• INTAKE FORM

  • PERSONAL INFORMATION

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  • OFFICE VISIT REASON

  • CHIEF COMPLAINT

  • OTHER COMPLAINTS

  • GENERAL HEALTH HISTORY

  • PERSONAL SURGICAL HISTORY

  • INJURY HISTORY

  • FAMILY HISTORY

  • WORK ACCIDENT

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  • CAR ACCIDENT

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  • I agree to pay a no-call, no-show fee on subsequent appointments if I have a scheduled appointment and don’t show up. (Reschedules are always welcome.)

  • INFORMED CONSENT FOR CHIROPRACTIC CARE

  • THE NATURE OF CHIROPRACTIC TREATMENT

    Chiropractic treatment primarily involves the manual manipulation of the treated area using the chiropractor's hands or mechanical devices. During treatment, you may experience sensations like clicks, pops, and movement. Additionally, our office may utilize various modalities in your care, as recommended by your chiropractor based on their professional judgment.

    POSSIBLE RISKS
    Chiropractic treatment for pain is safe and the majority of patients experience decreased pain and improved mobility. Approximately 30% of patients experience slightly increased pain in the treated area, possibly due to minor muscle, tendon, or ligament strain. When this occurs within the first few days of treatment, the increased pain is brief and returns to baseline or improves over the next few days. Increased pain may also occur with exercise, heat, cold, and electrical stimulation. Possible skin irritation or burns may occur with thermal or electrical therapy.

    It's important to note that serious bodily harm is extremely rare and not an inherent risk of chiropractic treatments. Various factors can influence one's health, including prior injuries,medications, and underlying medical conditions like osteoporosis, cancer, and other illnesses.When such conditions are present, chiropractic treatment may carry the risk of serious adverseevents, including fractures, dislocations, or the exacerbation of previous injuries to ligaments,intervertebral discs, nerves, or the spinal cord. It's essential for patients to remain vigilant andseek medical and/or chiropractic care if they experience symptoms suggestive of stroke or cerebrovascular injury. Your chiropractor is well-informed about this association and will assessfor relevant symptoms when appropriate. It is imperative to disclose your full medical history,including medications, surgeries, and all relevant health conditions like osteoporosis, heartdisease, cancer, stroke, fractures, or prior severe injuries.

    OTHER OPTIONS FOR THE TREATMENT OF PAIN INCLUDE
    Apart from chiropractic care, alternative approaches to managing pain include doing nothing and living with it, over-the-counter medications, physical therapy, medical interventions, injections, or surgery. There is a multitude of pain management options, each carrying potential benefits and risks. We encourage you to ask any questions you may have about the potential risks associated with chiropractic treatment.

    I, the undersigned, confirm that I have read and understood the information provided above, including the potential risks associated with chiropractic treatment, and have had theopportunity to inquire about any concerns I may have. I have disclosed my relevant medicalhistory, as well as any conditions that have previously caused me pain.

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