Rosewood Family Healing Center New Patient Intake Form Print Name Date Email Date of Birth Age Phone Number Marital Status- M D S W Occupation # of hours/day at a desk Repetitive movements Who may we thank for referring you/how did you hear of our service? Reason for seeking Chiropractic/Craniosacral Care If there are other conditions please list them in order of importance 1. 2. 3. Have you been treated before for this problem? What type of care did you receive? Concerning the primary issue, when did you first experience signs/symptoms? Did they occur suddenly or gradually? Is it getting progressively worse? Rate the severity of pain from 0-10 (0=no pain, 10=most severe pain experienced) Today Average Worst Describe the quality of your symptoms (sharp, achy, throbbing, numb/tingling, shooting, cramping, etc)
Symptoms are constant? Comes and goes? How often do you experience them? Is the pain local or does it go up and down the body? What makes it more painful? (sitting, walking, bending, etc) What gives relief? Does it interfere with (circle) work sleeping daily routine recreation -? Have you received Chiropractic Care in the past? Craniosacral Care? If so, for what reasons? Please list all surgeries and/or hospitalizations and you have undergone and their reasons and corresponding dates: Please list all current prescription and non-prescription drugs you take- Please describe any serious injuries or accidents (fractures, MVA s, sport injuries, falls, trauma) List the dates and types of any major illnesses Females List any problems with PMS or your menstrual cycle
Do you experience any allergies? If so which ones and when did they start? Are you on a special diet? List any vitamins and supplements- Do you feel like you have a strong pelvic floor? Why or why not? Do you have any incontinence? yes no If so, when? Do you have any pelvic pain? yes no If so, when? How many pregnancies have you carried? Have you ever had an episiotomy? yes no Have you ever had diastasis? yes no Do you have difficulty taking deep breaths? yes no Use the space below to elaborate on your problem or give any information that may have been missed in the above questionnaire.
WELLNESS PROFILE It is our intention to provide you with a Holistic evaluation of health, considering the physical, mental, emotional and spiritual levels of the human experience. There may be seemingly insignificant events or aspects of your daily life that are contributing to today s picture of you. Please answer to the best of your ability. From the World Health Organization s definition of Health- A state of Optimal physical, mental and social well-being and not merely the absence of disease or infirmity. On a scale of 0-10, 10 being ideal, how would you rate your overall health today? On that same scale how would you rate your current diet? How would you rate your current stress level (0-10, 0 = no stress) What are your health goals? Choose all that apply: More energy Better Concentration Improved flexibility Stronger Immune system Easier breathing Better sports performance Partaking in daily activities pain-free Better sleep Improved strength Balanced emotions Do you smoke? Quantity/day Years you have smoked Do you drink alcohol? Average quantity/week Do you drink caffeine? What form Drinks/day Do you take (circle) muscle relaxers pain killers- insulin- birth control pills over the counter meds? Do you exercise? Routine and quantity What is your normal sleeping position? How many hours do you sleep/night? How many pillows do you use? Type- (circle) THICK MEDIUM THIN MEMORY FOAM CONTOURED OTHER What are your hobbies? What do you do to relax?
INFORMED CONSENT TO CHIROPRACTIC TREATMENT AND CARE I hereby request and consent to the performance of procedures which are within the scope of practice of chiropractic including, but not limited to, chiropractic adjustments, various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had the opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed. I understand and am informed that there are some risks to chiropractic treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, and are in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions) for which I seek treatment. I, have read and fully understand the above statements. All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. (Signature) (Date) Consent to Evaluate and Adjust a Minor Child I, being the parent or legal guardian of Have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. (Signature) (Date)