• Intake Form

    Araza Chiropractic + Posture Rehab

  • Patient Information

    WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation. These methods have enabled our patients to achieve life changing results; even when many other systems have failed. Because of this specialized approach, we may not accept you as a patient until we are absolutely certain we know the cause of your condition, that we can perform the necessary tests to establish an optimal rehab program for you, and are completely confident we can help you recover your health. Please know if we do accept you as a patient, we will then make specific recommendations based upon our understanding that your health will become your TOP PRIORITY. Thank you again for applying as a patient in our clinic.
  • Date Completed

  • Patient Information

  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year
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  • Experience with Chiropractic

  • Have you Seen a Chiropractor before?*
  • Did your previous chiropractor take 'before' and 'after' x-rays?*
  • Did previous chiropractor recommend a specific course of treatment?*
  • Did previous chiropractor recommend a Home Health Care program?*
  • Last treatment date?
  • Are you aware of any poor posture habits?*
  • Is there any history of spinal problems in your family?*

  • Health Data

  • Draw on Image Where Pain is Located. You can draw dots, or add lines/arrows to indicate broader areas or movement. You may also erase your edits or use the forward and back arrows to edit. Write: A = Ache; B = Burning; D = Dull, N=Numbness, T=Tingling, ST=Stabbing SP=Spasms)

  • Pain Information

    To the best of your ability, fill out the below sections to indicate the type, location, during and behavior of your painful symptoms.
  • What type of pain is it? Select all that apply.*

  • Pain Scale

    Select your pain scale on the next few questions. 10 = broken leg; 0 = no pain
  • Current Pain: 1-10
  • Best in last four days: 1-10
  • Worst Pain in last four days: 1-10
  • Average Pain in last four days: 1-10
  • When did you start experiencing this problem?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever had this problem before?*
  • If yes, when was the first time you felt it?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this related to an accident or specific injury (other than auto or work-related)?*. *if your symptoms are the result of an auto accident or work-related injury, please ask the front-desk person for the corresponding application*
  • Is this problem:*
  • Does the pain vary in intensity?*
  • Does time of day affect pain? (i.e. pain is worse in the morning)*
  • Is the problem:*

  • Lifestyle Data

  • Do you exercise?*
  • What activities do you participate in?*

  • What is your diet style?*

  • Do you meditate/do breathing exercises?*
  • Do you do any spiritual practices?*
  • Do you journal?*
  • Do you write down your goals?*

  • Health Conditions

    Your spine is the foundation of health and core strength in your body. Shifts in the vertebrae or sections of the spine will spread ultimately causing weakness and distortion to AIL the areas of the spine. These distortions are reflected in abnormal posture. Research shows abnormal posture leads to chronic pain, disease and possibly a shortened life span.1 Please answer the following questions accurately so we may determine the full extent of your condition.
  • CERVICAL SPINE (NECK): Distortions here may cause any of the following. Please check NOW, if you are experiencing the pain now, and PAST for the past and mark BOTH if both apply:
    Rows
  • THORACIC SPINE (UPPER BACK). Select:
    Rows
  • THORACIC SHINE (MID BACK). Select:
    Rows
  • LUMBAR SPINE (LOW BACK). Select:
    Rows
  • Family Health History: please check if you or your family has experienced any of the following medical issues:*

  • Are you currently taking any medications? If yes, please list them below:

  • Pregnancy Release

    This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his associates have my permission to perform and x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
  • Today's date:

  • Authorization and Consent

  • I authorize and agree to allow the doctor and/or his designated staff to work with my spine or the spine of the person I represent through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration of normal bio-mechanical and neurological function. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of ail charges.

    The Doctor and/or his staff will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another healthcare practitioner, or are not related to the spinal structural conditions diagnosed at this clinic.

    I also dearly understand that if I do not follow the doctors and/or staff's specific recommendations at this clinic that I will not receive the full benefit from these programs; and that if I terminate my care prematurely that all fees incurred will be due and payable at that time.

    I confirm that all information given in this form is true, complete, and accurate. I released this organization for any responsibility in case of accident, illness, or injury. I acknowledge that no assurance was offered about the outcome. I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.

  • Date:
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