Health History Form

* This form is only to be filled out after you have paid a deposit to reserve a date for the Spero Clinic program.
Patient Deposit Agreement

I acknowledge that my deposit is a nonrefundable deposit to hold my calendar appointment and that this deposit is applied towards my treatment cost. I understand that if I need to change my appointment date, this will be required outside of 4 calendar weeks of my appointment date. I understand that this cancellation policy allows the Spero Clinic to give someone else the opportunity to make travel arrangements, so that they can rebook the appointment date.
Signature

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Today’s date*

MonthDayYear
Date
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Marital Status
Sex*
Social Security Number*
type n/a if not applicable
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

area codephone
Drivers License number*
Type n/a if not applicable
Email*
example@example.com
Emergency Contact Name*

First NameLast Name
Relation to Patient*
Type n/a if not applicable
Emergency Contact Phone Number*

area codephone
Your occupation *
Type n/a if not applicable
Your employer *
Type n/a if not applicable
How did you find out about our clinic?*
Areas Of Complaint
Using the pain drawing, Please mark the areas of the body where you have pain.
Please go into detail about the areas of pain you drew on the body diagram.*

0/100

Patient Medical History
Onset of symptoms:*
Approximate date symptoms appeared*

MonthDayYear
Date
Name and location of doctor previously seen for present condition(s):
Type n/a if not applicable
Do you have a spinal cord stimulator?*

YesNo
Do you have a pacemaker?*

YesNo
Do you suffer from blood clots?*

YesNo
Have you ever had a seizure?*

YesNo
Have you been diagnosed with or treated for cancer within the last year?*

YesNo
Do you smoke?*

YesNo
If you do smoke, how often?

Every dayEvery other dayEvery 2 weeksOther
Do you drink alcohol?

YesNo
If you do drink, how often?

Every dayEvery other dayEvery 2 weeks
Do you have convulsions?*

YesNo
Are you pregnant?*

YesNoN/A
How many hours of sleep do you get a night, on average?*
Type n/a if not applicable
Interrupted or uninterrupted?

InterruptedUninterrupted
Surgical History
Please list any surgeries you have had and their approximate dates:*
Type n/a if not applicable
Medications
Please list all medications you are taking, your reason for taking them, and dosages for each:*
Previously Completed Treatment
Please list any treatments or procedures you have previously completed for your condition:*
Scar Tissue History
It is crucially important that we are aware of every scar you have on your body.

Please read the following instructions and fill out the information accordingly.

Mark each area of your body where you have a scar and number the mark.

Scars are often missed. For example:

-Scars hidden under your chin

-Scars under your hair or on your scalp

-Scars you had as a child

-Laparoscopic surgery

-Piercings

-Dental surgery

-Tonsil removal

If you can, ask your parents about any childhood traumas you may have suffered as a baby or toddler.
Please mark and number each area where you have a scar.
List the number/location of each scar, how you got the scar, and your age at the time. *
Type n/a if not applicable
Accident History
Please list any accident or injury history (at ANY point in your life) and approximate dates:*
Type n/a if not applicable
Did any of these accidents or injuries result in a concussion?*
Type n/a if not applicable
Family Medical History

Has anyone in your family ever been diagnosed with the following:
Breast Cancer

NoOther
Diabetes

NoOther
Colon Cancer

NoOther
Heart Disease

NoOther
Genetic Disorders

NoOther
Kidney Disease

NoOther
High Blood Pressure

NoOther
Lung Cancer

NoOther
Ovarian Cancer

NoOther
Uterine Cancer

NoOther
Other Cancer

NoOther
Osteoperosis

NoOther
Stroke

NoOther
Bleeding Disorder

NoOther
Thyroid Disease

NoOther
Has anyone in your family suffered from chronic pain, CRPS, EDS, or Fibromyalgia?

