Morter Family Chiropractic Patient Intake

Morter Family Chiropractic Patient Intake
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number*
Work Phone Number
Cell Phone Number*
We use text messaging for appointment reminders. Who is your cell phone company?
Email*
example@example.com
Gender*

MaleFemaleN/A
Social Security Number*
Birth Date*

MonthDayYear
Age*
Occupation*
Employer Name and Address
Marital Status*

SingleMarried
Spouse's Name
Have you seen a Chiropractor before?*

YesNo
If yes, when?
Whom may we thank for referring you to our office?
Your Health Summary
Please check all symptoms you have ever had, even if they do not seem related to your current problem.*

HeadachesPins and Needles in the ArmDizzinessNumbness in FingersFatigueSleeping ProblemsDiarrheaCold SweatsMood SwingsPins and Needles in LegsLoss of SmellBuzzing in EarsNumbness in ToesDepressionNeck StiffnessConstipationLight Bothers EyesMenstrual PainFaintingBack PainRinging in EarsLoss of TasteIrritabilityCold HandsFeverProblem UrinatingMenstrual IrregularityNeck PainLoss of BalanceNervousnessStomach Upset
List any medications you are taking*
Functional Rating Index

For use with Neck and/or Back Problems only. To properly address your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities.
Pain Intensity

No PainMild PainModerate PainSevere PainWorst Possible Pain
Sleeping

Perfect SleepMildly Disrupted SleepModerately Disrupted SleepGreatly Disrupted SleepTotally Disrupted Sleep
Personal Care (Washing, Dressing, Etc.)

No Pain; No RestrictionsMild Pain; No RestrictionsModerate Pain; Need to Go SlowlyModerate Pain; Need Some AssistanceSevere Pain; Need 100% Assistance
Traveling (Driving, Etc.)

No Pain on Long TripsMild Pain on Long TripsModerate Pain on Long TripsModerate Pain on Short TripsSevere Pain on Short Trips
Work

Can Do Usual Work Plus Unlimited Extra WorkCan Do Usual Work but No Extra WorkCan Do 50% of Usual WorkCan Do 25% of Usual WorkCannot Work
Recreation

Can Do All ActivitiesCan Do Most ActivitiesCan Do Some ActivitiesCan Do A Few ActivitiesCannot Do Any Activities
Frequency of Pain

No PainOccasional Pain; 25% of the DayIntermittent Pain; 50% of the DayFrequent Pain; 75% of the DayConstant Pain; 100% of the Day
Lifting

No Pain with Heavy WeightIncreased Pain with Heavy WeightIncreased Pain with Moderate WeightIncreased Pain with Light WeightIncreased Pain with any Weight
Walking

No Pain; DistanceIncreased Pain after 1.0 MileIncreased Pain after ½ MileIncreased Pain after ¼ MileIncreased with All Walking
Standing

No Pain after Several HoursIncreased Pain after Several HoursIncreased Pain After 1 HourIncreased Pain After ½ HourIncreased Pain with Any Standing
Informed Consent
We encourage and support a shared decision-making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informer in order that you can knowledgably give or withhold your consent.

Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health.

Adjustments are made by the chiropractors in order to correct or reduce spinal and extremity joint subluxation. Vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and/or does not move properly causing interference and/or irritation to the nervous system. The primary goal in chiropractic care is the removal and/or reduction of nerve interference caused by vertebral subluxation.

A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpitation, specialized instrumentation, radiological examination (x-rays), and laboratory testing.

The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. In addition, physiotherapy or rehabilitative procedures may be included in management protocol. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life.

In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them.

Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/ strain, and fracture. Risk associated with physiotherapy may include the preceding as well as allergic reaction and muscle of joint pain. In addition, there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of stroke. In essence, there is stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment.

I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risk, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment.
I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE MORTER FAMILY CHIROPRACTIC TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.
Dated This*

MonthDayYear
Date
Patient Signature*

Clear
Doctor Signature

Clear
Parental Consent for Minor Patient
Patient Name
Patient Age
DOB

MonthDayYear
Printed name of person legally authorized to sign for Patient
Relationship to the Patient
Authorized Signature

Clear
In addition, by signing below, I give permission for the above named minor patient to be managed by the doctor even when I am not present to observe such care.
Patient Name
Printed name of the person legally authorized to sign for Patient
Relationship to the Patient
Authorized Signature

Clear
HIPAA Privacy Practices
I acknowledge that I have received and /or have been given the opportunity to review this Chiropractic Office’s Notice of HIPAA Privacy Practices for protected health information.
Print Patient’s Name*
Patient Signature*

Clear
Date*

MonthDayYear
Consent to Treat a Minor: (Minor’s Printed Name)
Guardian / Spouse’s Signature Authorizing Care

Clear
Date

MonthDayYear
Should be Empty:

Morter Family Chiropractic Patient Intake

Your Health Summary

Functional Rating Index

Informed Consent

Parental Consent for Minor Patient

HIPAA Privacy Practices