New Patient Form

New Patient Form
Please complete the forms in their entirety, prior to your appointment. If the appointment is for a minor, all forms must be completed by a parent or guardian and must include the parent's or guardian's signature on each form. If you are a guardian, it is important that you bring the court ordered paperwork with you for the minor's first visit.

If you have any questions regarding the completion of these forms, please contact our office and we will be happy to assist you.

Yours for better health,

Active Healing Center

ENTRANCE APPLICATION

This form provides us with your personal information required to complete your registration as a new patient in our office. Please be sure to fill out all forms as complete as possible.

PATIENT RECORD OF DISCOLSURE

On this form, please list who you give permission to pick up any of your medical records and provide your signature, printed name and birthdfate at the middle of the form. The bottom of the form is for office use only.
HIPPA AUTHORIZATION

On this form, please provide your signature acknowledging you are aware our office has a Notice of Privacy Practices that states we will maintain the privacy of your personal health information and that you consent to our office disclose your information to others only for the purposes of treatment, payment and healthcare operations.

FINANCIAL AGREEMENT

This form informs you of your financial responsibility for your treatment in our office. Please sign this form in all three places.
Name

First NameLast Name
Date

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Occupation
Referred By
Date of Birth

MonthDayYear
Date
Marital Status
Number of Children
List who you give permission to pick up medical records:
Symptoms and Present State of Health
Present Complaint/Reason for Seeking Care from this Office:
Pain or problem started on:
Pains are:

SharpDull/AcheConstantIntermittentOther
If other, please explain:
Does this pain shoot, radiate, or travel in your body? Where?
Are you experiencing numbness or tingling in any area of the body? Where?
Since it began it is:

SameBetterWorse
What aggravates your condition/pain?
What activities lessen your condition/pain?
Do you smoke?

YesNo
If yes, # of packs a day?
Do you drink alcohol?

YesNo
If yes, please list type and how often per week:
Do you drink coffee?

YesNo
If yes, how many cups per day?
Exercise?

NoneModerateDaily
If you answered Moderate or Daily above, what types of exercises do you do?

Family History

	Diabetes	HEart	Kidney	Back
Mother
Father
Brother
Sister

Please mark any of the following conditions or symptoms that you are NOW experiencing:

HeadachesNervousnessPain Between ShouldersLoss of BalanceNumbness in Legs or FeetLoss of MemoryAsthmaChest PainsCancerConstipationLoss of Smell or TasteNeck PainTensionNeck StiffnessRinging in EarsFatigueShoulder PainAllergiesHeart AttackPainful UrinationStomach UpsetMenstrual CrampsSleeping ProblemsIrritabilityJoint SwellingJaw/TMJ ProblemsDepressionSinusCold HandsHigh Blood PressureDiabetesHeartburn/RefluxMenopauseLow Back PainDizzinessFeverPain in HandsLights Bother EyesShortness of BreathCold FeetStrokeDiarrheaWeight Loss
Please mark any of the following conditions or symptoms that you have ever experienced:

HeadachesNervousnessPain Between ShouldersLoss of BalanceNumbness in Legs or FeetLoss of MemoryAsthmaChest PainsCancerConstipationLoss of Smell or TasteNeck PainTensionNeck StiffnessRinging in EarsFatigueShoulder PainAllergiesHeart AttackPainful UrinationStomach UpsetMenstrual CrampsSleeping ProblemsIrritabilityJoint SwellingJaw/TMJ ProblemsDepressionSinusCold HandsHigh Blood PressureDiabetesHeartburn/RefluxMenopauseLow Back PainDizzinessFeverPain in HandsLights Bother EyesShortness of BreathCold FeetStrokeDiarrheaWeight Loss
Are you currently under the care of a physician? If yes, please explain:
Are you currently taking any medication? If yes, please list each one:
Do you have any allergies? If yes, please list:
Have you had surgery? If yes, please list what type and when:
What side effects have you experienced from the drugs and surgery?

If female, check all that apply:

	Yes	No
Taking birth control pills
Currently Nursing
Currently Pregnant
Possibly Pregnant

If Female, what date did your last menstrual period begin on?
If pregnant, how many weeks?
Do you have any disease, condition or problem that you feel we should know about? If so, please describe:
Assignment and Release
Name

First NameLast Name
I agree with the statement below:

Yes, I agree
Date

MonthDayYear
Date
Time

:HourMinutesAM/PM Option
Please check here if patient is a minor, and parent signature is above:

Yes, patient is a minor
PLEASE READ BEFORE SIGNING:

By checking the ‘Yes, I agree’ box, and typing my name in the above box, I confirm that:

> I can print on paper this form or save or send the disclosure to a place where I can print it, for future reference and access; and

> I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I also understand that this information will be held in the strictest confidence.

> I specifically authorize the natural health practitioner at the Active Healing Center to perform a complete health analysis using various modalities and to develop a natural, complimentary health improvement program for me which may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for the treatment, or "cure" of any disease.

> I understand that The Body Code, The Emotion Code, Nutrition Response Testing, Body Talk, Neuroemotional Technique, BioKinetics, Bioenergetic Synchronization Technique and Chiropractic care are safe, non-invasive, natural methods of analyzing the body's physical and nutritional needs, structural imbalances, and correcting those imbalances. Chiropractic manual manipulation has been shown, in very few cases, to cause injury such as stroke.

> I understand the The Body Code, The Emotion Code, Nutrition Response Testing, Body Talk, Neuroemotional Technique, BioKinetics, Bioenergetic Synchronization Technique and Chiropractic care are not methods for the "diagnosing" or "treating" of any disease including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated.

> No promise or guarantee has been made regarding the results of these techniques or any natural health, nutritional or dietary programs recommended, but rather I understand that The Body Code, The Emotion Code, Nutrition Response Testing, Body Talk, Neuroemotional Technique, BioKinetics, Bioenergetic Synchronization Technique and Chiropractic care are means by which the body's natural reflexes can be used as an aid to determining possible nutritional and structural imbalances, and emotional stressors, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health.

> This permission for applies to subsequent visits and consultations.
HIPPA AUTHORIZATION

Please provide your signature acknowledging you are aware our office has a Notice of Privacy Practices that states we will maintain the privacy of your personal health information. You consent to our office disclosing your information to others only for the purposes of treatment, payment and healthcare operations.
Signature

Clear
DateTime
Should be Empty:

New Patient Form

Symptoms and Present State of Health

Assignment and Release