Personal History..Welcome Date: Full Name: Birthdate: Age: Address: City: State /Prov: Zip/Postal Code: Email Address: Home Phone: Cell Phone: Sex: [ ] Male [ ] Female Marital Status: [ ] Married [ ] Single [ ] Divorced [ ]Widowed Social Security #: Race: [ ] American Indian or Alaska Native [ ] Asian [ ] Black or African American [ ] White (Caucasian) [ ] Other [ ] Decline to Answer Business Employer: Type of Work: Business Phone: Name of Spouse: Spouse s Employer Type of Work: Names and Ages of Children: Name and Number of Emergency Contact: Relationship: How were you referred to our office? Current Health History Purpose of this Appointment: Other Doctors seen for this condition: [ ] Yes [ ] No Who? Type of treatment: Results: When did this condition begin? Has this condition occurred before? [ ] Yes [ ] No Is Condition: [ ] Job Related [ ] Auto Accident [ ] Home Injury [ ] Fall [ ] Other Date of Accident: Time of Accident: Are you currently taking any medications? [ ] Yes [ ] No Medication Name & Dosage/Frequency: Do you suffer from any other condition other than that which you are now consulting us? Name of your Primary Care Provider? Office Phone: Do you have any medication allergies? [ ] Yes [ ] No If yes, please explain: Medication Name/ Reactions/ Onset Date/ Comments: Lifestyle Do you exercise? [ ]Yes [ ] No How many times per week? What activities? [ ]Running [ ]Jogging [ ]Weight Training [ ]Cycling [ ]Yoga [ ]Pilates [ ]Swimming [ ]Other Smoking Status: [ ]Every Day Smoker [ ]Occasional Smoker [ ]Former Smoker [ ]Never Smoked Do you drink alcohol? [ ]Yes [ ]No How much / week? Do you drink coffee? [ ]Yes [ ]No How many cups / day? Do you drink water? [ ]Yes [ ]No How many cups / day? Blood Pressure: [ ] Normal [ ] Low [ ] High Weight: Height:
Past Health History Surgery / Operations: [ ] Appendectomy [ ] Tonsillectomy [ ] Gallbladder [ ] Ear Tubes/Adenoids [ ] Broken Bones [ ] Back / Neck Surgery [ ] Other Accidents or Falls: Hospitalizations (other than above): Previous Chiropractic Care: [ ] None [ ] Doctor s Name & Approximate Date of Last Visit Health Conditions: Have you experienced any of the following in the past or presently? Check all that apply. Low Energy / Fatigue Neck Pain Headaches Pain into Shoulders/Arms/Hands Numbness/Tingling in Arms/Hands Weakness in Grip Dizziness TMJ Pain / Clicking Colic Coldness in Hands ADD / ADHD Sinusitis Recurrent Colds/Flu Hearing Disturbances Visual Disturbances Thyroid Conditions Allergies/Hay Fever Ear Infections Pain into Hips/Legs/Feet Numbness/Tingling in Legs/Feet Coldness in Legs/Feet Muscle Cramps in Legs/Feet Constipation / Diarrhea Bed Wetting Weakness/Injuries in Hips/Knees/Ankles Recurrent Bladder Infections Frequent/Difficulty Urinating Menstrual Irregularities/Cramping (Females) Sexual Dysfunction Low Back Pain Heart Palpitations Recurrent Lung Infections/Bronchitis Pain On Deep Inspiration/Expiration Dizzy when Standing Suddenly Tachycardia Heart Murmurs Heart Attacks/Angina Shortness of Breath Asthma/Wheezing Mid Back Pain Pain into Ribs/Chest Indigestion/Heartburn Reflux Nausea Ulcers/Gastritis Hypoglycemia Tired / Irritable after Eating Belching/Gas within an hour of Eating Bloating/Cramping after Eating Dairy Sensitivity Heartburn/GERD Stomach Upset by Greasy Foods Gallbladder Attacks/Removed Greasy Stools Wheat Sensitivity Nausea Undigested Food in Stool Feel worse in Moldy/Musty Place Eczema Hives Chronic Antibiotic Use Dark Circles Under the Eyes Consuming Sugar/Alcohol Increases Symptoms Reduced Bone Density White Spots on Fingernails Restless Leg Syndrome East Desserts/Sugary Snacks Polycystic Ovarian Syndrome Small Bumps on Back of Arms Heavy Bleeding with Cycles Breast Tenderness Flush Easily Muscles Easily Fatigue Hot Flashes PMS Loss of Eyebrows Insomnia Vaginal Dryness Irregular Menstrual Cycles Excess Facial or Body Hair Coarse Hair/Hair Loss Lump in Throat Tendency to Anemia Bursitis or Tenderness Difficulty Losing Weight Mentally Sluggish/Brain Fog Anxiety Water Retention Poor Memory Depression Endometriosis Crave Chocolate Binge Eating Low Blood Pressure Irritable Before Meals Keyed Up/Jittery Store fat in Abdomen Perspire Easily even if not hot Crave Caffeine/Sugar in Afternoon Sleepy in Afternoon Crave Salty Foods Only complete if you are between the ages of 0 and 3 years old (if does not apply continue to next page) What was the position of your child in utero? [ ] Normal (head down) [ ] Posterior [ ] Transverse [ ] Breech What was the nature of your child s birth? [ ] Long labor [ ] C-section [ ] Forceps [ ] Vacuum [ ] Other Does your baby have any nursing difficulties? [ ] Yes [ ] No [ ] Weak latch [ ] Prefers Right [ ] Prefers Left [ ] Other Has your child had any minor or major falls? [ ] Repetitive falls with walking [ ] Fall from a height [ ] Other Is your child crawling? [ ] Yes [ ] No Crawling History: [ ] Normal (6 to 11 months) [ ] Army crawl [ ] Drags one leg [ ] Skipped crawling Does your child have any balance or coordination issues when walking?
