Download Intake Form - Health From Within

Patient Name_____________________________ E-mail address_______________________________
Address_______________________________ City _______________ State______ Zip code_________
Home#______________________ Work#____________________ Cell#_________________________
Which phone number and time is best to reach you? _________________________________________
Date of Birth ________________Social Security Number _________________________ Gender: M F
To better serve you please answer the following questions in advance:
1. What are your health goals? _________________________________________________________________
2. How do you expect to achieve them? __________________________________________________________
3. Addressing what brought you into this office:
(If you have no symptoms or complaints and are here for wellness services, please skip to question 5.)
Please list your health concerns
according to their severity
Rate of severity
When did this
1=mild
Episode start?
10=worst imaginable
If you had this
Condition before,
When?
Did the problem
% of the time pain
begin with an injury? is present
1.
2.
3.
4. Check off the following symptoms or disorders you have and CIRCLE the ones that affect you the most
Headache/Migraines
Neck Pain
Hip pain (right or left)
Sinus/Allergies
Shoulder pain (right or left) Knee pain (right or left)
Chest/Rib pain
Elbow pain (right or left) Ankle pain (right or left)
Dizziness
Wrist pain (right or left)
Muscle Stress
Ear Aches
Scoliosis
Constipation
Asthma
Low Back pain
Hyperactivity
Frequent colds/flu
Mid-back Pain
Arthritis
Heartburn/Reflux
Disc Problems
Stomach Problems
Low energy/Tired /Fatigue Insomnia
Depression
Unexpected Weight Gain Ringing/Buzzing in Ears Bed Wetting
Loss of Memory
High Blood Pressure
Menstrual Problems
Excess Gas/Bloating
Low Blood Pressure
Thyroid Trouble
Multiple Sclerosis
Fibromyalgia
Blood Circulatory Problems
High Cholesterol
Shortness of breath
Nausea
Bladder Problems
Cancer
Circulatory/Vascular Disorder
Digestive Problems
Indigestion
Heart Condition
Infertility
Kidney Disease
Mood Swings
Osteoporosis
Sinus Trouble
Urinary Difficulty
Other:________________
Chemical Stress
Physical Stress
Emotional Stress/Anxiety
Attention Disorders
Sciatica
Numbness/Tingling
Leg pain (right or left)
Arm pain (right or left)
Vertigo
Ulcers
Autoimmune Disease
Diabetes
Swollen Ankles
Skin Conditions/Acne
Diarrhea
Immune System Disorder
*****Vertebral Subluxations can cause your pain*****
Which pain or condition you have marked is the worst for you? ____________________________________
How long has it bothered you? ___________________________________________________________
Vertebral Subluxations can cause irritation to different fibers within nerves.
Is your pain sharp or dull? _______________________________________________________________
Subluxations can put pressure on the spinal cord which can be constant or occasional. Which do you feel? ________
Pressure on the spinal cord or nerves can be worse in the AM or the PM. Which one is harder for you? __________
Does this radiate into an extremity or stay in one area? ________________________________________
5a. Are any of the above symptoms linked to a current car accident or workers compensation case?____________________________
5. Other doctors you have seen for this condition:
a. “Limited Scope” Chiropractor (focuses mainly on neck and back pain)
b.
Holistic Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns)
c. Medical Doctor
Doctor’s Details: Name:______________________________________________________________________
When did you see them?_______________________________________________________
What did they say was wrong?___________________________________________________
Did it help?__________________________________________________________________
What did they do?____________________________________________________________
Have you been “forced” or “felt the need” to make any “positive” changes in your life due to this pain, illness, condition,
etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.) If so, what?
_______________________________________________________________________________________________
6. Please indicate which aspects of your life are compromised by your current level of health:
Bending
Lifting
Walking
Sitting
Climbing Stairs
Standing
Running
Exercise
Sleeping
Lying in Bed
Lifting Children
Sports
Recreational Activities
Getting in/out of Car
Housework
Yardwork
Travel
Grooming
Job Activities
Emotional Well-Being
6b. Circle the two areas of your life are most affected by your current level of health?
Family
Relationships
Job
Finance Health
Emotional Well-Being
Career
Time
Leisure
Communication
Knowledge
7. a. Do you have trouble with? (Check what applies)
____Anxiety
____Depression
____Irritability
8. Check all TRUE statements:
___Previous methods ineffective
___I want answers and/or results
b. What methods have you tested?
