CONFIDENTIAL PATIENT INFORMATION

CURRENT HEALTH CONDITIONS

YOUR HEALTH GOALS

First Name:

SS#: - -

Marital Status:

Street Address:

City:

Email:

Emergency Contact:

How did you hear about us?

Who is your primary care physician?

Date and reason for your last doctor visit:

Are you also receiving care from any other health professionals? Yes No

- If yes, please name them and their specialty:

Please note any significant family medical history:

Last Name:

DOB: / /

# of Children:

Cell Phone: - -

Emergency Relation:

Date: / /

Sex: M F

Occupation:

Height: ft. in.

Weight: lbs.

Other Phone: - -

Emergency Phone: - -

State: Zip:

What health condition(s) bring you into our office?

Have you received care for this problem before? Yes No

- If yes, please explain:

When did the condition(s) first begin?

How did the problem start? Suddenly Gradually Post-Injury

Is this condition: Getting worse Improving Intermittent Constant Unsure

What makes the problem better?

What makes the problem worse?

Your top three health goals:

1.

2.

3.

Dynamic Life Chiropractic Page 1 of 4

TRAUMAS: Physical Injury History

TOXINS: Chemical & Environmental Exposure

ACKNOWLEDGEMENT & CONSENT:

Please rate your CONSUMPTION for each:

Please rate your STRESS for each:

CHIROPRACTIC HISTORY

THOUGHTS: Emotional Stresses & Challenges

What would you like to gain from chiropractic care? Resolve existing condition(s) Overall wellness Both

Have you ever visited a chiropractor? Yes No If yes, what is their name?

What is their specialty? Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based Other:

Do you have any health concerns for other family members today?

Have you ever had any significant falls, surgeries or other injuries as an adult? Yes No- If yes, please explain:

Notable childhood injuries? Yes No If yes, please explain:

Youth or college sports? Yes No If yes, list major injuries:

Any auto accidents? Yes No If yes, please explain:

Exercise Frequency? None 1-2x per week 3-5x per week DailyWhat types of exercise?

How do you normally sleep? Back Side Stomach Do you wake up: Refreshed and ready Stiff and tired

Do you commute to work? Yes No If yes, how many minutes per day?

List any problems with flexibility. (ex. Putting on shoes/socks, etc.)

How many hours per day you typically spend sitting at a desk or on a computer, tablet or phone?

Please list any drugs/medications/vitamins/herbs/other that you are taking, and why.

Alcohol

Water

Sugar

Dairy

Gluten

Processed Foods

Artificial Sweeteners

Sugary Drinks

Tobacco Products

Recreational Drugs

None Moderate High None Moderate High

Home

Work

Life

Money

Health

Family

None Moderate High None Moderate High

Date:Patient Name:

 

/ /

Dynamic Life Chiropractic

Patient Signature:

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Dynamic Life Chiropractic(817) 912-1392

1230 N Kimball Ave Ste 140B Southlake, TX 76092www.DynamicLifeSouthlake.com

Patient Review of Systems

THE NERVOUS SYSTEM CONTROLS AND COORDINATES ALL ORGANS AND STRUCTURES OF THE HUMAN BODY

Patient Name:

Please check the corresponding boxes for each symptom or condition you have experienced – including both past and present.

REGIONS FUNCTIONS SYMPTOMS

Cervical

• Autonomic Nervous System

• ENT System

• Vision, Balance & Coordination

• Speech

• Immune System

• Digestive System

• Nerve Supply to Shoulders, Arms & Hands

• Sympathetic Nucleus

• Metabolism

Colic & Excessive Crying Epilepsy & Seizures

Ear & Sinus Infections Sensory & Spectrum

Allergies & Congestion ADD / ADHD

Immune Deficiency Focus & Memory Issues

Headaches & Migraines Anxiety & Stress

Vertigo & Dizziness Balance & Coordination

Sore Throat & Strep Speech Issues

Swollen Tonsils & Adenoids TMJ / Jaw Pain

Vision & Hearing Issues Stiff Neck & Shoulders

Low Energy & Fatigue Depression

Difficulty Sleeping High Blood Pressure

Pain, Numbness & Tingling in Arms to Hands

Poor Metabolism & Weight Control

Upper Thoracic

• Upper G.I.

• Respiratory System

• Cardiac Function

Reflux / GERD Bronchitis & Pneumonia

Chronic Colds & Cough Functional Heart Conditions

Asthma

Mid Thoracic

• Major Digestive Center

• Detox & Immunity

Gallbladder Pain / Issues Indigestion & Heartburn

Jaundice Stomach Pains & Ulcers

Fever Blood Sugar Problems

Lower Thoracic

• Stress Response

• Filtration & Elimination

• Gut & Digestion

• Hormonal Control

Behavior Issues Allergies & Eczema

Hyperactivity Skin Conditions / Rash

Chronic Fatigue Kidney Problems

Chronic Stress Gas Pain & Bloating

Lumbar, Sacrum & Pelvis

• Lower G.I. (Absorption & Motility)

