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Initial Consult & Treatment
Confidential Intake Form and Consent
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Email
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Your email
Untitled Title
Todays Date
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MM
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DD
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YYYY
Your Full Name
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Your answer
Your Birth Date
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MM
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DD
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YYYY
Age/Gender
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Your answer
Your Address
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Your answer
Moble Number
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Your answer
Single / Married / Divorce / Widowed ?
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Your answer
Your Occupation
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Your answer
Who referred you?
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Your answer
Emergency contact: Full name and mobile number.
Your answer
HIPPA CLIENT CONFIDENTIALITY AND RELEASE FORM. I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health. Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance. HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation. Clients should receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records (Please sign and date below to confirm you have read the above HIPPA CLIENT CONFIDENTIALITY AND RELEASE).
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Your answer
Primary reason for visit:
Your answer
When did your first notice it?
Your answer
What brought it on?
Your answer
Describe any stressors occurring at the time:
Your answer
What activities provide relief?
Your answer
What makes it worse?
Your answer
Is this condition:
Getting worse?
Interfering with work?
Interfering with Sleep?
Interfering with recreation?
None of the above.
Other:
SECONDARY COMPLAINT: Significant Illnesses:
Heart Disease
Pacemaker/Defibrillator
Diabetes
High Blood Pressure
Thyroid Disease
Hepatitis
Cancer
Seizures
HIV
None of the above
Other:
STRESS SCALE ~ 1= no stress, 10= extreme stress
NO STRESS
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2
3
4
5
6
7
8
9
10
EXTREME STRESS
Clear selection
PAIN SCALE ~ 1= no PAIN, 10= extreme PAIN
NO PAIN
1
2
3
4
5
6
7
8
9
10
EXTREME PAIN
Clear selection
ENERGY SCALE ~ 1= no energy, 10= best energy
NO ENERGY
1
2
3
4
5
6
7
8
9
10
BEST ENERGY
Clear selection
List all Western Diagnosis:
Your answer
List all Medicines (taken within the last 6 months including drugs, vitamins and herbs):
Your answer
Do you have an Allergies?
Yes (if yes, please list all allergies below in "other" option.
No
Other:
Clear selection
List all Major Operations (and dates):
Your answer
List all Accidents / Traumas (and dates):
Your answer
Are you pregnant and/or trying to conceive?
Yes
No
Unsure
Other:
Clear selection
Please review and check the following:
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PAST
PRESENT
N/A
Asthma
Cold Hands or feet
Swollen ankles
Sinus Conditions
Frequent Colds
Seizures
Low Back Pain
Skin Disorders
Sciatica
Painful/Swollen Joints
High Blood Pressure
Low Blood Pressure
Dentures/Partials
Headaches
Sore heels when walking
Anxiety
Depression
Sleep Disturbance
Fainting Spells
Muscular Tension
Varicose Veins
Hemorrhoids
Herniated/Bulging Discs
Artifical/Missing limbs
Contact Lenses
Cancer (past or current)
Numbness in feet or legs when standing
PAST
PRESENT
N/A
Asthma
Cold Hands or feet
Swollen ankles
Sinus Conditions
Frequent Colds
Seizures
Low Back Pain
Skin Disorders
Sciatica
Painful/Swollen Joints
High Blood Pressure
Low Blood Pressure
Dentures/Partials
Headaches
Sore heels when walking
Anxiety
Depression
Sleep Disturbance
Fainting Spells
Muscular Tension
Varicose Veins
Hemorrhoids
Herniated/Bulging Discs
Artifical/Missing limbs
Contact Lenses
Cancer (past or current)
Numbness in feet or legs when standing
FAMILY HISTORY: Short answers for the following immediate family members: Please include Mother, Father, Siblings, Maternal Grandparents, Paternal Grandparents.... Any Major Health Issues? Are the Still Living? (If deceased, Cause and Age of Death)
Your answer
This space is to share more details from above answers if needed:
Your answer
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