personal information - nichols chiropractic...receiving chiropractic treatment. please ask questions...

Date_________________

Personal Information

Dr./Mr./Mrs./Ms./Miss

_____________________________________________________________________________________

Last Name First Name Middle Initial Nick Name

______________________________________________________________________________________________

Address City State Zip Code

Cell Phone _________________________________ Home Phone _____________________________________

E-mail _______________________________________________________________ (Will not be shared)

Social Security No. _____________________________ Date of Birth _______________________________

Occupation ____________________________________ Employer___________________________________________

Person to contact in an emergency ___________________________________Phone_____________________________

Primary Care Physician ________________________Name of Primary Care Office______________________________

How did you hear about us? _________________________________________________________________________ (Please be specific, so we can thank them for their referral!)

Responsible Party

Name of person responsible for payment of this account ____________________________________________________

Relationship to patient __________________________________________ Phone _______________________________

__________________________________________________________________________________________________

Address (if different than patient address) City State Zip Code

May we contact this person for account/payment information? Y / N

Please list your chief complaints in order from most urgent to least urgent:

CC - Chief Complaints/Problems:

1. ________________________________________

When did you first notice this occurring?___________________________________________________

What makes this better or worse?_________________________________________________________

Thoughts on possible causes_____________________________________________________________

2. _________________________________________




Date: __________ Last Name: __________________________________________ First Name: ________________________________ MI: _____ Pg. 2

3. ___________________________________________




4. ____________________________________________




5. ____________________________________________




Are You Taking Any Medications? ____ NO - Currently NOT taking any medications.

YES - Currently taking the following:

___ Anacin

___ Acid Blocking Drugs

___ Anti-anxiety medications

___ Antibiotics

___ Anticonvulsants

___ Antidepressants

___ Anti-fungals

___ Anti-inflammatory

___ Aspirin

___ Asthma inhalers

___ Advil

___ Beta blockers

___ Birth control pills

___ Bufferin

___ Chemotherapy

___ Cholesterol lowering

___ Contraceptives implants

___ Cortisone/steroids

___ Diabetic medications

___ Diabetic insulin

___ Diuretics

___ Estrogen or progesterone (pharmaceutical, prescription)

___ Estrogen or progesterone (natural)

___ Heart medications

___ High Blood Pressure

___ Ibuprofen

___ Immune booster meds

___ Laxatives

___ Motrin

___ Muscle Relaxants

___ Pain Relievers

___ Relaxants/Sleeping pills

___ Seizure medications

___ Stroke prevention meds

___ Testosterone (natural or prescription)

___ Thyroid medication

___ Tylenol (Acetaminophen)

___ Ulcer medications

___ Viagra/Cialis (or similar)

Other Medications: ____________________________________________________________________


Have you had any root canals or dental work (List and describe):

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Previous Surgeries (including implants or replacement surgeries):

__________________________________________________________________________________________

__________________________________________________________________________________________

Supplements: List all vitamins, minerals, herbs and any other nutritional supplements you are taking:

__________________________________________________________________________________________

__________________________________________________________________________________________

Known Food or Drug Allergies:

__________________________________________________________________________________________

__________________________________________________________________________________________

Discussion: tell me the activity you would like to do, but can’t, because of your clinical condition:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

What are you hoping from today’s visit?

__________________________________________________________________________________________

__________________________________________________________________________________________

Known history of infections or illnesses (chronic or acute) that could be causing issues?

__________________________________________________________________________________________

__________________________________________________________________________________________


Please identify specific goals you would like to achieve from care:

__________________________________________________________________________________________

__________________________________________________________________________________________

Comments or additional concerns of the patient:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Authorization: I certify that I have read and understand the above information to the best of my knowledge. I understand that providing incorrect

information can be hazardous to my health. I authorize this office to perform an examination and recommended treatment at this time

and release any information including the diagnosis and records of any examination or treatment rendered to me or my child during

the period of such care to third party payers. I agree to be responsible for payment of all services rendered on my behalf or my

dependents.

Patient Signature_________________________________________________________Date_______________________

(Signature of parent/guardian if the patient is a minor)

I understand Functional Medicine is cash pay (non-covered by insurance). Therefore I agree to not submit Functional Medicine claims to insurance.

