Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How Long? Occupation Employer Place of Business Address Phone Are you insured? Yes No Name of Insurance Company Today s Major Complaints Please check Please Circle Your Level of Pain. Area of Pain and Type of Pain 0= No Pain through 10=Extreme Pain Headache Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Neck Pain Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Shoulder Pain Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Arm Pain Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Mid Back Pain Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Low Back Pain Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Hip Pain Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Leg Pain Lt Rt Ache Dull Sharp Stabbing 0 1 2 3 4 5 6 7 8 9 10 Other 0 1 2 3 4 5 6 7 8 9 10 Other 0 1 2 3 4 5 6 7 8 9 10 I feel more pain when doing the following activities: Check the activities that cause pain and then Circle minimal, mild, moderate or severe. Sleeping Minimal Mild Moderate Severe Sitting Minimal Mild Moderate Severe Walking Minimal Mild Moderate Severe Standing Minimal Mild Moderate Severe Lifting Minimal Mild Moderate Severe Household Chores Minimal Mild Moderate Severe Routine Personal Care Minimal Mild Moderate Severe Other Minimal Mild Moderate Severe Other Minimal Mild Moderate Severe Is your condition due to a work injury or automobile collision? Yes No (If yes, then please alert the front desk assistant. You will have some additional paperwork to fill out.) What happened to cause the condition(s)? If you are not sure, just write unknown. 1
How long has this been bothering you? Has this bothered you before? When? Please list other health care providers you have seen for the condition(s), and treatment received. Have you found any activities that make your complaints feel better? (Examples are ice, heat, stretching, other treatment) Describe briefly and give approximate dates for any major injuries, illnesses, surgeries or accidents: Does your immediate family have a history of any diseases? (Cancer, Heart Disease, Diabetes, Etc.) Mother s side Father s side Are you presently on any medications? (please specify) Do you smoke? Yes No Drink Alcohol? Yes No Number of drinks per week Exercise Regularly? Yes No Height Weight Have you been to a chiropractor before? Yes No Chiropractor s name/ location: Last seen: Name of Primary Care Physician Date of last Physical Please provide your email address if you wish to be added to our monthly e-newsletter list. Email: Patient Signature (Guardian if under 18) Date 2
Circle All The Symptoms That Apply. ARE YOUR HEALTH PROBLEMS RELATED TO YOUR SPINAL PROBLEMS? EVERY CELL OF YOUR BODY HAS A NERVE COMPONENT. Neck (Cervical Spine) C1-C7 Headaches Migraines Sinus Problems Allergies Head Colds Fatigue Vision Problems Runny Nose Sore Throat Stiff neck Cough Arm Pain Numbness or Tingling in Hands & Fingers Neck Pain Dizziness Upper & Middle Back (Thoracic Spine) T1-T12 Middle Back Pain Congestion Difficulty Breathing Asthma High Blood Pressure Heart Conditions Bronchitis Pneumonia Gallbladder Liver Conditions Stomach Problems Ulcers Gastritis Kidney Problems Low Back (Lumbar Spine) L1-L5 Constipation Colitis Diarrhea Gas Pain Irritable Bowel Bladder Problems Menstrual Problems Low Back Pain Numbness in Legs Numbness in Thighs Pelvis (Sacro-Iliac Joints) S1-Coccyx Reproductive Problems Prostate Problems Pain or Swelling in the Legs Pain or Swelling in the Ankles Pain or Swelling in the Feet or Toes Hip or Pelvic Pain 3
TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health A state of optimal physical, mental and social well being, not merely the absence of disease or infirmity. Vertebral Subluxation A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease. We only offer to diagnose either subluxations or neuro-musculoskeletal conditions. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will recommend that you seek the services of another health care provider. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustments. I, have read and fully understand the above statements. (Print name) 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 (Legal Guardian/ Parent) (Child) have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. / / (Legal Guardian/ Parent Signature) (Date) Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual period: Signature: Date: 4
HEALTH INSURANCE INFORMATION Patient s Name DOB Insured s Name Insured s DOB Insured s Address if different than yours ID# Insurance Company Group# Please present insurance card to front desk so we can make a copy for your file. *If not insured, list the Name & Address of person RESPONSIBLE FOR PAYMENT. VERY IMPORTANT------PLEASE READ AND SIGN BELOW ASSIGNMENT OF INSURANCE BENEFITS I understand that as a courtesy Rainier Valley Chiropractic, P.S. will attempt to verify my Chiropractic and/or Massage benefits but that I should confirm my benefits on my own as well. Benefit quotes are not a guarantee of payment. I understand that ultimately I am responsible for charges not covered by my insurance. I hereby authorize payment directly to Rainier Valley Chiropractic, P.S. for the chiropractic services that I am provided. Signature: (Policy Holder/Child s Guardian) Date: 5