KEY TO LIFE CHIROPRACTIC

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Transcription:

KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office? PARENTAL CONSENT TO EVALUATE AND TREAT A MINOR I, being the parent/legal guardian of hereby grant permission for my child to receive chiropractic care. Witness Signature: CONSENT TO INITIATE CARE At our office, we have one simple goal we want to render the highest quality Chiropractic care at the lowest possible fee. In order to accomplish this goal, we have altered some of our business procedures to keep our fees reduced. Please read over these procedures below to understand how our office functions, and to decide if you wish to participate. If you have any questions, please direct them to the receptionist. You may choose to submit receipts to your insurance company or other third-party health care programs, but payment for such services by insurance companies is neither implied nor agreed to by this office. We take no responsibility for non-payment by insurance companies for services rendered at our office. Our office will not respond to any requests for paperwork for insurance purposes or even acknowledge insurance requests for information on any patient s case. However, patients may have a copy of their records at any time they request. No balances can be kept or run by patients at any time. All visits are paid the same day the service is rendered. Our office reserves the right to deny services to anyone for any reason, or if the doctor feels that the patient s health is not being best served. I wish to initiate care at this office. I have read and understand the Consent to Initiate Care and agree to all terms. I understand that I am under no obligation to receive or continue care. Print Your Name Today s Date Sign Your Name

SOME QUESTIONS TO HELP US HELP YOU NAME: DATE: If we could help you with only one health problem, what would it be? What other health problem would you like us to help you with? How did these problems start? When did these problems begin? Have you ever had these problems before? Is it worse in the morning or at night? (check one) Morning or Night Do you ever have numbness, tingling or pain in the arms or legs? How often do you feel the pain and how long does it last? Please list any other doctors seen for the above problem: Please list medications you are currently taking: Please list any surgeries you have had: Please list any auto or work injuries you have had: Please circle any in your family history: -Heart disease -Diabetes -Arthritis -Cancer -Back problems Do you get dizziness? Yes or No Do you have heart, lung or stomach problems? Yes or No Are you right or left-handed? How tall are you? How little do you weigh? Name of previous chiropractor: Are you looking for temporary relief or do you want the cause of your problem fully corrected? Why? What activities or hobbies have you been unable to do because of your problem?

NAME: Please mark the areas on the drawings where you have pain. Be as specific as you can. Include all affected areas. Rate your pain today. Circle the appropriate number on the pain scale below. If zero, perfect, you are here for wellness care. Congratulations! If 10, we need to get you to the ER. PAIN SCALE 0 1 2 3 4 5 6 7 8 9 10 PLEASE CHECK ANY OF THE FOLLOWING WHICH YOU ARE EXPERIENCING TODAY GASTRO-INTESTINAL SYSTEM NERVOUS SYSTEM MUSCULO-SKELETAL EYE,EAR,NOSE,THROAT Numbness SYSTEM Poor appetite Loss of feeling Eye strain Excessive hunger Paralysis Low back problems Eye inflammation Difficult chewing Dizziness Pain between Vision problems Excessive thirst Fainting shoulders Ear pain Difficult swallowing Headaches Neck Problems Ear noises Nausea Muscle jerking Arm problems Hearing loss Vomiting food Convulsions Leg problems Ear discharge Vomiting blood Forgetfulness Swollen joints Nose pain Abdominal pain Confusion Painful joints Nose discharge Diarrhea Depression Stiff joints Difficulty breathing Constipation Sore muscles through nose Black stool CARDIO-VASCULAR Weak nuscles Sore gums Bloody stool RESPIRATORY Walking problems Dental problems Hemorrhoids Chest Pain Ruptures Sore mouth Liver trouble Pain over heart Broken bones Sore throat Gall bladder problem Difficult breathing Hoarseness Weight trouble Persistent cough FEMALE Difficult speech Coughing phlegm Vaginal discharge GENITO-URINARY SYSTEM Coughing blood Vaginal bleeding Rapid heartbeat Vaginal pain Bladder trouble Blood pressure Breast pain Excessive urination problem Lumps on breast Scanty urination Heart problems Painful urination Lung problems ARE YOU PREGNANT? Discolored urine Varicose veins Yes No

PURPOSE OF AN ADJUSTMENT DISCLOSURE By signing below, I acknowledge that I understand that chiropractic care is given to correct misalignments of the spine called SUBLUXATIONS. One of the benefits of a chiropractic adjustment is that you MAY feel better but this is not the goal of an adjustment. The GOAL of an adjustment is to correct SUBLUXATIONS, thereby removing the interference to the nervous system allowing the body to heal itself. As a result, WE DO NOT TREAT PAIN OR DISEASE; we remove subluxations so that the body is able to function properly and be better enabled to heal itself. INSURANCE AND INJURY NOTICE I am aware that Key to Life Chiropractic and Dr. Wayne Christianson do not provide care for work related injuries, automobile accident injuries, or personal injuries. I also acknowledge that I must inform this office of any injuries sustained. I also am completely aware that Key to Life Chiropractic and Dr. Wayne Christianson, WILL NOT; bill, submit claims, nor prepare or submit reports for any insurance claims of any kind. I also understand that I must inform this office if I have Medicare coverage and I understand that I am responsible to pay for each visit myself at the time of service. Signed: Date: Please Print Patient Name: Relationship to Patient:

KEY TO LIFE CHIROPRACTIC Orientation Questionnaire 1. What controls and coordinates all the functions in your body? 2. What is it called when the spine is misaligned? V S 3. Is the purpose of an adjustment to make the body Heal better or Feel better? (circle one) 4. Do Chiropractors: Adjust subluxations or Treat pain? (circle one) 5. What are 3 ways a Chiropractor can find a vertebral subluxation 6. What causes a Subluxation? 7. How often does the research show we should be checked for subluxations? 8. Name 4 things you can do to keep you and your family healthy: Well, Well, Well and Stay Well I have watched the online orientation and understand the purpose of chiropractic and how often to be checked for vertebral subluxations in the office. Signed Date

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