____Exercise
____Physical therapy
____Prescription drugs
____Massage
____Nothing
___My problems could get worse
___I want to be healthy
Spirituality
___I want to be energetic again
9. How long have you been living this way?
10. What results do you want for yourself?
Weeks(#)_____
Reduce Pain
11. What excuse has stopped you from being well?
Money
Months(#)_____
Restore Health
Time
Years(#)_____
Maintain Health Wellness
Other____________
12. Check all statements that apply to you:
___I don’t think anything can help me anymore
___I know I am in the right place
___I’m giving it a try but I doubt it will work
___I’m just here to inquire
___I’m giving it a try and I think it will work
___With the help of God anything is possible
13. How would you be convinced that something ‘works”? (only choose ONE)
Seeing it
Hearing it
Feeling it
Understanding it
Other_____________________________
14. Stress History
Please indicate whether you have ever experienced stress in any of the following areas. Your answers will enable us to determine
which factors have contributed to your present health concerns.
1) Childhood
Repeated/Prolonged Antibiotic Use
Car Accident
Childhood Illness
Fall/Jump from a Height < 3 feet
Fall/Jump from a Height > 3 feet
Head Trauma
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
2) Adulthood
Alcohol Consumption
Repeated/Prolonged Antibiotic Use
Car Accident
Coffee Drinker
Drug Use/Abuse
Fall/Jump from a Height
Head Trauma
Home Environment Stress
Inhaler Use
Yes No
Prescription Medications
Yes No
Surgery
Yes No
Vaccination
Yes No
Youth Sports
Yes No
Other Traumas (physical or emotional):
_____________________________________________
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Inhaler Use
Yes No
Prescription Medications
Yes No
Smoker
Yes No
Surgery
Yes No
Contact Sports
Yes No
Extreme Sports
Yes No
Workplace Stress
Yes No
Other Traumas (physical or emotional):
__________________________________________
15. Stressors:
Because accumulation of stress affects our health and ability to heal please list your top three stressors (you have ever had) in
each category:
1. Physical stress (falls, accidents, work postures, etc.)
a. ___________________________________________________________________________________
b. ___________________________________________________________________________________
c. ___________________________________________________________________________________
2. Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.)
a. _____________________________________________________________________________________
b. _____________________________________________________________________________________
c. _____________________________________________________________________________________
3. Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.)
a. _____________________________________________________________________________________
b. _____________________________________________________________________________________
c. _____________________________________________________________________________________
16. On a scale from 1-10 please grade your present levels of stress (including physical, bio-chemical and psychological or
mental/emotional):
At work:
At home:
At play:
17. On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your:
Eating habits:
Exercise habits:
Sleep:
General health:
Mind set:
18. How many glasses of pure water do you drink per day? (no soda, coffee, or tea)__________
19. How do you grade your physical health?
Excellent
Good
Fair
Poor
Getting better
Getting worse
Poor
Getting better
Getting worse
20. How do you grade your emotional/mental health?
Excellent
Good
Fair
21. On a 1-10 scale,
a. Where would you rate your overall health and well-being? _____
b. Where would you want it to be?____
And how long do you think this process will take?______
22. On a scale from 1-10(1 being least, 10 being most) rate your interest in the following:
a. Correcting the cause of any existing ailment _______
b. Nutrition/herbs to increase overall health______
c. Eliminating negative emotions that may be compromising your health_____
d. Detoxifying your body of pollutants (heavy metals, tobacco, blood clot)_____
e. Massage therapy_____
23. What do you search for when seeking a healthcare provider? ____________________________________________________
_________________________________________________________________________________________________________
24. Have you had any experience with chiropractic? YES NO
a. Did you like the results? YES NO
b. What did you enjoy most and least about your visits there?________________________________________________
25. Have you attended any of our health talks yet? YES
NO
26. Based on your experience, what do you expect from this visit?
a. A short and to the point presentation of what you can offer me
b. The science and statistics behind what you do
c. The clinical experience and background of the Dr.
d. An explanation of what I can expect to experience here
e. Other: ______________________________________
27. Is there anything else which may help to better understand you which has not been discussed?__________________________
_________________________________________________________________________________________________________
Medical History
List all physicians and practitioners you have seen for your current condition________________________________
_____________________________________________________________________________________
Have you had any surgeries? YES NO If so, when and what?_________________________________________
_____________________________________________________________________________________________
Do you have any scars? YES NO If yes, where?____________________________________________________
Do you currently have any injuries as a result of an auto or work related accident. If yes, please specify.___________
______________________________________________________________________________________________
Have you ever been hospitalized? YES NO If yes, list reason___________________________________________
______________________________________________________________________________________________
List any medical conditions you currently have_________________________________________________________
List any medications you are currently on_____________________________________________________________
If there was a way we can help you come off these medications would you be interested?
YES
NO
List any known allergies (food, inhalants, etc.)_________________________________________________________
Have you ever had any of the following diagnostic tests?
