Welcome to our office! It is well known that families who maintain strong healthy, well-aligned spines stay healthier in the long term. People whose spines are not kept in proper alignment are more likely to develop health disorders later in life such as arthritis, illness, loss of movement, function and vitality.
General information
Please provide some general information about yourself.
Personal details and contact informationName / ………………………………………………………….……. / Home Phone
Address / ………………………………..………………………..……..
…………………………………………………….…………. / Mobile &
Work Phone
Postcode / Occupation
E-mail / Birthdate & Age
Marital Status: / S M W D Sep.
Spouse Name
No. of Children
Health details – Please answer the following questions as thoroughly as possible. /
1. Most patients are referred to our office by a caring family member or friend. What made you decide to visit our office? please circle / Walked By Yellow Pages Sign Website Google Event ……………… Other - explain……………….
Friend Family Member Name…………………….…. /
2. Research shows that your spine should be checked regularly. How many times have you visited a chiropractor in your lifetime? / Enter number…………….. Never
Date of last adjustment…………………… /
3. Have you ever had a spinal examination or x-rays? Was it helpful? No Yes Why? / Never
When …………………………………….……..
Where…………………………………………..
Why ………………………………..………….. /
4. Have you ever been told that you have a spinal curvature, spinal arthritis, or inherited spinal problem? / No Yes What?
………………………………………………….. /
5. Spinal misalignments cause decay and degeneration which results in grinding or cracking. Do you ever hear noises when you move your head or neck? / No Yes /
6. Spinal misalignments can make you feel like you need to twist, stretch or crack your neck or back. Do you ever feel the need to crack or pop your neck or lower spine? / No Yes /
7. Poor posture leads to poor health and often indicates a spinal problem. How would you rate your posture? / Poor - 1 2 3 4 5 - Excellent /
8. Stress can cause or accelerate spinal damage. Rate your stress level over the last 90 days. / Low - 1 2 3 4 5 - High /
10. Prescription medications may cause various side effects, hide the severity of health problems and may interfere with your body's ability to heal. What medications are you currently taking? For what and for how long? / List medications . For what and for how long? ……………………………………………………………
…………………………………………………………… /
11. Auto, bike, sports and work accidents can cause serious spinal problems. Have you had any of these types of accidents? / No Yes
Date of Accident…………………………………….
What happened?...... /
12. Spinal health is especially important during pregnancy and can reduce labour delivery times. Is there any chance that you are pregnant? / No Yes /
13. Have you ever been diagnosed with a) cancer or b) diabetes? Please circle & explain / a) Type …………………..Year
b) Type …………………..Year /
14. If the doctor feels that chiropractic will help you, are you willing to follow his/her recommendations? / No Yes /
15. Do you have family members or friends who may benefit from chiropractic?
Please list their names and phone numbers so we can invite them to a complimentary spinal information class. / No Yes
Names …………………………………………..
………………………………………………….. /
Main health concerns
Tell us your main health concerns. If you are here for to maintain health and maximise the healing potential of your body then please skip to the next section.
Health Concerns (List according to Severity)Concern / For how long? / Rate Severity
Mild -1 2 3 4 5 -Severe / Constant
or intermittent? / Aggravated by what? / Relieved by what?
1
2
3
Do your health problems interfere with: (please circle all that apply)
Daily activities Walking Sitting Work Happiness Exercise Family life Sleeping
Relationships Playing with your children/grandchildren Sports Can’t do the things I want to do
Organ Function
Your spinal nerves control everything in your body including organs and muscles. Slight pressure on a nerve can decrease its function by 50%, affecting organ function, new cell production, immunity and your ability to heal. Please list any problems with your organs below and rate according to how it affects your life
(0= none 1 2 3 4 5= alot). Also list any family history of the problem.
Function / System / Problem and how long? / Does it affect daily life? 0=none 1 2 3 4 5=alot / Is there a family history & who?Breathing / Lungs
Digestion / Stomach
Circulation / Heart, Blood Pressure
Elimination / Intestines
Reproductive / Fertility
Urination / Kidneys / Bladder
Skin / Allergies
Frequent Colds / Infections
Fatigue / Insomnia
Mental / Anxiety
Depression
Cancer
Metabolism / Thyroid
Previous surgery
Have you had any surgeries? No Yes Please list all below:
Type / Date
1 Surgeries
2
3
Stress History: Please list the top three stresses in each category.
Physical Stress – traumas, accidents, falls, fractures, work posture, computer, lifting, physical activities, driving, sports injuries, picking up children, gardening, whiplash, car or bike accidents / 1.……………………………
2…………………………….
3…………………………….
Mental Stress – emotional and internal stresses like work, relationships, finances, worry, sickness, exams, family life, divorce, loss of loved one / 1.……………………………
2…………………………….
