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HOME
HOME
OUR STORY
WHO WE ARE
CAN WE HELP
WHAT TO EXPECT
CONTACT
HOME
Please complete the form below
Name
*
First Name
Last Name
Has any of your personal information changed since your last office visit?
*
Yes
No
If you answered YES please complete the following information so we can update your records
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Main (Cell/Home) Phone Number
Email
Occupation
Employer
Marital Status
Single
Married
Divorced
Widowed
Have you been hospitalized in the past 6 months?
*
Yes
No
If yes please explain reason for hospitalization
Reason for today's visit?
Wellness
Spinal Check-up
Pain/discomfort
History of Complaint
First Complaint
*
In your words, how would you describe the pain? (examples: ache, burning, numbness)
*
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
Date of Onset (when did it begin)
*
MM
DD
YYYY
How often do you experience the pain?
*
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
*
AM
Mid-day
PM
Late PM
No specific time of day
Does the pain/discomfort radiate into your extremities?
*
Yes
No
If yes please explain:
Second Complaint
How would you describe the pain/discomfort?
On a scale from 0 to 10 with 10 being the "worst pain you have ever felt" and 0 being no pain, how would you rate your discomfort?
Date of Onset
MM
DD
YYYY
How often do you experience the pain/discomfort?
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
AM
Mid-day
PM
Late PM
No specific time of day
Does the pain/discomfort radiate into your extremities?
Yes
No
If yes please explain:
Do you have more than two complaints?
If yes, we will discuss in-person with the doctor
Yes
No
In the past 6 months have you experienced any of the following health challenges? Please check all that apply.
General
Fatigue
Fever(s)
Unexplained weight loss
Insomnia
Ears, Eyes, Nose & Throat
Visual changes
Hearing loss
Sore throat
Trouble swallowing
Nasal congestion
Ear pain
Respiratory
Prolonged cough
Unable to catch breath
Wheezing
Snoring
Cardiovascular Issues
Irregular heartbeat
Racing heart
Chest pain
Swelling of legs or feet
Shortness of breath
Musculoskeletal
Joint pain
Muscle pain
Neurologic
Headaches
Dizziness
Difficulty walking
Numbness or tingling in face
Seizures
Gastro-Intestinal Issues
Abdominal pain
Constipation
Diarrhea
Gas
Heartburn
Nausea
Vomiting
Genitourinary
Painful urination
Bloody urine
Increased urination
Leaking urine
Females Only Section
Ionizing radiation can be hazardous to an unborn child
*
To the best of my knowledge I am not pregnant and the doctor has my permission to perform an x-ray evaluation.
I am currently, pregnant and therefore I am unable to receive ionizing radiation at this time.
Are you trying to become pregnant?
Yes
No
If yes, have you had trouble conceiving?
Yes
No
Social History
Do you smoke (cigarettes, cigars, pipe)?
*
Daily
Weekends
Occasionally
Never
Do you consume alcoholic beverages?
*
Daily
Weekends
Occasionally
Never
Do you use marijuana?
*
Daily
Weekends
Occasionally
Never
Do you use drugs recreationally (Example: cocaine, methamphetamines)?
*
Daily
Weekends
Occasionally
Never
If yes, please list which drugs you use and how often.
Exercise level (number of times per week 0-7 days)
What position do you typically sleep in?
Back
Stomach
Side
Unsure
List all medications currently (in the space provided). And please give the reason for use (not all medications are prescribed for the symptom(s) or condition(s) they were approved for) and the length of time using:
If you wish for our office to verify your insurance benefits, please provide us with the following information.
Primary Insurance
Identification Number
Secondary Insurance
Identification Number
Standard Waiver of Liability
I understand that I am financially responsible for any charges incurred at this office, for those patients using insurance, this would include co-pays, deductibles, and charges denied or not covered by my insurance company. I realize that my care may be subject to pre-authorization by my insurance company, and I accept any responsibility for charges which may not be approved. My insurance company will review any/all documentation submitted by New Beginnings Chiropractic for medical necessity, however; final determination is based upon my insurance company’s medical guidelines. Insurance policy limitations are per individual insurance policy plans, as are co-payments, co-insurance, deductibles, referrals, etc. I understand this office agrees to notify me as soon as possible whether my care is approved or denied by my insurance company. I understand my initial visits may be denied and this may be beyond the office’s ability to notify me prior to rendering acute care, while waiting for insurance coverage approval. These charges will be my responsibility if denied by my insurance company. *
*
I hereby authorize my insurance benefits to be paid directly to New Beginnings Chiropractic. I have read this document and understand my obligations for payment in the absence of insurance coverage.
Informed Consent
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. Other commonly reported side effects include muscle spasm(s), stiffness, headaches, and dizziness. Although extremely rare, rib fracture has been reported but is (typically) due to an underlying condition being present. Imaging helps us rule in/out the presence of such conditions. 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.
*
I have read and fully understand the above statements and therefore accept chiropractic care on this basis. By checking the box, I am consenting to care.
Keycard
As you may remember, your keycard checks you into the room for the doctor to access your file. Are you in possession of the keycard?
*
Yes
No (you will have to purchase a new card $3)
Thank you! One of our team members will be contacting you shortly.
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