___X-rays
___MRI scans
___Bone scan
___Myelogram
___Disco gram
___EMG
___CT scan
If any selected, list reason:_____________________________________________________________________
Do you have a history of cancer? YES NO
Are you currently pregnant?
YES
NO
Check all that apply:
___Smoker ___Non-smoker ___Drinks Alcohol ___Does not drink alcohol
___Takes drugs
___Does not take drug
How were you referred to us_______________________________________________________________________
Employer______________________________________________________________________________________
Occupation (Please be specific. Often times the work that we do greatly affects our health and/or stress level. This information
will help the doctor with your course of care). _______________________________________________________________
Circle one:
Single Married
DivorcedSeparated
Widow/ed
Name of children and age(s)____________________________________________________________________________
Education completed:
High school
College Graduate
Post-Graduate
H e a lt h F ro m W it h in F a m i ly W e l ln e s s C e n t e r
1818 Marron Rd, Ste 103 ~ Carlsbad, CA 92008
(760) 385-8352
www.healthfromwithinCA.com
Please read the below and if you have any question please feel free to ask one of our staff members.
Informed Consent:
I do hereby authorize the doctors of Advanced Chiropractic Healthcare to administer such care that is necessary for my particular case. This
may include consultation, examination, adjustments or any other procedure, which is advisable and necessary for my healthcare.
In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits
coverage with the above captioned, and hereby assign and convey directly to Health From Within Family Wellness Center, all medical benefits
and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am
financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all
medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release
to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and
clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my
insurance and/or employee health benefits claim submissions.
I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance
policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care
benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a
result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such
medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree
to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my
insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee
health care plan in my name but at such doctor and clinic's expenses.
I understand that payment plans are mandatory unless balance can be paid in full. Finance charges will be applied to balances 60 days
overdue at 1.5% and every 30 days there after.
INTEREST AND COLLECTION: I acknowledge and agree that, should my account become more than thirty (30) days overdue, I will incur
interest on my past due balance of seven percent (7%) per annum. I further acknowledge and agree that Advanced Holistic Healthcare shall be
entitled to reimbursement from me for any legal costs, including attorney fees, for all efforts to collect on any past due account with Advanced
Holistic Healthcare.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as
the original. I have read and fully understand this agreement.
A patient, in coming to the chiropractic physician, gives the doctor permission and authority to care for the patient in accordance with
the chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause
any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of
course, will not give any treatment or care if he is aware that such care may be contra-indicated. Again, it is the responsibility of the patient to
make it known, or to learn through healthcare procedures whatever he/she is suffering from: latent pathological defects, illnesses or deformities
which would otherwise not come to the attention of the chiropractic physician. The chiropractic physician provides a specialized, nonduplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of
providers in your health care regimen. I understand that if I am accepted as a patient by a physician at Health From Within Family Wellness
Center, I am authorizing them to proceed with any treatment that may be necessary. Furthermore, any risk involved, regarding chiropractic
treatment, will be explained to me upon my request.
Acknowledgement
I have been informed that upon request I can receive a copy of the privacy practices (HIPPA)
and I am aware that I have an opportunity to discuss my rights to privacy if I please.
Missed Appointments:
There will be a $30 fee charged for all appointments that are not canceled within 24 hours prior to scheduled visit.
Print Name: ______________________________________________
Signature: ________________________________________ Date: __________________________
H e a lt h F ro m W it h in F a m i ly W e l ln e s s C e n t e r
1818 Marron Rd, Ste 103 ~ Carlsbad, CA 92008
(760) 385-8352
www.healthfromwithinCA.com
Consent to Evaluate and Treat a Minor:
I, _______________________________ being the parent or legal guardian of _____________________________, have read and
fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
Print Name: ______________________________________________
Signature: ________________________________________ Date: __________________________
Communications:
In the event that we would need to communicate your healthcare information, to who may we do so?
Spouse: ____________________________________________________
Children: ___________________________________________________
Others: _____________________________________________________
May we leave messages on any answering device, i.e. home answering machines or voicemails? Yes [ ] No [ ]
Insurance Information (if applicable)
Primary Insurance:
Policy Holder ____________________Relationship to insured: Self
Spouse Child
Other
Insured address (if different from yours) ___________________________________________
____________________________________________________________________________
Insured Date of Birth ______________ Insured Gender: M F
Policy name: _________________________ Policy #: ________________________________
Secondary Insurance:
Policy Holder ____________________Relationship to insured: Self
Spouse Child
Other
Insured address (if different from yours) ___________________________________________
____________________________________________________________________________
Insured Date of Birth ______________ Insured Gender: M F
Policy name: _________________________ Policy #: ________________________________