• Gut-Immune System

• Major Hormonal Control

Constipation Sciatica & Radiating Pain

Chrohn’s, Colitis & IBS Lumbopelvic / SI Joint Pain

Diarrhea Hamstring Tightness

Bed-wetting Disc Degeneration

Bladder & Urination Issues Leg Weakness & Cramps

Cramps & Menstrual Issues Poor Circulation & Cold Feet

Cysts & Endometriosis Knee, Ankle & Foot Pain

Infertility Weak Ankles & Arches

Impotency Lower Back Pain

Hemorrhoids Gluten & Casein Intolerance

PAST

PRES

ENT

PAST

PRES

ENT

Date:

Dy n a m i c Li f e Ch i r o p r a c t i c

Patient Signature:

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Informed Consent for Chiropractic CarePlease read this entire form and ask any questions prior to signing it.

Chiropractic Care: I hereby request and consent to the performance of chiropractic procedures including adjustments, various modes of physical therapy, diagnostic X-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by Dr. Beatty and/or other licensed doctors of chiropractic and/or any of the support staff who now or in the future treat me while employed by, working or associated with, or serving as back-up for Dr. Beatty, including those working at Dynamic Life or any other place associated with Dynamic Life, whether signatories to this form or not. Additionally, I have had an opportunity to discuss with Dr. Beatty and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures.

Potential Risks: I understand, and I’m informed that, as is will all Healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand, and I am informed, that in the practice of chiropractic there are some risks of treatment, including but not limited to: muscle spasm, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes (CVA), dislocations and sprains. I understand the risks due to chiropractic treatments have been labeled as “rare” and the probability of adverse reaction due to ancillary procedures is also considered “rare”. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during care which the doctor feels at the time, based upon the facts known, is in my best interests.

Potential Benefits: I understand that the vast majority of chiropractic patients tend to achieve good to excellent improvement in their physical conditions with chiropractic care. Improvement can be measured in many ways including: reduction in pain, increased range of motion, reduced stiffness, increased athletic performance, and list goes on. I understand that each person achieves different results and/or benefits from chiropractic care, different people have pre-existing conditions and are of different ages and occupations (with varied kinds of physical stress). I understand that my situation is unique, and no guarantees are given. I understand that Dynamic Life does not treat or cure any disease, but instead, has the sole purpose restoring proper bio-mechanical alignment to the joints of the spine and extremities though the form of adjustments. These adjustments promote proper nerve function allowing the brain to better communicate with the body, without interference, which allows the body to function at a higher level and heal on its own at the best of its ability.

Alternatives to Chiropractic Care: I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options may include: rest, acupuncture, physical therapy, steroid injections, medical care, medications (both over-the-counter and prescribed), hospitalizations, bracing, surgery, and others. I understand and have been informed that I have the right to a second opinion and to secure other options if I have concerns as to the nature of my symptoms and treatment options. If you chose to use other treatment options, you should discuss the risks and benefits with your medical doctor or other health care provider.

Financial Responsibility: I understand that Dynamic Life operates as a cash only office and does not accept any insurance. I understand and agree that I am personally responsible for payment of any services rendered to me (or to the patient named below, for whom I am legally responsible) and that payment is due at the time of service. I understand that there are no refunds for services already rendered and that if I terminate my care and treatment, any fees for services already rendered to me (or to the patient named below, for whom I am legally responsible) will be immediately due and payable. I understand that I can prepay for chiropractic services and that I am entitled to a complete refund for any care that I have not yet received.

Notice of Privacy Practices: We at Dynamic Life are very concerned with protecting your personal health information. There may be times our office may need to contact you to discuss information about your personal health information (P.H.I.) or other various reasons. By signing below, you have authorized this office to contact you in the following manners: phone (work/home/mobile), text message (or 3rd party messenger service), e-mail and regular mail. Messages may be left on an answering devise or voice-mail, or with the person answering your phone. Also, in accordance with HIPAA, this office will provide you a copy of the office privacy policies and procedures upon request. This document outlines the use and limitations of the disclosure of your P.H.I. and your rights as a patient. By signing below, you acknowledge that you have been offered a copy of this document.

Agreement: I have read, or have had read to me, all the above statements and consents and have had an opportunity to ask questions about its content. By signing below, I am stating that I understand and consent to all the above-named statements and agree to begin chiropractic procedures. I intend for 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 as well as for preventative care.

___________________________________________________________ ______________________________________________________ ___________________Patient Name (print) Patient Signature Date

_________________________________________________ _____________________ _________________________________________ ___________________Parental / Guardian Name (print) Relationship to Patient Parental / Guardian Signature Date

______________________________________________________ ___________________ Dr. Beatty Signature Date

Pregnancy Release (female patients only): This is to certify to the best of my knowledge I am not pregnant, and Dr. Beatty and his associates have my permission to perform X-ray evaluation on me. I have been advised that X-rays can be hazardous to an unborn child.

Date of last menstrual period: ____________________________

_________________________________________ ___________________Patient Signature Date