Patient Signature_________________________________________________________Date_______________________

(Signature of parent/guardian, if the patient is a minor)

N i c h o l s C h i r o p r a c t i c , P A

E - m a i l a n d T e x t ( S M S ) M e s s a g i n g I n f o r m e d C o n s e n t

Nichols Chiropractic may communicate with the patient through e-mail or text message. I am aware that by

communicating via e-mail or text message, there are various confidentiality risks and other issues that may arise.

I understand all e-mail messages sent over the internet that are not encrypted are not secure and may be seen by

others. I understand my e-mail communications with Nichols Chiropractic are not encrypted; thus, neither Nichols

Chiropractic nor the provider can guarantee the confidentiality and security of any information sent to them or

that they send out. Further, I understand text messages are less secure than e-mail messages and the same

conditions apply.

I understand sending personal information via e-mail or text message is not recommended. This includes

information concerning current or past symptoms, conditions, treatment, or identifying information such as social

security numbers and insurance documentation.

I understand Nichols Chiropractic will limit text messages to brief notifications regarding scheduling.

I understand Nichols Chiropractic may e-mail me information regarding my treatment. I consent to receive such

information via e-mail.

I understand e-mail and text messaging should not be used for urgent or sensitive matters as technical or other

factors may prevent a timely response. I understand if I use e-mail or text messaging to make or request

scheduling changes it is my responsibility to confirm that Nichols Chiropractic has received my communication

more than 24 hours before the appointment time being changed. If I believe a response is necessary within 48

hours, I will not use e-mail or text messaging, but will call Nichols Chiropractic. If I do not receive a response to

an e-mail or text message within two working days, I understand that I should call Nichols Chiropractic.

I understand e-mail and text messaging communications may be made part of my permanent medical record and

will be accessible to anyone given access to those records. I understand I may withdraw permission for Nichols

Chiropractic to communicate with me via e-mail or text messaging by notifying them in person.

_________________________________ ____________________________________

Patient Name Printed Patient Signature

__________________________________________

Parent/Guardian Signature (if patient is a minor)

___________________________________________

Date

N i c h o l s C h i r o p r a c t i c , P A Nichols Chiropractic may need to use my name, address, phone number, and clinical records to contact me with

appointment reminders, information about treatment alternatives, or other health related information that may be of

interest. If this contact is made by phone and there is no answer, a message will be left on the answering service or with the person left responsible. I understand that I am giving Nichols Chiropractic the authorization to contact me with these

reminders and information.

My signature on this form restricts the individuals or organizations to which my health care information is released: 1)

individuals involved in my care or payment for my care; 2) health oversight authorized by law (activities necessary for

government to monitor health care systems such as audits, inspections, etc); 3) national security; 4) public health risks;

and 5) court order.

I understand information that Nichols Chiropractic will use or disclose based on the authorization I am giving may be

subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by the federal privacy rules.

I understand in the case that I am required to give authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

I understand I have the right to refuse to give Nichols Chiropractic this authorization. I understand if I choose not to give

Nichols Chiropractic authorization through signing this document, services will not be provided. I may inspect or copy the information that Nichols Chiropractic will use to contact me with appointment reminders, information about treatment

alternatives, or other health related information at any time.

This notice is effective as of June 20, 2005 and will expire seven years after the date in which I last received services from

Nichols Chiropractic.

I authorize Nichols Chiropractic to use or disclose my health information in the manner described above. I also understand that I may receive a copy of this form at my request.

I give my consent to the performance of an examination, conservative chiropractic treatment, and physical medicine modalities to the joints and associated soft tissues of the body. This may include physical therapies considered

investigational by my insurance provider and not cleared by the FDA. Such physical therapies include electric muscle

stimulation, herb formulary, and natural supplementation. I acknowledge that no guarantee has been made to me regarding the outcome of these procedures.

Patient Signature_______________________________ Date_________________

I understand Functional Medicine is cash pay (non-covered by insurance). Therefore I agree to not submit Functional Medicine claims to insurance.

Patient Signature______________________________ Date___________________

I n f o r m e d C o n s e n t f o r C h i r o p r a c t i c C a r e

Patient Name:

Please read this entire document prior to signing. It is important to understand the information contained in this document before

receiving chiropractic treatment. Please ask questions before signing if there is anything that is unclear.

The Nature of the Chiropractic Adjustment

The primary treatment used by a Doctor of Chiropractic is spinal manipulative therapy. The provider may use their hands or a

mechanical instrument upon the body in such a way as to move the joints. That may cause an audible “pop” or “click,” much

like the experience when “cracking” the knuckles. The patient may feel a sense of movement.