NoOther
Health Review Questionnaire

Please follow the directions below.
Check the conditions and symptoms you've experienced in the PAST MONTH:*

AlcoholismAllergiesAnemiaAnxietyArteriosclerosisArthritisAsthmaAutoimmune DiseaseBack PainBed WettingBleeding DisordersBlood in UrineBreast LumpBronchitisBruisingBypass SurgeryCancerCataractsChest PainChronic CoughCold ExtremitiesCongestive Heart FailureConstipationCOPD/EmphysemaCoronary Artery DiseaseCrampsDepressionDiabetes: Type 1Diabetes: Type 2Diabetes: JuvenileDiagnosed Emotional/Mental DisorderDiarrheaDifficulty BreathingDifficulty SwallowingDigestive ProblemsDementia/Alzheimer'sDizzinessDrynessEarachesEpilepsyExcessive FlowEye PainFatigueFoot ProblemsFrequent UrinationGallbladder Disease / StonesGlaucomaGoutHeadachesHemorrhoidsHerniaHigh Blood PressureHoarsenessHot FlashesHypercholesterolemiaInability to Control UrineIrregular CyclesIrregular HeartbeatKidney InfectionKidney StonesLiver Disease / CirrhosisLoss of BalanceLoss of MemoryLoss of SmellLoss of TasteLow Blood PressureMacular DegenerationMigraineMyocardial InfarctionNose BleedsPacemakerPainful IntercoursePainful MenstruationPainful UrinationParkinson'sPoor PostureProstate TroubleRefluxRetinal DiseaseRinging of EarsSciaticaSeizuresShortness of BreathSinus InfectionSkin SensitivitySleep problems / InsomniaSpinal CurvaturesSpitting BloodStomach PainStrokeSwelling of AnklesSwollen JointsSelf HarmHitting, burning, biting, itching, pulling out hairBulimiaCutting/Piercing SkinThyroid ConditionTuberculosisUlcersVaricose VeinsVenereal DiseaseVomiting BloodNauseaPhotosensitivityBrain Fog
Check the conditions and symptoms you've experienced throughout your life:*

AlcoholismAllergiesAnemiaAnxietyArteriosclerosisArthritisAsthmaAutoimmune DiseaseBack PainBed WettingBleeding DisordersBlood in UrineBreast LumpBronchitisBruisingBypass SurgeryCancerCataractsChest PainChronic CoughCold ExtremitiesCongestive Heart FailureConstipationCOPD/EmphysemaCoronary Artery DiseaseCrampsDepressionDiabetes: Type 1Diabetes: Type 2Diabetes: JuvenileDiagnosed Emotional/Mental DisorderDiarrheaDifficulty BreathingDifficulty SwallowingDigestive ProblemsDementia/Alzheimer'sDizzinessDrynessEarachesEpilepsyExcessive FlowEye PainFatigueFoot ProblemsFrequent UrinationGallbladder Disease / StonesGlaucomaGoutHeadachesHemorrhoidsHerniaHigh Blood PressureHoarsenessHot FlashesHypercholesterolemiaInability to Control UrineIrregular CyclesIrregular HeartbeatKidney InfectionKidney StonesLiver Disease / CirrhosisLoss of BalanceLoss of MemoryLoss of SmellLoss of TasteLow Blood PressureMacular DegenerationMigraineMyocardial InfarctionNose BleedsPacemakerPainful IntercoursePainful MenstruationPainful UrinationParkinson'sPoor PostureProstate TroubleRefluxRetinal DiseaseRinging of EarsSciaticaSeizuresShortness of BreathSinus InfectionSkin SensitivitySleep problems / InsomniaSpinal CurvaturesSpitting BloodStomach PainStrokeSwelling of AnklesSwollen JointsSelf-HarmCutting/Piercing SkinBulimiaHitting, burning, biting, itching, pulling out hairThyroid ConditionTuberculosisUlcersVaricose VeinsVenereal DiseaseVomiting BloodNauseaPhotosensitivityBrain Fog
Are there any other symptoms you want us to know about?*

YesNoN/A
If your answer is yes, please list your additional symptoms here:*
Type n/a if not applicable
Medicare/Medicade Status*

