Please Take a Few Moments to Fill in Your Information

Date ______

Welcome to Brookside Chiropractic

Please take a few moments to fill in your information.

Name ______

Street Address ______

City______State ______Zip ______

Date of Birth ______Height ______Weight ______

E-mail address ______

Home Phone # (______) - _____ - ______

Work Phone # (______) - _____ - ______

Cell Phone # (______) – _____ - ______May we send you text appt reminders? Yes/No

Job Profession ______

Do you have children? Yes or No If so, how many? ______

How did you hear about us at Brookside Chiropractic?

______

In an emergency, whom do we contact?

Name ______Relation ______

Phone number(s) ______

What are your primary goals in coming to Brookside Chiropractic?

1. ______

2. ______

3. ______

As each patient is unique, so are their needs. In order to best serve you, how would you best describe your needs (please select one):

My time is very important to me. I am here for the services provided not the

details of why they are being done.

I like to understand why I’m feeling the way I do, but don’t like a lot of detail.
I like the additional time spent to help me best understand what’s going on with my body and all that can be done to transform my health to its optimum.

What problems are you experiencing today? ______

______

Any car accident related problems? Yes or No

If yes, please describe: ______

Have you ever seen a chiropractor before? Yes or No If yes, who?______

Nature of problem you were treated for? ______

Approximate date of last visit? ______

Are you currently under care for any reason with another doctor? Yes or No

If yes, what for? ______

Doctor’s Name ______

Have you had X-rays in the past 6 months? ______If yes, what for? ______

Are you currently taking any medications? Yes or No

If yes, please list all medications, vitamins or minerals you are presently taking:

______

Which of the following affect your problem?

Better / Worse
Moving
Sitting
Standing
Lying down
During the Night
First thing in the morning
During exercise
With meals

Please Mark area of Discomfort Below

What is the intensity of your pain today, on a scale from 0 to 10,

0 = no pain, 10 = the worst pain you can imagine ______

Have you unexplainably lost or gained weight in the past 5 years?

Gained ______Lost ______Current Weight ______

Do you Exercise on a regular basis? ______If so, how many days per week? ______

List any major traumas, car accidents, falls, and/or injuries along with approximate dates:

______

List any major diseases along with approximate dates:

______

List any major surgeries along with approximate dates:

______

List any major dental work along with approximate dates:

______

Please mark the following as they apply to you:

Daily / Weekly / Monthly / Never
Alcohol
Soft Drinks or Energy Drinks (Pop, Red Bull, etc)
Dairy (ice cream, cheese, milk, yogurt)
Caffeine Drinks (Tea, Coffee)
Drugs
Water
Preprocessed or Fast-Food
Grains (Bread, pasta, cereal, other)

What foods disagree with you? ______

Do you have indigestion? ______If yes, explain ______

What did you eat yesterday?

BREAKFAST ______

LUNCH ______

DINNER ______

SNACKS ______

Has this been you average diet for the past 3 to 5 years? _____ If no, how long? ______

Please mark any conditions that you have had in the past or currently have:

Allergies

Alcoholism

Anemia

Aneurysm

Arthritis

Asthma

Autoimmune Disease

Back Pain

Bleeding Disorders

Breast Lump

Bronchitis

Bruise easily

Bypass Surgery

Cancer

Cataracts

Chest pain

Cold extremities

Constipation

Coronary artery disease

COPD / Emphysema

Cramps (Abdominal / Muscle)

CVA (Stroke/TIA)

Dementia

Depression

Diabetes (Type I / II / Juvenile)

Digestion Problems

Dizziness

Epilepsy

Eye pain / Sensitivity to light

Fatigue

Frequent urination

Gallbladder disease / removal / stones

Glaucoma

Gout

Headaches

Heart Disease

Hemorrhoids

High Blood Pressure – Hypertension

Hives

Hot Flashes

Hypercholesterolemia

IBS (Irritable Bowel Syndrome)

Irregular Heart Beat

Irregular Menstrual Cycle

Kidney Infection

Kidney Stones

Liver Disease / Cirrhosis

Loss of Memory

Loss of Balance

Loss of Smell

Loss of Taste

Low Blood Pressure

Lung Disease

Macular Degeneration

Menstrual Problems

Migraines

Myocardial Infarction (Heart Attack)

Neuritis

Nosebleeds

Osteoporosis

Pacemaker

Parkinson’s Disease

Poor Posture

Prostate Trouble

Reflux

Retinal Disease

Sciatica

Seizures

Severe Neck / Spine injury

Shortness of Breath

Sinus Problems

Sleep Problems / Insomnia

Sneezing with Temperature change

Skin Problems / Sensitivity

Sleep Disorders

Smoking

Spinal Curvature / Scoliosis

STD

Stomach Problems

Stroke

Swelling of Ankles / Limbs

Swollen Joints

Thyroid Condition

Tuberculosis

Ulcers

Varicose Veins

Other ______

Brookside Chiropractic Fee Schedule

New Patient Consultation Fee$30

* This is a one-time, non-negotiable fee, which is NOT subject to insurance coverage.

Chiropractic Adjustment$50

* Insurance company prices vary based on the number of symptoms addressed. These fees are subject to change throughout the year. Based on your insurance company and plan, the amount of reimbursement also varies.

* If your insurance company does not reimburse for certain treatments, you are responsible for the fee.

Cranio-Sacral Technique (SOT) $30

* Low-force Chiropractic Adjusting Technique

Applied Kinesiology Treatment (Dr. Rachel)$15

* Appointments which include extensive nutrient testing or diet evaluation and exceed 20 minutes will be subject to this upcharge.

Functional Medicine Consultation$75

* This is the new patient fee for patients seeking nutrition and alternative medicine treatment options.

Class IV Laser Therapy Packages

1st Tx (existing patients)Free!

1st Tx (Laser Only New Patient)$40

3 Tx$99

6 Tx$195

10 Tx (Plus 1 Free!)$299

* Class IV Laser Therapy is NOT covered by insurance.

Brookside Chiropractic
2844 Krafft Rd

Fort Gratiot, MI 48059

(810) 385-8450

Consent to Chiropractic Services

I hereby request and consent to chiropractic manipulation and other procedures including various modes of physical therapy, diagnostic x-ray, or tests Dr. Rachel Brooks or

Dr. Travis Tourjee and their staff who now or in the future will treat me while employed by this office. I have had an opportunity to discuss with the doctor and/or with office personnel the nature and purpose of treatment indicated. I understand that results are not guaranteed and I 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, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and wish to rely on the doctor to exercise judgment during the course of any procedure which the doctor feels at the time is in my best interest. I have read, or have had read to me, the full above consent and have also had an opportunity to ask questions about its content and by signing below I agree to the above terms and procedures. I intend this consent to cover any treatment for my present condition and for any future conditions for which I seek treatment by this office and/or employed staff.

Signed ______Date______