Preparing for your Nutrition and Functional Medicine Appointment All clinical nutrition appointments do require a $50 deposit to reserve your time slot. In order to schedule your first appointment, please fill out and return the following paperwork. Please understand, our goal is to provide you with the best service experience possible, and these procedures are in place in order to do so. You will be given an email address which you can send nutrition questions to at any time, please expect a 72 hour response time (business days). You are also welcome to contact the front desk and leave your question, but please understand the response time is the same as email. There is no additional fee for email responses or phone calls. If you ever require private time to speak with one of our clinicians please communicate with our front desk and scheduling department to do so. We are here to help you on your journey to better health naturally. Please Initial: I am in agreement to be seen by whichever health care provider can take my case at the earliest available opening. I understand there is a $50 deposit is required to hold my appointment. If I do not give a 24 hour notice of change or cancellation, I am responsible for the $50 no show fee. (Emergencies are an expectation and do need to be approved at the clinicians discretion.) I understand I need to complete the following functional medicine questionnaire and the 3 day food log and fax, email or send back to the office in order to schedule my first initial appointment. I understand that I need to bring ALL current supplement bottles to my appointment and list of current prescriptions. Functional Medicine Questionnaire Please list your top five main health concerns or health goals in order of importance: 1)_ 2)_ 3)_ 4)_ 5)_ Check any medications you are currently taking: [ ] Antacids [ ] Antidepressants [ ] Estrogen [ ] Blood pressure [ ] Asthma Inhalers [ ] Sleeping Pills [ ] Birth Control [ ] Cholesterol [ ] Antihistamines [ ] Thyroid [ ] Steroids [ ] Diabetic [ ]Antibiotics [ ] Progesterone [ ] Diuretics [ ] ADD/ADHD Fill in the number that applies. [1] Monthly [2] Weekly [3] Daily Artificial Sweeteners Coffee Fast Foods Margarine Carbonated Beverage Lunchmeat Margarine High fructose corn syrup Nicotine List any additional vitamins or herbs you take: ***Please bring ALL current supplements bottles to appointment
Daily Food Log Please Fill Out Completely With Your Typical Food Choices Day 1 Day 2 Day 3 Time Breakfast: Time Breakfast: Time Breakfast: Time Mid-Morning: Time Mid-Morning: Time Mid-Morning: Time Lunch: Time Lunch: Time Lunch: Time Mid-Afternoon: Time Mid-Afternoon: Time Mid-Afternoon: Time Dinner: Time Dinner: Time Dinner: Time Evening: Time Evening: Time Evening: Ounces Water Intake: Ounces Water Intake: Ounces Water Intake: Other Drinks: Other Drinks: Other Drinks: Energy: Energy: Energy: Sleep Quality: Sleep Quality: Sleep Quality:
Only Complete this section if you have been in an Auto Accident (if does not apply continue to next page) Date and time of accident: Make and model of the vehicle you were occupying: Make and model of other vehicle(s) involved: Name of the location/street on which you were traveling: What did your vehicle hit upon impact? [ ] Another Vehicle [ ] Other If other, please describe: What was the approx. speed of your vehicle? In which direction were you headed? [ ] North [ ] South [ ] East [ ] West What was the approx. speed of the other vehicle? Direction other vehicle was headed: [ ] North [ ] South [ ] East [ ] West Did the police come to the accident site? [ ] Yes [ ] No Was a police report filed? [ ] Yes [ ] No Were there any witnesses? [ ] Yes [ ] No If a traffic violation was issued, to whom was it issued? Number of people in your vehicle Were you wearing a seat belt? [ ] Yes [ ] No Was the vehicle equipped with airbags? [ ] Yes [ ] No If yes, did it/they inflate? [ ] Yes [ ] No In relation to the base of your skull, where was the headrest? [ ] Above [ ] Below [ ] At base of the skull [ ] Other Did any part of your body strike anything in the vehicle? [ ] Yes [ ] No If yes, please describe Did the impact to your vehicle come from the: [ ] Front [ ] Rear [ ] R-Side [ ] L-Side [ ] Other During the impact, were you facing: [ ] Right [ ] Left [ ] Forward [ ] Other In your own words, please describe the accident: _ Work How many hours are in your normal work day? Please indicate below your daily job duties and any activities which you are occasionally asked to perform: [ ] Standing [ ] Sitting [ ] Walking [ ] Lifting [ ] Driving [ ] Twisting [ ] Crawling [ ] Bending [ ] Operating Equipment [ ] Working with arms above the head [ ] Pulling [ ] Other If other, please describe: Prior to the injury were you capable of working on an equal basis with others your age? [ ] Yes [ ] No [ ] N/A Do you work with others who can help you with any heavy lifting? [ ] Yes [ ] No [ ] N/A While in recovery, is there any light duty work you could request? [ ] Yes [ ] No [ ] N/A We invite you to discuss with us any questions regarding our services. The best services are based on a friendly, mutual understanding between provider and patient. Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of services and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and other expenses incurred on your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform the office of any changes to the information provided. Attorney Information: Have you retained an attorney? [ ] Yes [ ] No Attorney Name: Attorney Number Auto Insurance Information Your auto insurance company s name (even if another party is at fault): Claim # Name of auto insurance company of the party that hit you: Claim # Signature Date [ ] Adult [ ] Parent or Guardian [ ] Spouse
Consent to Care I do hereby authorize the Doctors of The Wellness Connection to administer such care that is necessary for my particular case. This care may include consultation, examination, spinal adjustments and other chiropractic procedures, including various modes of physical therapy, diagnostic x-rays, nutritional counseling and acupuncture or any other procedure that is advisable, and necessary for my health care. Furthermore, I authorize and agree to allow the Doctor of chiropractic 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, to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological function. I authorize the doctors of The Wellness Connection to discuss the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to fractures, disk 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, is in my best interests. The doctor will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions treated at this clinic. I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if I terminate my care prematurely that all fees previously incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor. I permit The Wellness Connection and their business associates to contact me, and all other responsible parties on my account, on my cell phone or other mobile devices concerning any and all aspects of my account. I clearly understand that all insurance coverage, whether accident, work related, or general coverage is an arrangement between my insurance carrier and myself. If this office chooses to bill any services to my insurance carrier that they are performing these services strictly as a convenience for me. The Doctors office will provide any necessary report or required information to aid in insurance reimbursement of services, but I understand that insurance carriers may deny any claim and that I am ultimately held responsible for any unpaid balances. Any monies received will be credited to my account. I, have read or have had read to me, the above consent. I have also had the opportunity to ask questions about this consent, 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 (s) for which I seek treatment. Signature (If under age 18) Parent s signature Date Acknowledgement of Notice of Privacy Practices I hereby acknowledge that I have the right to receive a copy of the practices Notice of Privacy Practices. I understand if I have questions or complaints in regards to my privacy rights that I may contact the Privacy Officer of The Wellness Connection. I further understand that the practice will offer me updates to the Notice of Privacy Practices should it be amended, modified, or changed in anyway. Signature (If under age 18) Parent s signature Date [ ] Patient doesn t want a copy at this time, but available if requested [ ] Patient refused to sign.