I am enrolled in Medicare/MedicadeI am NOT enrolled in Medicare/Medicade
I agree to the Medicare/Medicade disclaimer for the Spero Clinic/Integrated Health and Wellness Center.*

I understand, should I be enrolled in either program, The Spero Clinic/Integrated Health and Wellness Center are not participating providers and do not file with Medicare/Medicade. I, therefore, am not able to receive benefits from either program in regard to any treatment modality including chiropractic adjustments within the facility.
I agree to pay all charges related to my care or treatment in full each Thursday before 6:00 P.M. in order to resume treatment the following week.*

I agree
I have read and agreed to the Personal Release Form as listed on The Spero Clinic Website: https://www.thesperoclinic.com/privacy-policy-personal-release/ and grant permission to take photographs or videos of me, and to use these images, videos, and recordings, as well as my likeness, name and voice.*

I hereby grant permission to The Spero Clinic, Integrated Health & Wellness Center (IH&WC) and its assigns and licensees to take photographs or videos of me, and to make recordings of my voice. I give the The Spero Clinic and TH&WC permission to use these images, videos, and recording, as well as my likeness, name and voice.I do NOT grant permission for The Spero Clinic, Integrated Health & Wellness Center and its assigns and licensees to take photographs or videos of me, and to make recordings of my voice. I do not grant The Spero Clinic permission to use these images, videos, and recordings, as well as my likeness, name and voice.
I have read and agreed to the Consent to Use and Disclosure of Protected Health Information as listed on The Spero Clinic Website: https://www.thesperoclinic.com/privacy-policy-consent-phi/ which states that my data may be used for up to 1 calendar year.*

I give permission to use and disclose my health information.
The staff at The Spero Clinic Integrated Health & Wellness Center (IH&WC)’s sole purpose is to remove interferences to the Central Nervous System. We do not claim to treat any specific condition, symptom, disease or syndrome.*

I agree
You understand that while at The Spero Clinic Integrated Health & Wellness Center (IH&WC), you may receive care that is above industry standards in both frequency and cost, due to time constraints and the severity of your nerve interference.*

I agree
You understand that any activities you choose to participate in outside the office, including drug use, alcohol consumption, or any other activity that could potentially risk your own health and wellbeing are your choice alone. You understand that these activities may potentially negatively affect your health and/or endanger your life. You will not hold The Spero Clinic Integrated Health & Wellness Center (IH&WC) responsible for any negative effects nor consequences resulting from these choices.*

I agree
The staff at The Spero Clinic Integrated Health & Wellness Center (IH&WC) does not guarantee any specific outcome and will not offer a refund based on treatment outcome under any circumstances.*

I agree
If you choose to rent a Personal Recovery System (PRS) Unit, or a portable Frequency Specific Microcurrent unit, there will be a daily $37.50 fee. There is also a permanent $0.45 per minute charge while using the ARP Wave RX Unit. You understand these fees are not includes in you financial plan. Should you choose to purchase my own unit(s) the rental fees will no longer apply to you.*

I agree
You understand that the focus is to ensure optimum environment for you to be successful in your journey to better health, The Spero Clinic Integrated Health & Wellness Center (IH&WC) uses a wide range of protocols including social behavior, dietary habits, honoring the schedule recommended to you, as well as keeping healthy boundaries with other patients and staff of the center.*

I agree
You will maintain and be punctual for all your appointments and prescribed treatments without interrupting your scheduled care. Exceptions are made on a case-by-case basis with prior approval from Dr. van der Merwe. You also understand that any interruptions to your care can affect your progress. You the doctors and staff of The Spero Clinic Integrated Health & Wellness Center (IH&WC) blameless for any consequence due to interruptions in your plan.*

I agree
You understand that if you are over 15 minutes late for your scheduled appointments, you will be charged in full for the appointment, and if you are 30 minutes late you will forfeit your appointment and need to reschedule for a later time. The Spero Clinic Integrated Health & Wellness Center (IH&WC) reserves the right to make exceptions upon one-hour prior notification.*

