PATIENT DEMOGRAPHICS

Today's Date

YYYY

Name

First Name

Last Name

Birthday

YYYY

Age:

Gender

Male

Female

Prefer Not To Say

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home/Work Phone

(###)

###

####

Mobile Phone:

(###)

###

####

Emergency Contact

First Name

Last Name

How Did You Hear About Rejuve-Nation?

Marital Status

Spouse's Name:

Number of children and ages:

Do you have insurance?

Employer:

Occupation:

Emergency Contact:

First Name

Last Name

Emergency Contact Phone Number:

HISTORY OF COMPLAINT

Please identify the condition(s) that brought you to this office:

Primarily:

Secondarily:

Third: (if applicable)

On a scale of 1 to 10 please rate your above complaints by circling the number below:

Primary Complaint

Second Complaint:

Third Complaint:

When is the problem at its worst?

How long does it last?

How did the injury happen?

Have these condition(s) ever been treated by anyone in the past?

Yes

If you answered yes to the above question, by whom?

How long were you under care and what were the results?

Name of previous Chiropractor:

Type NA if you have never had Chiropractic Care.

Is your problem the result of ANY type of accident?

Yes

Identify any other injury(s) to your spine, minor or major, that the doctor should know about:

PAST HISTORY

Have you suffered with any of this or a similar problem in the past?

Yes

If yes, how many times?

When was the last episode?

How did the injury happen?

Type NA if you answered no to the first question in this section.

Have you tried other forms of treatment?

Yes

If yes, please state what type of treatment:

If yes, who provided it?

If yes, how long ago?

What were the results?

Please explain why you chose the answer above:

Type NA if it is not relevant

Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:

Please indicate if you have ever been diagnosed with any of the following conditions:

Broken Bone:

Dislocations:

Tumors:

Rheumatoid Arthritis

Fracture

Disability

Cancer

Heart Attack

Osteo Arthritis

Diabetes

Cerebral Vascular

Other Serious Injuries:

PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem.

Injuries:

Please list how long ago, the type of care received and by whom.

Surgeries:

Please list how long ago, the type of care received and by whom.

Childhood Diseases:

Please list how long ago, the type of care received and by whom.

Adult Diseases:

Please list how long ago, the type of care received and by whom.

SOCIAL HISTORY

How often do you smoke?

Cigars, Pipe, Cigarettes

How often do you consume alcohol?

How often do you take recreational drugs?

FAMILY HISTORY

Does anyone in your family suffer with the same condition(s)?

If yes whom:

Any other hereditary conditions the doctor should be aware of :

If yes, what?

ACTIVITIES OF DAILY LIVING/SYMPTOMS/MEDICATIONS

Daily Activities: Effects of Current Conditions On Performance

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

Bending:

Concentration:

Doing Computer Work

Playing Sports:

Recreational Activities:

Shoveling:

Sleeping:

Watching TV:

Carrying:

Lifting:

Rolling Over:

Sitting:

Standing:

Working:

Driving:

Performing Sexual Activity:

Reading:

Running:

Walking:

Please list all medication taken in the last 12 months:

Please mark each box below:

Headache

Neck Pain

Jaw Pain, TMJ

Tremor

Pain with Cough/Sneeze

Foot or Knee Problems

Sinus/Drainage Problem

Swallow/Painful Joints

Skin Problems

Hepatitis (A,B,C)

Ulcers

Heartburn

Pregnant (Now)

Frequent Colds/Flu

Convulsions/Epilepsy

Double/Blurred Vision

Ringing in Ears

Hearing Loss

Depression/Anxiety

Irritability

Mood Changes

Trouble Sleeping

Allergies

Mid Back Pain

Dizziness/Fainting

Loss of Balance

Chest Pain

Colon Trouble

Menstrual Problems/ PMS

Diarrhea/Constipation

Bed Wetting

Learning Disability

Numb/Tingling arms, hands, fingers

Hip Pain

Upper Back Pain

Prostate Problems

Impotence/Sexual Dysfunction

Digestive Problems

High/Low Blood Pressure

Lung Problems/Asthma/Difficulty Breathing

Chest Pain

Eating Disorder

Kidney Trouble

ADD/ADHS

Scoliosis

Sciatica

Low Back Pain

Shoulder Pain

INITIAL NERVE SYSTEM PROFILE

Have you ever been in an auto accident?

If so when and at what speed was the collision?

If yes, what type of impact?

If yes, was treatment received? Please list the type of treatment

When was your most recent strain/stress at work?

Does your job require you remain in long term stressful posture? ( i.e. sitting/standing for long periods, repeated lifting, long-term computer use)

Have you had spinal traumas in the past? (including: Collision, quick burst or repetitive motion sports: football, wrestling, basketball, baseball, soccer, tennis golf, track and field)

Types of trauma as a child or Adult:

Fall on your head

Impact to your head

Concussion

Fall onto your back or tailbone (slippery floor or ice)

Biking Accident

INITIAL TOXICITY PROFILE

Are you regularly exposed to cleaning products or industrial chemicals?

Have you ever noticed mold growing in your home or your place of work?

Does your home, work, school, or car have a damp or mildew smell?

Have you received a full standard profile of vaccinations?

Do you receive yearly flu shots?

Approximately how many flu shots have you received?

Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?

Do you have symptoms of hormonal system imbalance (thyroid, reproductive,adrenal)?

INITIAL FITNESS PROFILE

How many times per week do you exercise?

How many hours and days per a week do you do cardiovascular training?

How many hours and days per a week do you do weight training?

How many hours and days per a week do you do low impact training? (Yoga)

What is your target weight?

What is your current weight?

How willing are you to change any of these things to reach your health goals? (Scale of 1-10)

INITIAL NUTRITIONAL PROFILE

Have you tested with high triglycerides or high cholesterol?

If yes, what were the values?

Have you tested with high blood pressure?

Are you diabetic?

Have you been diagnosed as pre-diabetic or with metabolic syndrome?

Do you have breakfast daily?

How many days a week do you skip one meal

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures and, if necessary, diagnostic x-rays on me by the Doctor of Chiropractic, Dr. Paul A. Given, and/or anyone at Rejuve-Nation Wellness Experts authorized by the Doctor of Chiropractic. I further understand and am informed that in the practice of chiropractic, as in all health care practices, there are some very slight risks to treatment. These risks include but are not limited to muscle strains and sprains, disc injuries, and strokes. I intend to rely upon the doctor to exercise judgement based on the facts during the course of the procedure known and to act in my best interests throughout the course of treatment. I understand results are not guaranteed though satisfaction is. I have read the above consent. I also have the opportunity to ask questions about this consent form, and by signing below I agree to the above mentioned chiropractic procedures. I intend this consent form to cover the entire course of my care. For the purpose of reimbursement by my insure, I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible for any and all services I receive at this office.

I agree, understand and give consent to the terms above.

Date Completed

YYYY

CHIROPRACTIC CARE PATIENT INTAKE FORM

OUR COMMITMENT