Analysis/Examination/Treatment

As a part of the analysis, examination, and treatment, I am consenting to the following procedures: spinal manipulative therapy, range of motion testing, muscle strength testing, palpation, orthopedic testing, postural analysis, vital signs, basic

neurological testing, radiographic studies, and therapeutic modalities (EMS, ultrasound, hot/cold therapy, iTrac, etc.).

The Material Risks Inherent in Chiropractic Manipulation

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and

therapy. These complications include but are not limited to: fracture, disc injuries, dislocations, muscle strains/sprains,

cervical myelopathy, and cost-vertebral strains and separations. Some types of manipulation of the neck have been associated

with injuries to the arteries in the neck leading to or contributing to serious complications, including stroke. Some patients

will feel some stiffness and soreness following the first few days of treatment. The provider will make every reasonable effort

during the examination to screen for contraindications to care; however, if I have a condition that would otherwise not come

to attention, it is my responsibility to inform the provider prior to treatment.

The Probably of Those Risks Occurring

Fractures are rare occurrences and generally result from some underlying weakness of the bone which the provider will check

for during the taking of your history and during examination and/or x-ray. Stroke has been the subject of tremendous

disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in

five million cervical adjustments. The other complications are also generally described as rare.

The Availability and Nature of Other Treatment Options

Other treatment alternatives may include but are not limited to:

Self-administered, over-the-counter analgesics and rest

Medical care and prescription drugs such as anti-inflammatory, muscle relaxants, and pain-killers

Hospitalization

Surgery

I understand by choosing any of the above noted “other treatment” options, there are risks and benefits of such options that

should be discussed with my primary care physician.

The Risks and Dangers Attendant to Remaining Untreated

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further

reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is

postponed.

Nichols Chiropractic, PA reserves the right to change or modify these terms and conditions at any time.

I have read or have had read to me the above explanation of the chiropractic manipulation and related treatment. I have discussed it

with the provider and have had my questions answered to my satisfaction. By signing below I have weighed the risks involved in

undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended.

Date:

Patient Signature

Patient/Guardian Signature (if patient is a minor)

Name: ___________________________________________ Age: ______ Sex: _____ Date: ____________________ PART I Please list your 5 major health concerns in order of importance:1. ____________________________________________ 4. ___________________________________________ 2. ____________________________________________ 5. ___________________________________________3. ____________________________________________

PART II Please circle the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Metabolic Assessment Formtm

Symptom groups listed on this form are not intended to be used as a diagnosis of any disease or condition.

Category I Feeling that bowels do not empty completely Lower abdominal pain relieved by passing stool or gas Alternating constipation and diarrhea Diarrhea Constipation Hard, dry, or small stool Coated tongue or “fuzzy” debris on tongue Pass large amount of foul-smelling gasMore than 3 bowel movements daily Use laxatives frequently

Category II Increasing frequency of food reactions Unpredictable food reactions Aches, pains, and swelling throughout the body Unpredictable abdominal swellingFrequent bloating and distention after eating Category III Intolerance to smellsIntolerance to jewelryIntolerance to shampoo, lotion, detergents, etcMultiple smell and chemical sensitivitiesConstant skin outbreaks Category IV Excessive belching, burping, or bloatingGas immediately following a mealOffensive breathDifficult bowel movementsSense of fullness during and after mealsDifficulty digesting proteins and meats; undigested food found in stools

Category VStomach pain, burning, or aching 1-4 hours after eatingUse of antacidsFeel hungry an hour or two after eatingHeartburn when lying down or bending forwardTemporary relief by using antacids, food, milk, or carbonated beveragesDigestive problems subside with rest and relaxationHeartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine

Category VI Difficulty digesting roughage and fiberIndigestion and fullness last 2-4 hours after eatingPain, tenderness, soreness on left side under rib cageExcessive passage of gasNausea and/or vomitingStool undigested, foul smelling, mucus like, greasy, or poorly formedFrequent loss of appetite

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 3

Category VIIAbdominal distention after consumption of fiber, starches, and sugarAbdominal distention after certain probiotic or natural supplementsDecreased gastrointestinal motility, constipationIncreased gastrointestinal motility, diarrheaAlternating constipation and diarrheaSuspicion of nutritional malabsorptionFrequent use of antacid medicationHave you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?

Category VIII Greasy or high-fat foods cause distressLower bowel gas and/or bloating several hours after eatingBitter metallic taste in mouth, especially in the morningBurpy, fishy taste after consuming fish oilsUnexplained itchy skinYellowish cast to eyesStool color alternates from clay colored to normal brownReddened skin, especially palmsDry or flaky skin and/or hairHistory of gallbladder attacks or stonesHave you had your gallbladder removed?

Category IX Acne and unhealthy skinExcessive hair lossOverall sense of bloatingBodily swelling for no reasonHormone imbalancesWeight gainPoor bowel functionExcessively foul-smelling sweat

Category XCrave sweets during the dayIrritable if meals are missedDepend on coffee to keep going/get startedGet light-headed if meals are missedEating relieves fatigueFeel shaky, jittery, or have tremorsAgitated, easily upset, nervousPoor memory, forgetful between mealsBlurred vision

Category XIFatigue after mealsCrave sweets during the dayEating sweets does not relieve cravings for sugarMust have sweets after mealsWaist girth is equal or larger than hip girthFrequent urinationIncreased thirst and appetiteDifficulty losing weight

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 3 Yes No

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

Category XII Cannot stay asleepCrave saltSlow starter in the morningAfternoon fatigueDizziness when standing up quicklyAfternoon headachesHeadaches with exertion or stressWeak nails

Category XIIICannot fall asleepPerspire easilyUnder a high amount of stressWeight gain when under stress Wake up tired even after 6 or more hours of sleepExcessive perspiration or perspiration with little or no activity

Category XIV Edema and swelling in ankles and wristsMuscle crampingPoor muscle enduranceFrequent urinationFrequent thirstCrave saltAbnormal sweating from minimal activityAlteration in bowel regularityInability to hold breath for long periodsShallow, rapid breathing

Category XVTired/sluggishFeel cold―hands, feet, all overRequire excessive amounts of sleep to function properlyIncrease in weight even with low-calorie dietGain weight easilyDifficult, infrequent bowel movementsDepression/lack of motivationMorning headaches that wear off as the day progressesOuter third of eyebrow thinsThinning of hair on scalp, face, or genitals, or excessive hair lossDryness of skin and/or scalpMental sluggishness

Category XVIHeart palpitationsInward tremblingIncreased pulse even at restNervous and emotionalInsomnia

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 3 0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3 0 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Yes No Yes No Yes No Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

_______ years Yes No0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Category XVI (Cont.) Night sweatsDifficulty gaining weight

Category XVII (Males Only)Urination difficulty or dribblingFrequent urinationPain inside of legs or heelsFeeling of incomplete bowel emptyingLeg twitching at night

Category XVIII (Males Only)Decreased libidoDecreased number of spontaneous morning erectionsDecreased fullness of erectionsDifficulty maintaining morning erectionsSpells of mental fatigueInability to concentrateEpisodes of depressionMuscle sorenessDecreased physical staminaUnexplained weight gainIncrease in fat distribution around chest and hipsSweating attacksMore emotional than in the past

Category XIX (Menstruating Females Only)PerimenopausalAlternating menstrual cycle lengthsExtended menstrual cycle (greater than 32 days)Shortened menstrual cycle (less than 24 days)Pain and cramping during periodsScanty blood flowHeavy blood flowBreast pain and swelling during mensesPelvic pain during mensesIrritable and depressed during mensesAcneFacial hair growthHair loss/thinning

Category XX (Menopausal Females Only)How many years have you been menopausal?Since menopause, do you ever have uterine bleeding?Hot flashesMental fogginessDisinterest in sexMood swingsDepressionPainful intercourseShrinking breastsFacial hair growthAcneIncreased vaginal pain, dryness, or itching

PART IIIHow many alcoholic beverages do you consume per week? How many caffeinated beverages do you consume per day? How many times do you eat out per week? How many times do you eat raw nuts or seeds per week?List the three worst foods you eat during the average week:List the three healthiest foods you eat during the average week:PART IVPlease list any medications you currently take and for what conditions:

Please list any natural supplements you currently take and for what conditions:

Rate your stress level on a scale of 1-10 during the average week:How many times do you eat fish per week?How many times do you work out per week?

© 2015 Datis Kharrazian. All Rights Reserved.SMGEMAF(122215)Version 3

personal information - nichols chiropractic...receiving chiropractic treatment. please ask questions...

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