I agree
You are responsible for making/maintaining your appointment times, and that they are set up on a first come basis, and at the discretion of the scheduler. The Spero Clinic Integrated Health & Wellness Center (IH&WC) will do their best to accommodate their patients need within their hours of operation.*

I agree
You understand that practicing unhealthy habits (including but not limited to smoking, ingesting artificial sweeteners like aspartame often found in chewing gum, carbonated beverages and/or eating health foods) may alter the outcome of your treatments. This may cause your treatments to be more unpleasant and/or less effective.*

I agree
You understand that at any moment during your treatment program, your assigned therapist can be changed.*

I agree
While you are receiving treatment, you are responsible for transports, transfers, and moving between appointments. If you can not do this on your own, you understand that you will need to arrange for a caregiver to come with you. We do not have employed caregivers at our clinic.

I agree
You will participate in your prescribed treatments taking all recommended supplements while under care of The Spero Clinic Integrated Health & Wellness Center (IH&WC). Before you start taking recommended supplements from The Spero Clinic Integrated Health & Wellness Center (IH&WC), you will bring in all outside supplements for testing in combination with the new supplements from The Spero Clinic Integrated Health & Wellness Center (IH&WC). If you are taking prescribed, medications or other supplements that may interact with any supplements recommended by The Spero Clinic Integrated Health & Wellness Center (IH&WC)’s Doctors and/or staff members, you will address this with your physician.*

I agree
You will do your utmost to maintain a positive attitude conducive to a beneficial outcome to your treatment and others around you.*

I agree
You understand that a positive outcome is not guaranteed. Dr. van der Merwe and/or staff do not guarantee any particular outcome to any treatment. You understand that they will provide premium care and that healing happens from the inside out and not the outside in. Every individual is different and may respond differently even to identical care protocols.*

I agree
You understand that the following provided by The Spero Clinic Integrated Health & Wellness Center (IH&WC) are all FDA approved: Relaxation of muscle spasms, Prevention of retardation of disease therapy, Increasing local blood circulation, Muscle re-education, Immediate post-surgical stimulation of calf muscles to prevent venous thrombosis, Maintaining or increasing Rage of Motion CROM, Pain management*

I agree
You understand that some treatment areas are open, but private areas are available upon request.*

I agree
In order to undergo any electronic modalities, you certify that you do not have a pacemaker/ICD (implanted cardiac device_, you are not pregnant, and you have not had blood clots in the past 12 months.*

I agree
You understand that CRPS/RSD is specifically a progressive syndrome that may advance in an unpredictable manner. This may occur even while under the care of The Spero Clinic Integrated Health & Wellness Center (IH&WC). While Dr. van der Merwe and their staff’s treatments are considered non-invasive, you understand that any change to the nervous system may exacerbate your pain. You accept the risk and wish to continue with your treatment. You understand that the staff at The Spero Clinic Integrated Health & Wellness Center (IH&WC), is treating your nervous system only, not a specific condition.*

I agree
You will not behave in a disruptive manner that may interfere with the clinic or with another patient’s care. You will not dispense any medications, prescribed or over-the-counter, to other patients while under the care of The Spero Clinic Integrated Health & Wellness Center (IH&WC), it’s Doctors and its staff. This includes legal and illegal substances.*

I agree
You agree to follow all guidelines and be prepared for your treatments that require the intake of water and/or protein. 64oz of water are required per day to maintain proper hydration level to receive the best treatments possible. 32oz prior to treatment and 32oz after is necessary. Also, good sources and sufficient amounts of protein are required before and after treatments. If patient experiences detox effects such as a headache (or increase in one) or cold/flu like symptoms, please contact The Spero Clinic Integrated Health & Wellness Center (IH&WC) so we can assist you in reducing your symptoms.*

I agree
You understand clearly that Technician’s phone numbers are not to be shared with patients. Should you need to contact your technician, you may reach them via their Spero Clinic email address, or by contacting the front desk.*

I agree
You will not communicate with the staff on any social media platform in regards to your health or care at Spero. (i.e.: Facebook, Instagram, Snapchat, etc. …)*

