive heart failure Cracks at corner of mouth (Cheilosis) Pulse below 65 beats/min (0 = No; 1 = Yes) Fragile skin, easily chaffed, as in shaving Ringing in ears (Tinnitus) Polyps or warts Numbness, tingling or itching in hands & feet MSG sensitivity Depression Wake without remembering dreams Fear of impending doom Small bumps on back of arms Worrier, apprehensive, anxious Strong light at night irritates eyes Nervous, agitated Nose bleeds and/or tend to bruise easily Feelings of insecurity Bleeding gums esp. when brushing teeth Heart races Section 7 - Essential Fatty Acids Experience pain relief with aspirin (0= No; 1= Yes) Headaches when out in the hot sun Crave fatty, greasy foods Sunburn easily or suffer sun poisoning Low or reduced-fat diet (0 = Never; 1 = Years ago; Muscles easily fatigued 2 = Within past year; 3 = Currently) Dry flaky skin or dandruff Tension headaches at base of skull Section 8 - Sugar Handling Awaken a few hours after falling asleep, Headache if meals are skipped or delayed difficult to get back to sleep Irritable before meals Crave Sweets Shaky if meals delayed Binge or uncontrolled eating Family members with diabetes Excessive appetite (0 = None; 1 = 1 or 2; 2 = 3 or 4; 3 = more than 4) Crave coffee or sugar in the afternoon Frequent thirst Sleepy in afternoon Frequent urination Fatigue that is relieved by eating

7 KEY: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom. Occurs frequently (daily) Section 9 - Adrenal Tend to be a "night person" Artritic tendencies Difficulty falling asleep Crave salty foods Slow starter in the morning Salt foods before tasting Tend to be keyed up, have trouble calming down Prespire easily Blood pressure above 120/ Chronic fatigue, or get drowsy often Headache after exercising Afternoon yawning Feeling wired or jittery after drinking coffee Afternoon headache Clench or grind teeth Asthma, wheezing or difficulty breathing Calm on the outside, troubled on the inside Pain on the medial or inner side of knee Chronic low back pain, worse with fatigue Tendency to sprain ankles or "shin splints" Become dizzy when standing up suddenly Tendency to need sunglasses Difficulty maintaining chiropractic adjustment Allergies and/or hives Pain after chiropractic adjustment Weakness, dizziness Section 10 - Pituitary Height over 6'6" (0 = No; 1 = Yes) Height under 4'10" ( 0 = No; 1 = Yes ) Early sexual development - before age Delayed sexual development - after age 13 ( 0 = No; 1 = Yes) ( 0 = No; 1 = Yes ) Increased libido Decreased libido Splitting-type headache Excessive thirst Memory failing Weight gain around hips or waist Tolerate sugar, feel fine when eating sugar Mentrual disorders ( 0 = No; 1 = Yes) Tendency to ulcers or colitis Section 11 - Thyroid Sensitive allergic to iodine Mentally sluggish, reduced initiative Difficulty gaining weight, even with Easily fatigued, sleepy during the day large appetite Sensitive to cold, poor circulation Nervous, emotional, can't work under pressure (cold hands and feet) Inward trembling Constipation, chronic Flush easily Excessive hair loss and/or coarse hair Fast pulse at rest Morning headaches, wear off during day Intolerance to high temperatures Loss of lateral 1/3 of eyebrow Difficulty losing weight Seasonal sadness Section 12 - Women Only Depression during periods Breast fibroids, benign masses Mood swings associated with periods (PMS) Painful intercourse (dysparenia) Crave chocolate around periods Vaginal discharge Breast tenderness associated with cycle Vaginal dryness Excessive menstrual flow Vaginal itchiness Scanty blood flow during periods Gain weight around hips, thighs & buttocks Occasional skipped periods Excessive facial or body hair Variations in menstrual cycles Hot flashes Endometriosis Night sweats (in menopausal females) Uterine fibroids Thinning skin Section 13 - Men Only Prostate problems Waking to urinate at night Difficulty with urination, dribbling Interruption of stream during urination Difficult to start and stop urine stream Pain on inside of legs or heels Pain or burning with urination Feeling of incomplete bowel evacuation

8 Decreased sexual function KEY: 0 = No, symptom does not occur 2 = Moderate symptom, occurs occasionally (weekly) 1 = Yes, minor or mild symptom, rarely occurs (monthly) 3 = Severe symptom. Occurs frequently (daily) Section 14 - Cardiovascular Health Aware of heavy and/or irregular breathing Ankles swell, especially at end of day Discomfort at high altitudes Cough at night "Air hunger" or sigh frequently Blushing, or face turns red for no reason Compelled to open windows in small room Dull pain or tightness in chest and/or Shortness of breath with moderate exertion radiate into right arm, worse with exertion Muscle cramps with exertion Section 15 - Kidney and Bladder Health Pain in mid-back region Cloudy, bloody or darkened urine Puffy around the eyes, dark circles under eyes Urine has strong odor History of kidney stones ( 0 = No; 1 = Yes ) Section 16 - Immune System Health Runny or drippy nose Never get sick (0= sick only 1 or 2 times in Catch colds easily at the beginning of winter last yr; 1= not sick in last 2 yrs; 2= not sick Mucus producing cough in last 4 yrs; 3= not sick in last 7 yrs) Frequent colds or "flu" Acne (adult) (0= 1 or less per year; 1= 2-3x per year; Itchy skin (dermatitis) 2= 4-5x per year; 3= 6 or more per year) Cysts, boils, rashes Other infections: Sinus; Ear; Lung; Skin; Bladder History of Epstein-Barr, Mono, Herpes, Kidney, etc. (0= 1 or less per year; 1= 2-3x per year Shingles, Chronic Fatigue Syndrome, 2= 4-5x per year; 3= 6 or more per year) Hepatitis or other Viral condition ( 0= No; 1= yes, in the past; 2= currently, mild condition; 3= severe condition) Please list all supplements you are currently taking and brand name of each: Please list your favorite foods and how often you eat these types of foods:

