New Patient Intake Form - Grand Saline Chiropractic
Welcome to Grand Saline Chiropractic!
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Email *
Name *
Email *
Address *
Phone number *
Date of Birth
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Main Reason For Your Visit *
Please describe in as much detail as possible. Thank you.
What is the specific location of your main complaint? *
Tell us about the onset of your main complaint *
Check all that apply
Required
When did the problem start? (A day ago, week ago, several weeks ago, a month ago? Or a specific date?)
How Bad if your pain - 0 means no pain at all, 10 means you are in agony and must call an ambulance *
  • 0 = No pain.
  • 1 = Pain is very mild, barely noticeable. Most of the time you don't think about it.
  • 2 = Minor pain. It's annoying. You may have sharp pain now and then.
  • 3 = Noticeable pain. It may distract you, but you can get used to it.
  • 4 = Moderate pain. If you are involved in an activity, you're able to ignore the pain for a while. But it is still distracting.
  • 5 = Moderately strong pain. You can't ignore it for more than a few minutes. But with effort you can still work or do some social activities.
  • 6 = Moderately stronger pain. You avoid some of your normal daily activities. You have trouble concentrating.
  • 7 = Strong pain. It keeps you from doing normal activities.
  • 8 = Very strong pain. It's hard to do anything at all.
  • 9 = Pain that is very hard to bear. You can't carry on a conversation.
  • 10 = Worst pain possible.
What does your pain feel like? Check all that apply *
Required
If you have radiating pain, do you have it in
Check all that apply
Do you have weakness in *
Check all that apply
Required
How frequent is your pain? Check all that apply *
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Have you had this condition before? For example, if your back hurts, have you had back issues in the past? *
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If yes, please explain
What makes the pain worse? Please be specific like lifting things from the floor or reaching overhead *
Write NOTHING if nothing makes the pain worse.
What makes the pain better? Please be specific like stopping all activity or walking slowly *
Write NOTHING if nothing makes the pain better.
Have You Had Any Medical or Chiropractic Care for this complaint?
Clear selection
If Yes, Please Explain
Do you have any or do any of the following? Check all that apply *
https://www.ifompt.org/site/ifompt/International%20Framework%20for%20Red%20Flags%20for%20Potential%20Serious%20Spinal%20Pathologies%20master%20copy%20.pdf
Required
For Headache Only
What is your occupation? *
MEDICATIONS: Please list ALL your current medications. List the name, what it is for, the dose, the date (year) you started taking it, and how many times a day you take it. This includes any over the counter medications. *
Put NONE if you do not take any medications
DRUG INTERACTION CHECKERS
1. https://go.drugbank.com/drug-interaction-checker
2. https://www.drugs.com/drug_interactions.html
If you take more than one drug, then please use either of these Drug Interaction Checkers to see if there are any interactions between medications that you need to be aware of. 
SUPPLEMENTS: Please list all supplements
SURGERIES: Please list ALL prior surgeries with the dates of the surgery  *
Put NONE if you have not had any surgery
HOSPITALIZATIONS: Please list ALL prior hospitalizations with the dates and the reason *
Put NONE if you have not had any hospitalizations
If yes, please explain
Lifestyle - check all that apply
Have You Had Prior Chiropractic Care?
Clear selection
Family Medical History *
https://www.ncbi.nlm.nih.gov/books/NBK115506/
Required
INFORMED CONSENT - please read and check the box below *

To the Patient: Please read this entire document prior to your visit. It is important that you understand the information contained in this document. Please ask questions during your first visit if there is anything that is unclear.  This information is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or refuse to give your consent to treatment.

​Spinal Manipulation or “an adjustment:”

The primary treatment used by a Doctor of Chiropractic (DC) or chiropractor is spinal manipulation. Spinal manipulation is frequently referred to as “an adjustment.” I may apply an adjustment or multiple adjustments to different joints to treat you. I may apply a mechanical instrument to your body in such a way as to move your joints. Either may cause an audible "pop" or "click," much as you have experienced when you "crack" your knuckles. You may feel a sense of movement. You may feel a bit sore, stiff, or fatigued after an adjustment. This is normal. However, if you feel increased pain, sharp pain, or any other abnormal sensations, contact me immediately.

​Muscle and Myofascial Therapies:

I use hands on and instrument assisted muscle and myofascial therapies. Hands on muscle therapy can be a bit painful. The goal is to increase blood flow and relax the muscles. Instrument assisted therapy like Graston Technique may also be painful and may even leave bruising. This is also normal and varies greatly from patient to patient. I will discuss these with you prior to treatment.

​Exercise Therapy and Posture:

I will review posture, ergonomics, and give you home exercises to perform. These are all a very important part of your care. The exercises may make you sore and again, this is normal. If any of them cause you significant pain, stop the exercise and contact me.

​Risks

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation. Stroke and /or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote. This 2021 paper states, “cervical manipulation has been estimated to have a complication rate of 5-10 per 10 million spinal manipulations.” Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke.

​Additional complications include but are not limited to: fractures, disc injuries, dislocations, joint injury, muscle strains. Here is a recent paper discussing the efficacy of spinal manipulation and spine care. This 2021 paper states, “Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain.“

​Here is a 2019 paper discussing spinal manipulation and lower back care.

​Possible Contraindications to spinal manipulation include, but are not limited to:

*** If you have any of these it is your responsibility to inform me!

  • Active or prior history of cancer

  • Dislocations, fractures, or joint instability (like Ehlers-Danlos Syndrome)

  • Arthritis of any type

  • Bone weakening disorders like osteoporosis or infection

  • Bleeding disorders

  • Stroke

  • Head or Brain Injury (Concussion)

  • Neurological disorder

  • I ask you to be a partner in your care and keep an open mind and open dialogue throughout your treatment program. Thank you for trusting me with your care.

  • https://www.sciencedirect.com/science/article/abs/pii/S1878875021002606

  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8915715/

  • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6396088/

Required
Minor Consent
I hereby authorize Grand Saline Chiropractic, Steven M. Horwitz, DC and all assistants to administer any and all treatment as deemed necessary to my child. 
OFFICE POLICY

APPOINTMENTS 

Your appointment time is reserved for only you.  Our practice DOES NOT double book appointments.  24 hours notice is required should you need to cancel an appointment. You will be charged the full fee of your office visit should you fail to give 24 hours notice: $175 for a new patient, $75 for an office visit.  It is important that you be on time for your appointment.  If you are late, we will make every effort to see you, but it may not always be possible.  Your will still be responsible for your appointment fee if you are late. 

 PAYMENT POLICY

1. Payment is due at the time services are rendered. 

2. A $50 reprocessing fee will be charged to your account should any personal check fail to clear.

 TEXT AND EMAIL CONSENT

I do hereby authorize Grand Saline Chiropractic, Steven M. Horwitz, D.C. to communicate with me via text and email at the phone/text number and email address I have provided on my intake forms

 This office transmits patient protected health information electronically.

PLEASE TYPE YOUR NAME
Submitting this Patient Registration Form indicates that you have read, understand, and agree to the all the aforementioned policies, consents, terms, and conditions.
A copy of your responses will be emailed to the address you provided.
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