I agree
You will not provide transportation to any other patient while under Dr. van der Merwe or their staff’s care. You also will not request or expect to be provided transportation for yourself or others while under Dr. van der Merwe or their staff’s care.*

I agree
You understand that breaking this contract may result in termination of your care. At that time, a refund will be provided for any unused portion of your prepaid care plan. You understand that if you are a weekly paying patient, you will need to settle any outstanding balances before you are release from care.*

I agree
If you terminate your care, any unused portion of your prepaid care plan will be refunded (prorated) to you.*

I agree
Under any circumstances if you are in the building before/after hours or during lunch, you will not unlock the doors for anyone, for any reason due to HIPPA Compliance and security reasons. You will not ask anyone to open the door for you.*

I agree
You agree that you will not record your therapy sessions unless approved by the therapist. Treatments include proprietary protocols and information and cannot be recorded unless pre-approved.

I agree
You will not bring any pets into the building unless they are certified service animals.*

I agree
You understand that if you don't show up for your scheduled starting appointment without notice, you are robbing someone else of a chance of recovery. We cannot fill this appointment without notice. Therefore, you will not be allowed to reschedule for a later date.*

I agree
I have read and agreed to the Patient Treatment Contract as listed on The Spero Clinic Website: https://www.thesperoclinic.com/privacy-policy-patient-treatment-contract/*

I hereby acknowledge that I have read, understood, and consent to all the terms of this agreement and that, if I am not the patient, hereby agree to be jointly and severally liable for, and absolutely, unconditionally, and irrevocably, guarantee the prompt and complete payment and performance of all the obligations of such patient under the terms of this agreement.
Dr. Katinka van der Merwe and the team here at Neurologic Relief Center/Integrated Health & Wellness are dedicated to providing you with the best care possible, with the goal of you reaching your optimal health and function. For that reason, we will always recommend everything you need for the benefit of your condition and will not make recommendations based only on what your insurance will cover. The decision to proceed with care is always up to you, the patient, since your healthcare choices are a personal decision.

With that in mind, this notice will help you understand that several of the services or procedures performed in this office are designated "unproven" by the Arkansas State Board of Chiropractic Examiners and their effectiveness has not been demonstrated. "Unproven" means that the service or procedure is one that is not generally recognized or does not have scientific validity whose research was not sponsored, and investigative findings have not been printed in scientific journals.

"Unproven" procedures may also be identified by state guidelines and/or 3rd party payors as "investigational procedures" or "experimental procedures". This status does not indicate that the procedures are not allowed or are not effective. However, this status does indidcate that the services with this status have not been through the approval process as required by FDA and/or other governing entities.

This includes those items listed below:
-Manual Vagus Nerve Stimulation

-Piezo Scar Tissue Treatment

-Lymphatic Drainage

-Neurosage

-Electric Stimulation

-Low Level Laser Therapy

-Footbath Detoxification

-EWOT Oxygen Therapy

-Genetic Profiling

-Magnetic Resonance Therapy

-Non-Invasive Neuromodulation

-Frequency Specific Microcurrent

By signing this form, the patient understands that the services listed above are designated as "unproved" by the State Board of Chiropractic Examiners and therefore, will not be billed to a 3rd party payor.
Printed Name of Patient
Signature of Patient, Guardian, or Authorized Representative*

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Please read and sign the information below to complete your medical history profile. Thank you for helping us understand you, and what your needs will be moving forward. All of our sincere thanks.

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of Chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. Terms of Acceptance:When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both parties to be working towards the same objective.Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to obtain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of force to facilitated the body's correction of the vertebral subluxation. Our chiropractic methods of correction is by specific adjustment of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae of the in the spinal column which causes alteration of the nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express is maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if, during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider that specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.I have read and understand the above statement. I accept chiropractic care on this basis.
Date

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Areas Of Complaint

Surgical History

Medications

Previously Completed Treatment

Scar Tissue History

Accident History

Family Medical History

Health Review Questionnaire