Patient Information and History

Please fill out COMPLETELY. If something does not apply to you, simply write N/A in the space provided. Please Print Legibly.

History Of Present Illness

Other Problem

Allergies

Family History

Please tell us about the health of you grandparents, parents, and siblings. Choose or check everything that applies. If someone is deceased, please check or write in the cause.

Social History

Past Medical History

PLEASE READ: This questionnaire is designed to enable us to understand how much your back pain has affected your ability to manage your everyday activities. Please answer section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CHOOSE ONE, CHOICE THAT BEST DESCRIBES YOUR PROBLEM RIGHT NOW.

Oswestry Neck Pain Disability Questionnaire (Complete only if you have Low Back Pain)

PLEASE READ: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST CHOOSE ONE, CHOICE THAT BEST DESCRIBES YOUR PROBLEM RIGHT NOW.

Owestry Low Back Pain Disability Questionnair (Complete only if you have Low Back Pain)

Notice of Privacy Practices

Medical Information Release Form

Release of Information

I authorize the release of information including the diagnosis, records;

Examination rendered to me and claims information. This information may be released to;

Assignment of Benefits

I certify that I (or my dependent) have insurance coverage and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME, I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.

Consent to Treat

by the doctor. I also consent to the procedures performed by his trained staff assistants under direct instructions and supervision.

I have had an opportunity to discuss with the doctor or other office personnel the nature and purpose of chiropractic adjustment/acupuncture and the other therapy procedures. I understand that the practice of neither chiropractic/acupuncture nor medicine is an exact science and that my care may involve the making of judgements based upon the facts known to the doctor at the time; that it is not reasonable to expect the doctor to be able to anticipate or explain all risk and completions; that an undesirable result does not necessarily indicate an error in judgement; that no guarantee of results has been made to, no relied upon by, me, and I wish to rely on the doctor to exercise  judgement during the course of the procedures which he feels at the time, based upon the facts then known, is in my best interests.

I have also been advised that although the incidence of complications associated with chiropractic/acupuncture procedures is very low, anyone undergoing chiropractic adjustments/acupuncture, physical therapy services or joint manipulations procedures should know of possible complications, which have been alleged. These include, but are not limited to; burns, fractures, disc injuries, strokes, dislocations, sprains, increase or worsening of symptoms and those which relate to physical aberrations unknown or reasonably undetectable by the doctor.

I have been informed that acupuncture is a generally safe method of treatment, but that I may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scaring potential risk of moxibustions and cupping, or when treatment involves the use of heat lamps. Bruising is common side effect of cupping. Unusual risk of acupuncture include spontaneous miscarriage, nerve clinic uses sterile disposable needle and maintains a clean safe environment.

I have read or have had read me to above Consent. I have also had the opportunity to ask question about is contents, and by signing below, acknowledge my understanding of its contents.

FUNCTION FIRST

Authorization to Relate Medical Information