Download Heneberry Chiropractic

Heneberry Chiropractic
1234 Middlebrook Ave Suite D Staunton, VA 24401
(540) 280-4539
First Name: _________________________ Last Name: ____________________________ DOB: ____________
Address: _________________________________ City: _________________ State: ____ Zip Code: __________
Home Phone: _________________________ Cell: ___________________ Work: _________________________
Preferred contact number:
Home
Cell
Work
SSN# ______________________
Email address: _________________________________ May we use this to contact you?
Yes
No
Emergency Contact Name: ____________________________ Relationship: _____________________________
Phone Number: ________________________________ Type:
Home
Cell
Work
How did you hear about us? ____________________________________________________________________
I authorize Heneberry Chiropractic, to release information regarding the above named patient to: (Name,
telephone number, relationship to patient, example: mother, father, spouse, etc.,) please note that ONLY THE
NAME LISTED will be able to obtain medical information about you.
Name_________________________ Phone Number_______________ Relationship___________________
Heneberry Chiropractic
1234 Middlebrook Ave Suite D Staunton, VA 24401
(540) 280-4539
Patient Name: _______________________________________
Date: __________
Reason for seeking care:
______________________________________________________________________________
List any other doctors seen for this:
______________________________________________________________________________
List any diagnosis and type of treatment:
______________________________________________________________________________
Have you had similar accidents or injuries before? __ Yes __ No If yes explain:
______________________________________________________________________________
Does this condition limit your ability to do any of the following? (Circle all that apply)
Sitting
Standing
Laying
Bending
Lifting
Driving
Exercising
Walking
Other: _________________
How long have you had this condition? _______________________________________
Have you received chiropractic treatment previously? __ Yes __ No
If yes, by whom: ______________________________________________________
Have you been treated by a physician for this condition? __ Yes __ No
If yes, explain: ______________________________________________________________________________
Are you currently taking medication? __ Yes __ No list medications:
___________________________________________________________________________________________
_________________________________________________________________
List the approximate dates of any surgery or treated conditions:
___________________________________________________________________________________________
_________________________________________________________________
Do you take Vitamins/Supplements Y/N If yes, type and how often
______________________________________________________________________________
Please circle degree of pain, 0 none, 10 severe pain.
0 1 2 3 4 5 6 7 8 9 10
Using the symbols below, mark on the pictures where you feel
pain.
Numbness
===
Dull Ache
OOO
Burning
XXX
Sharp/Stabbing / / /
Pins, Needles + + +
Other ______ ^ ^ ^
What activities aggravate your condition/pain? ___________
What activities lessen your condition/pain? ______________
Is this condition worse during certain times of the day? Y/N
When? __________
Is this condition interfering with Work? ____Sleep? _____
Routine? ______ Other? _____
Is this condition progressively getting worse? ___________
CHIEF Complaints or Symptoms:
Neck pain
check off the areas that the pain
runs into from the neck
Headache
Location of pain:
Ringing in Ears
Blurry Vision
Wrist Pain
Jaw Pain
Name:
Date:
None Left shoulder Left arm Left forearm Left hand
Right shoulder Right arm Right forearm Right hand
Up to head
Type:
Yes
Yes
Yes
Yes
No
No
No
No
Migraine
Left
Left
Left
Left
Tension/Stress
Right
Right
Right
Right
Dizziness
Nervousness Fatigue Anxiety Depression
Fear of driving a car Loss of concentration Jaw clenching
Difficulty sleeping at night
Mid/Upper Back Pain
Select the areas of radiating pain
Numbness:
Left Hand
Left Foot
Both Ears
Both Eyes
Both Wrists
Both Sides
Excessive irritability
Grinding teeth at night
Nightmares
None left scapula left shoulder left arm
Right scapula right arm right ribcage left ribcage
sternum up the spine down the spine
Low Back Pain
Select the areas of radiation, if any...
Hip Pain
Knee Pain
Foot Pain
Sinus
Left
Left
Left
Left Upper Arm
Left Leg
None buttocks left buttock left thigh left knee
Left foot right buttock right thigh right knee right foot
Right
Right
Right
Bilateral
Bilateral
Bilateral
Right Hand
Right Foot
Right Upper Arm
Right Leg
Additional Symptoms/ Complaints:
Have you lost any time from work due to your injuries? Yes No
If yes please give dates:
____________________________________________________________________
Type of employment:
_____________________________________________________________________________
Informed Consent
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic
procedures, including various modes of physical therapy by Dr. Rachel Heneberry and/or other licensed
doctors of chiropractic who now or in the future work at the clinic or office listed above or any other
office or clinic. I have had an opportunity to discuss with Dr. Heneberry and /or with other office or
clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand
that results are not guaranteed.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there
are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and
sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I
wish to rely upon the doctor to be able to anticipate and explain all risks and complications, and I wish
to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at
the time, based upon the facts then known to him or her, is in my best interest.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions
about its content, and by signing below I agree to the above-named procedures. I intend this consent
form to cover the entire course of treatment for my present condition and for any future condition(s) for
which I seek treatment.
Payment Policy
All fees must be paid in full for all services rendered at the time of visit, unless PRIOR arrangements
have been made. You are personally and fully responsible for all payments, regardless of whether or not
we take insurance assignments. Returned checked will incur a $35 fee, and interest may be charged at
1.5% per month.
I hereby certify that the statements and answers given on this form are accurate to the best of knowledge
and understand it is my responsibility to inform this office of any changes in my health.
Patient Signature__________________________________________________Date__________
Parent/Guardian
Signature _____________________________________________________ Date ___________