9 Windmill Chiropractic Consent for Purposes of Treatment, Payment & Healthcare Operations (3/03) In this document, I and my refer to the patient, and Chiropractor refers to Windmill Chiropractic. I consent to the use or disclosure of my protected health information by Chiropractor for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Chiropractor. I understand that analysis, diagnosis or treatment of me by Chiropractor may be conditioned upon my consent as evidenced by my signature below. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Chiropractor is not required to agree to the restrictions that I may request. However, if Chiropractor agrees to a restriction that I request, the restriction is binding on Chiropractor. I have the right to revoke this consent, in writing, at any time, except to the extent that Chiropractor has taken action in reliance on this Consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I have been provided with a copy of the Notice of Privacy Practices of Chiropractor and understand that I have a right that Notice 's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiropractor. The Notice of Privacy Practices for Chiropractor is also posted in the waiting room at Windmill Chiropractic. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information. Chiropractor reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of Chiropractor and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. Signature of Patient or Personal Representative Printed Name of Patient Date of Signing Description of Personal Representative s Authority

10 People underestimate their capacity for change. There is never a right time to do a difficult thing. - John Porter Sometimes the first step is the most difficult, the most eye-opening and the most real THIS is the most important first step to helping you make significant changes in your present health. Before you/we begin this new journey to transforming who you are, I would like to discuss something very important that will have a major impact on your ability to work toward, recover and achieve maximum improvement from this program. After many years in private practice and thousands of patients, I have seen many achieve significant improvement while others have become frustrated and failed in their attempt to get well. After careful review, I have discovered the reasons why some people succeed and others fail. This questionnaire is about much more than identifying and eliminating symptoms it's about WANTING to Live a life of vibrant health and nothing less! I've discovered that any discussion of the correct way to achieve health and stay healthy is, in actuality; a discussion of you have Lived your Life up to THIS point and how you will live it in the FUTURE. Therefore, to make such lasting changes a TRANSFORMATION in your present health, I want to ask you a few vitally important questions. I want most, for you to be honest with yourself and really dig deep inside for the true answers. These answers can help you determine if NOW is the time for your TRANSFORMATION. Let's begin. #1. HAVE YOU MADE THE DECISION TO CHANGE? TO DO WHAT IT TAKES TO GET WELL? Yes or No The definition of Insanity is: to keep doing the same thing, expecting different results. If you keep following the same course of treatment and/or care you have been following will your results really change? Have you ever wondered if you are on the right path to achieving optimal health? Sometimes it requires taking a new and improved road to your destination. Most people I ask tell me they've made the decision to change. But how many people have truly decided to change? I can answer very few! Why? Because there is a big difference between deciding something and having REASONS to actually do it! When you have made the decision to make a change and you know your reasons, you create an internal power that can propel you to achieving health and wellness. So now, I ask: #2. LIST UP TO 5 THINGS THAT YOU HAVE BEEN UNABLE TO DO AS A RESULT OF YOUR PRESENT SYMPTOMS AND/OR CONDITION. Please be specific. 1.) 2.) 3.) 4.) 5.) #3. LIST UP TO 5 THINGS THAT YOU PLAN TO DO ONCE YOU ARE FEELING BETTER, HAVE MORE MOBILITY, ENERGY, ETC. Please be specific here as well. Remember, these are important answers to support your reasons WHY you are ready to change. 1.) 2.) 3.) 4.) 5.)

11 #4. PLEASE CHECK ALL OF THE FOLLOWING THAT YOU WOULD LIKE TO TRANSFORM WITH MY HELP: Have more energy To feel less sleepy in the afternoon Sleep Better Lose Weight Have better digestion Increase my sex drive Be able to eat more foods Increase my metabolism to burn more fat Get rid of my allergies Increase my flexibility I want to reduce my stress Have a better immune system i.e. less coughs and colds Not be medicine dependent I want to improve my memory Be able to work out again I want to be more focused Have better muscle tone I want a better mood & more positive outlook Be in less pain I want to work on an anti-aging program No longer use pain meds I want to reduce my risk of developing a chronic disease No longer use allergy meds I want to detoxify my body No longer use sleep meds I want to improve my diet I want to clear up my skin I want to know more about healing through nutrition #5. ARE THERE ANY OTHER HEALTH OR PERSONAL GOALS YOU WANT TO ACHIEVE THAT YOU WANT ME TO KNOW ABOUT? If you can answer that you are ready physically, mentally and emotionally to truly transform yourself to a level of optimal health, I invite you to share this information with me and attend introductory class where I will present to you the ways to achieve this transformation. I look forward to working with you - helping you make significant improvements and lasting changes! In Health, Dr. Shawn Reiter