3…………………………….
Chemical Stress – stress that affects organs like smoking, junk foods, poor diet, caffeine, alcohol, drugs, pollution, prolonged use of medications / 1.……………………………
2…………………………….
3…………………………….
Daily Habits
Please circle or fill in
Exercise: / None Moderate Daily Heavy What type? How often do you exercise?
Work Habits: / Sitting Computer Standing Driving Light labor Heavy labor Other–please list below
Sleep Position: / Right Side Left Side Stomach Back Rate sleep quality – please circle below
Poor 1 2 3 4 5 Excellent
Explanation of Chiropractic and Consent to Chiropractic Care at Dancingspine Chiropractic
Chiropractic has one goal and that is to adjust subluxation in the spine to allow proper nerve flow. A subluxation is the misalignment of a spinal joint that blocks a nerve and prevents normal nerve flow, function, life and healing in the body. Proper nerve flow is essential for normal movement, growth, organ function, healing, immunity and life within the body.
A chiropractic adjustment is the specific application of the doctor’s hands on a subluxated or misaligned spinal bone to remove nerve interference.
When your body’s life force or nervous system is free of interference you have a better chance of expressing true health and your life potential. True health is the body’s ability to successfully adapt to every environmental challenge and involves a state of optimal physical, mental and social well being. Health is NOT the absence of symptoms or pain. Masking pain with painkillers or waiting for pain to disappear does not correct health problems or fix subluxations of the spine. The absence of pain or symptoms does not mean you are healthy. This has been verified by medical research as many health problems including cancer and arthritis begin silently and with no symptoms. I understand that there are some rare risks with chiropractic including soreness, rib fracture, muscle/ligament strain, although no scientific study has ever verified this. The risk of vertebral artery injury from chiropractic is so rare, it cannot be accurately calculated.
In this office, we do not offer to diagnose or treat any disease or condition other than subluxation of the spine. In this office, we do not offer treatments or cures for any diseases or conditions. Nor do we offer advice regarding treatment prescribed by others. If, during the course of a chiropractic care, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of medical specialist.
I, ______(Print name), have read and fully understand the above information. On this basis, I therefore consent to chiropractic care, including exams and adjustments, at Dancingspine Chiropractic. I have completed this form and answered all questions truthfully and to the best of my ability. I understand that chiropractic services and plans are non refundable.
Patient’s Signature ______Date ______
Doctor’s Use Only:
Date of Exam: ______Xrays: ______
Px? Acute Chron Cer UB Tho L L/R/B/C Rad? L/ R above/below knee/elbow Cerv Px L/R/B/C upp mid low Freq?
HA? Migr / Tens/ Subocc Time? am pm Onset?______Should Hand Knee Foot L /R/B Other______
ROM / C / Px / L / PxFlex
Ext
RR
LR
Rlat
Llat
Ears / Educ
Shoulders / ROF / 1 / 2 / 3 / 4
Iliac crest / Rec
Ishial tub / Ref
C 1 2 3 4 5 6 7 T 1 2 3 4 5 6 7 8 9 10 11 12 L 1 2 3 4 5 S RI LI Should Elbow Knee Ankle Hand Foot
______
Date of Exam: ______Xrays: ______
Px? Acute Chron Cer UB Tho L L/R/B/C Rad? L/ R above/below knee/elbow Cerv Px L/R/B/C upp mid low Freq?
HA? Migr / Tens/ Subocc Time? am pm Onset?______Should Hand Knee Foot L /R/B Other______
ROM / C / Px / L / PxFlex
Ext
RR
LR
Rlat
Llat
Ears / Educ
Shoulders / ROF / 1 / 2 / 3 / 4
Iliac crest / Rec
Ishial tub / Ref
C 1 2 3 4 5 6 7 T 1 2 3 4 5 6 7 8 9 10 11 12 L 1 2 3 4 5 S RI LI Should Elbow Knee Ankle Hand Foot
______
Date of Exam: ______Xrays: ______
Px? Acute Chron Cer UB Tho L L/R/B/C Rad? L/ R above/below knee/elbow Cerv Px L/R/B/C upp mid low Freq?
HA? Migr / Tens/ Subocc Time? am pm Onset?______Should Hand Knee Foot L /R/B Other______
ROM / C / Px / L / PxFlex
Ext
RR
LR
Rlat
Llat
Ears / Educ
Shoulders / ROF / 1 / 2 / 3 / 4
Iliac crest / Rec
Ishial tub / Ref
C 1 2 3 4 5 6 7 T 1 2 3 4 5 6 7 8 9 10 11 12 L 1 2 3 4 5 S RI LI Should Elbow Knee Ankle Hand Foot
1