• New Patient Application For Care

    Our mission is to empower individuals to regain control of their health and lives.

  • Patient Demographics

  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • History of Complaint

  • Please identify the health concern(s) that brought you to our office.*
    Rows

  • On a scale of 0 to 10 with ten being the worst pain and zero being no pain, rate your above complaints by selecting the appropriate number below

  •
  • When did the primary complaint begin?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • If YES when?
     - -
    2 digit month, 2 digit day, 4 digit year
  • How would you describe what your primary complaint feels like?*
  • Is your problem the result of ANY type of accident?*

  • Past Health History

  • Have you suffered with any of this or a similar problem in the past?*
  • When was the last episode?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Other forms of treatment tried?*
  • What were the results?
  • Have you had the COVID-19 infection?
  • Have you been diagnosed with Long COVID?
  • Have you had the COVID-19 vaccination?
  • If you have ever been diagnosed with any of the following conditions, please indicate in the table below:*
    Rows
  • Please identify all past and any current conditions:*
    Rows

  • Family History

  • Does anyone in your family suffer with the same condition(s)*
  • If Yes, Whom?
  • Check the conditions that apply to you or to any members of your immediate relatives:*

  • Review Of Systems

  • Check the symptoms that you're currently experiencing:*
  • Please check if you currently have or ever had any of the conditions below*

  • Social History

  • Do you use or do you have history of using tobacco?*
  • Do you use or do you have history of using illegal drugs?*
  • How often do you consume alcohol?*
  • Please identify how your current condition is affecting your ability to carry out activities that are routinely party of your life:*
    Rows
  • Are you currently taking any medication?*
  • Do you have any medication allergies?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Quadruple Visual Analogue Scale

    On a scale of 0 to 10 with ten being the worst pain and zero being no pain, answer the question pertaining to your primary complaint by selecting the appropriate number below
  •

  • Provider will calculate your score

    Score: Q1____+Q2____+Q4____=____/3x10=____(Low = 50)

  • X-Rays/Imaging Studies

    FEMALES ONLY: Please read carefully, check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our front desk staff for further explanation.
  • The first day of my last menstrual cycle was on:
     - -
    2 digit month, 2 digit day, 4 digit year

  • By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.

  • Informed Consent

  • Abundant Health Physical Medicine - Informed Consent: REGARDING: Medical Services, Chiropractic Adjustments, Modalities, Functional Medicine, Regenerative Medicine, Extracorporeral Shockwave Therapy, Aesthetic Procedures and Therapeutic Procedures: A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often minimal, complications such as sprain/strain injuries, irritation of a disc condition, dislocations of joints, and although very rare, fractures, and possible stroke (estimated to be related in one in one million to one in two million cervical adjustments), have been associated with chiropractic adjustments. Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Abundant Health Physical Medicine have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. I hereby acknowledge that Abundant Health Physical Medicine operates as a self-pay clinic, and I agree to be financially responsible for all services I receive at this office. I authorize Abundant Health Physical Medicine to utilize this application or copies thereof for administrative purposes related to my account. This acknowledgment does not in any way relieve me of payment liability, and I accept full financial responsibility for payment for services rendered.I have reviewed and accepted informed consent. 

  • HIPAA Personal Health Information Release

  • I, * herby authorize Abundant Health Physical Medicine to discuss with and/or release information to the following people concerning my appointments, insurance, billing, and health treatment rendered.

  • Restrictions*
  • Messages: (Please Call)*
  • If unable to reach me:*

  • I understand I may terminate this consent at any time by giving written notice to Abundant Health Physical Medicine. Any changes to this form will require a new consent to be completed, signed and dated.

  • Notice of Privacy Practices

    THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW TO ACCESS THIS INFORMATION. Please Review Carefully

  • Acknowledgement of Receipt of Notice of Privacy Practices

  • I acknowledge that I have reviewed the Notice of Privacy Practices of Abundant Health Physical Medicine.

  • (PLEASE INITIAL ONE OF THE FOLLOWING OPTIONS AND SIGN BELOW.)*
  • Should be Empty: