In the past 6 months have you experienced any of the following health challenges? Please check all that apply.
Please identify how your current condition is affecting your ability to perform normal activities of daily living.
If no surgeries in past say "none"
If no broken bones say "none"
If no major illnesses say "none"
If you wish for our office to verify your insurance benefits, please provide us with the following information.
Standard Waiver of Liability
Chiropractic is a art, science, and philosophy which concerns itself with the relationship between the spinal structure and the health of the central nervous system. Any disturbance to the CNS will create sickness and disease. One such disturbance to the nervous system is known as a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properlycreating nerve interference which may result in pain and dysfunction or may be entirely asymptomatic. In order to reduced or correct the vertebral subluxation the doctor will be using his/her hands to gently move the vertebra back in to a healthier position. At which time, you may feel a sense of movement of the vertebra and hear an audible “pop” or “click”. The sound created is completely natural and is merely a release of gas within the joints of the spine. Chiropractic care has been proven to be extremely safe and effective; however, it is not unusual to be sore after your first few specific chiropractic adjustments. Although rare, it is possible to suffer from other side effects; i.e. muscle spasms, stiffness, headaches, dizziness and in rare cases rib fracture. If at the beginning or during the course of care we encounter a non-chiropractic issue we will refer you out to the appropriate health care provider. I have the right, as a patient, to be informed about the condition and the recommended care to be provided so that I can make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives. All questions regarding the doctor’s objective to my care in this office has been answered to my complete satisfaction. *