Download HAVE YOU HAD, OR DO YOU HAVE

HAVE YOU HAD, OR DO YOU HAVE:
o
o
o
o
o
o
o
Diabetes
Arthritis
Heart disease/attack
0
High Blood Pressure
Bone disease
o
Nervous system disease
Connective Tissue Disorder (i.e. Lupus)
0
Grind your teeth'
0
Immune system suppressed/HIV
D
Sleep disorder/apnea
Cancer -list type/year/surgery
o
0
Muscle disease
Night guard
0
o
Stroke
0
Chronic fatigue syndrome
0
Fibromyalgia
Chrons/Colitis/lrritable
D
Depression
bowel disease
Smoke
_
PAST HISTORY:
Adult/Childhood Illnesses:
Past Surgical/Hospital:
Previous Injuries:
Motor vehicle? Yes 0
Workers Compensation?
Yes 0
No 0
No 0
.
_
(explain)
Other: _______________
Other Doctors seen for this condition:
(explain)
_
Previous Treatment and Diagnostic Tests:
o
MD 0
DC 0
DO 0
DDS
Previous Spinal X-rays: Done For What Reason
Current Medications: (prescription, over-the-counter,
_
or self-medication)(
Date: Results, If Known:
please list)
List any vitamins, supplements, or herbal remedies you are currently taking:
FOR WOMEN ONLY: Have you taken oral contraceptives?
Yes - When did you begin?
__________
No
TERMS OF ACCEPTANCE
The purpose of chiropractic is to restore and maintain the mechanical integrity the spinal column. Vital nerve pathways are housed within
and protected by the bones of the spine. These bones are called vertebrae. Misalignments, vertebral subluxations, of the spinal bones may
interfere with the function of the nerves housed within the spinal column. Subluxations have many causes and may prevent the various
organs of the body from working properly.
The chiropractic adjustment is administered for the purpose of correcting the vertebral subluxation(s), so that every part of the body receives
unimpaired neural messages. Reduction of the vertebral subluxation(s) will result in improved communication of the neural messages,
allowing the body to perform all its functions more efficiently, including the healing process.
In some cases where disease and symptoms have been present, the removal of this form of interference renders the body sufficiently able
to bring about a restoration of health very quickly. In others, the process is slower and in some cases it is only partial or not at all.
Regardless of what the disease is called, the chiropractor does not offer to heal or treat it. The goal of the chiropractor is to correct
subluxations, this very damaging form of interference to the body's natural functioning. The chiropractor promises no cure from and offers
no treatment of disease.
The chiropractor has the responsibility to report to the patient any unusual findings discovered in the course of the chiropractic examination.
All such findings will be recorded in the patient's record as reported to the patient. The patient may then seek evaluation and advice from
other health care professionals.
I,
Acceptance",
understand it fully, and accept chiropractic
PATIENT/GUARDIAN
SIGNATURE:
represent that the above information
care on this basis.
DATE:
is accurate.
I have read the "Terms of
_