Advantage Health Center New Patient Application

Advantage Health Center New Patient Application

Chiropractic, Gut Health, Softwave, Vitamin Therapy
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number:*
Please enter a valid phone number.
Who/how were you referred to us:*
HOW CAN WE HELP YOU?
What brings you in?*

Please rate the impact of your symptoms on your life:*

	No Impact	Some Impact	Moderate Impact	Severe Impact
Work
Exercise
Recreation
Relationships
Sleep
Self Care
Energy
Attitude
Patience
Productivity
Creativity

How committed are you to correcting this issue?

1

2

3

4

5

6

7

8

9

10

1 is Not Committed, 10 is Very Committed
What are your immediate health goals? (What do you want to do right now?)
Please be specific
What are your short-term health goals? (What do you want to get back to?)
Please be specific
What are your long-term health goals? (What do you want to be able to do in the future?)
Please be specific
I am interested in further exploring the following services:*

ChiropracticSoftwaveVitamin TherapyGut HealthNeuropathyI already receive chiropractic care
HEALTH & ILLNESS QUESTIONAIRE

Accurate disclosure of this information helps us to make informed decisions regarding our recommendations for care.
Please check the box beside any condition that you have currently or have had:*

AlcoholismCancerCrohn's Disease or other intestinal disordersDiabetes MellitusChronic FatigueAutismSkin RashesStrokeNeuropathy/Nerve ProblemsHeadaches/MigrainesAbdominal bloating, cramps or gasChronic SinusitisLupusHashimotosAutismHivesAnemiaPMSIrritable Bowel SyndromeAsthmaArthritisHypothyroidismADD/ADHDGallbladder DiseaseEmotional Imbalance/DepressionUlcerative ColitisAllergiesFibromyalgiaHyperthyroidismEczemaKidney DiseaseHigh CholesterolFainting SpellsLiver DiseaseThyroid ProblemsKidney stonesMyasthenia GravisCerebral HemorrhageMyxedemaCurrent UTIOptic Nerve AtrophyLeber's DiseaseLow Blood PressureNone Listed

Do you have or have you had any of the below:

	Yes	No
Skin Infection
Cardiac Pacemaker
Cortisone Injection in the past month
Taking NSAIDS or anti-coagulant treatment
Bleeding Disorder
Organ Transplant
Dialysis
Blood Pressure Medication
Blood Thinner Medication
Gastric Bypass Surgery
Chemo-induced neuropathy

Are you pregnant, breastfeeding or planning to become pregnant?*

I am pregnantI am breastfeedingI plan to become pregnant in the near futureNA
Do you smoke or use tobacco products:

YesOccasionallyNever
Do you drink alcohol or consume THC products:

>2x/week<2x/weekRarelyNever
List all allergies and reactions (food and medication):*
List all medications and/or supplements you take:*
Who is your primary doctor:
GUT HEALTH QUESTIONNAIRE

In healthcare today, leaky gut aka intestinal permeability, isn't typically diagnosed. However, that doesn't mean it's not affecting your health. Many health issues related to gut health go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this section to help our doctors determine how we can help you get better results, faster!

Please rate each question:

	Never (0)	Sometimes (1)	Often(2)	Severe (3)
Constipation
Diarrhea
Abdominal pain or bloating
Mucous or blood in stool
Joint pain or swelling, arthritis
Chronic or frequent fatigue or tiredness
Food allergies, sensitivities or intolerances
Sinus or nasal congestions
Chronic or frequent inflmmation
Eczema, skin rashes or hives
Asthma, hay fever or airborne allergies
Confusion, poor memory, or mood swings
Use of NSAIDS (Aspirin, Tylenol, Motrin
History of antibiotic use
Alcohol consumption makes you feel sick
Gluten sensitivity or Celiac Disease
Nausea
Weight Concerns

CONSENT
I hereby give permission to AHC to use any pictures or video with my image for testimonial and marketing purposes:*

YESNO
Do you give AHC permission to communicate directly with your physician in order to collaborate and coordinate your care?*

Yes, I give permission to release known information and communicate with my doctorNo, AHC does not have my permission
Release of medical information: I hereby authorize Advantage Health Center to disclose my medical records to EMS, my spouse, and emergency contact listed below. I also authorize Advantage Health Center to discuss my care and share my medical information for the purpose of monitoring quality control or safety concerns.*

Clear
Softwave

ESWT (Extracorporeal Shockwave Therapy) also known as "The Stem Cell Machine" from the T.V. show: The Doctors.
Insurance companies do NOT deem this service medically necessary. Please sign below that you understand this statement. Risks of procedure: Petechia or mild bruising. This usually subsides without treatment. Pain and soreness may occur but usually resolve after a week. I undersigned, do herby consent to authorize the application of ESWT for my condition. I have been fully informed of the focal ESWT which it's use has been fully explained to me by my treating physician and staff. I full understand the nature of this treatment. I also have confirmed that I have been given the opportunity to discuss and clarify any concerns and no guarantees have been made to me mostly for pain and relief and improvement of function. I also understand foregoing treatment is not the first option for my condition and an alternate treatment has either been already provided or offered to me.*

Clear
Vitamin Therapy

Statement of person giving informed consent
My request for nutrient IV therapy as described is entirely voluntary and I have NOT been offered any inducement to consent. I understand that I may refuse treatment at any time.*

Yes
I understand that: 1. The procedure involves inserting a needle into a vein or muscle and injecting the prescribed solution 2. Alternatives to intravenous therapy/intramuscular injection are oral supplementation and / or dietary and lifestyle changes. 3. Risks of intravenous therapy/intramuscular injection include but not limited to:a. Occasionally to commonly:1. Discomfort, bruising and pain at the site injection 2. Generally feeling of warmth during and after injection b. Rarely:1. Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.2. Reactive Hypotension (rapid drop in blood pressure)3. Reactive Hypoglycemia (rapid drop in blood sugar)c. Extremely rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest or death.*

I acknowledge the above
I have read this consent form and understand the information contained in it. I understand the risk and benefits and have had the opportunity to have all my questions answered to my satisfaction. I am aware that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and or explain all risks and possible complications. I rely on the provider(s) to exercise judgment during the course of treatment with regard to my procedure. My signature on this form affirms that I give my consent to the IV nutrient therapy.*

Clear
I First Name Last Name herby grant my permission for Dr. Jeff and his team at Advantage Health Center to conduct chiropractic adjustments to my child, with and without my presence. I understand the nature and purpose of the treatment and the potential risks, benefits, and alternatives involved. I understand I am financially responsible for the care my child receives.
Signature

Clear
Should be Empty:

Advantage Health Center New Patient Application

HOW CAN WE HELP YOU?

HEALTH & ILLNESS QUESTIONAIRE

GUT HEALTH QUESTIONNAIRE

CONSENT

Softwave

Vitamin Therapy