The following forms and documents are used to better assist us in understanding your health concerns and specific needs. At the request of the clinician, the appropriate form(s) should be completed and returned to this office on your initial visit. Most patients will be requested to print out the first four documents; three of which must be completed and given to the practitioner, while the other document (Notice of Provider Privacy Practices) is for your records.
All of the following forms/documents require Adobe Acrobate Reader to view and print. If you don't have Adobe Acrobate Reader, please visit the following website for a FREE copy: www.Adobe.com.
This is the initial health form requested in order to assess your reason for visit, past medical/health history, healthy lifestyle habits, athletic/sports participation, expectations, and other particular information about your current health concern. We need this information because your answers will help us to determin if we can help you. If we do not sincerely believe your condition will respond satisfactory, we will not accept your case. In order to understand your condition properly, please be as comprehensive and accurate as possible while completing this form.
This doccument explains the risks and benefits of employing chiropractic care. While the risks associated with care through chiropractic has been listed as "rare" (less then that seen with taking an asprin), there are risks associated with any treatment modality. To be considered "informed," consent for care must provide you with both the associated risks and benefits and allow you to make the desision to pursue care. Read this form carefully before signing.
This is the the privacy policy which governs what we will do with any information you openly share with our office or that which we aquire through your evaluation and treatment. Please read the doccument carefully. Basically, we will not share your information with anyone unless you clearly inform us that we may do so or if ordered by a court of law.
The completion of this doccument signifies that you have been given and read the Notice of Provider Privacy Practices (see above). This form also allows you to declare to whom we may or may not share any of your health information. It is to your benefit to review the Notice of Provider Privacy Practices flier thoroughly before signing and returning this form.
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This form may be requested in place of the Confidential Patient Health Record for those who are seeking to employ classical homeopathic remedies in their care. Homeopathy is practiced in two very specific ways; classical and modern. While modern homeopathy uses combination remedies to effect a general cure, classical homeopathy attempts to match the individual with the "exact" symptom set seen with a specific remedy's provings. Classical homeopathy is very specific and quite effective, but can be a tedious process and therefore requires a thorough evaluation of a patient's history. This form will help facilitate that process.
This questionnaire is designed to assess your symptoms in light of your overall nutrition status. This form is not used as a sole means of providing a clinical disgnosis. When provided with a thorough clinical evaluation, however, it can be very helpful in identifying any underlying nutritional deficiencies or organ stress which may be benefited through various supplements.
This is a log for recording all of the different foods and drinks that you are ingesting for a given period. You can also record the various types of physical activity and exercise for which you are participating. Often we will request this information to better understand your current energy balance. We usually ask for you to maintain this log for a period of seven (7) days. You will want to be as accurate as possible while recording the requested information so we can have a better analysis of your nutritional and exercise needs.
This questionnaire is used to as a general assessment tool for your overall emotional state. Since much of our health is manifested in the degree of stress we are under, it is helpful for the clinician to have a good picture of this aspect of your health. If necessary we may recommend Bach Flower Remedies or other emotional support modalities for any issues that we may feel would otherwise hinder your full recovery.