Adult Form

CHIROPRACTIC INTAKE & HISTORY

PATIENT INFORMATION

Last name

First name *

Middle Initial *

Address

City

State

Zip

Phone number

Cell number

Email address *

Sex

Female

Male

Other

Age

Date of Birth

Married

Widowed

Single

Minor

Divorced

Separated

Partnered

Employer / School

Occupation

Spouse’s Name

Spouse’s Employer

Spouse’s Occupation

IN CASE OF EMERGENCY, CONTACT

Name (Emergency Contact)

Relationship

Emergency Contact number

How did you hear about us?

HOW CAN WE HELP YOU?

What brings you in today?

If you are already experiencing a symptom, what is it?

How bad is it? How intense are your symptoms? (0= NO SYMPTOMS 100 =INTENSE SYMPTOMS)

Please indicate any specific areas of pain:

What does it feel like? (check where appropriate)

Numbness

Tingling

Stiffness

Dull

Aching

Cramping

Nagging

Sharp

Shooting

Burning

Throbbing

Stabbing

Swelling

Other

IMPACT OF YOUR SYMPTOMS?

How is this symptom / condition interfering with your life? (check where appropriate)

Work

No Effect

Mild Effect

Moderate Effect

Severe Effect

Exercise

No Effect

Mild Effect

Moderate Effect

Severe Effect

Recreation

No Effect

Mild Effect

Moderate Effect

Severe Effect

Relationships

No Effect

Mild Effect

Moderate Effect

Severe Effect

Sleep

No Effect

Mild Effect

Moderate Effect

Severe Effect

Self-Care

No Effect

Mild Effect

Moderate Effect

Severe Effect

Energy

No Effect

Mild Effect

Moderate Effect

Severe Effect

Attitude

No Effect

Mild Effect

Moderate Effect

Severe Effect

Patience

No Effect

Mild Effect

Moderate Effect

Severe Effect

Productivity

No Effect

Mild Effect

Moderate Effect

Severe Effect

Creativity

No Effect

Mild Effect

Moderate Effect

Severe Effect

Other:

How committed are you to correcting this issue? (1= NOT COMMITTED 10=VERY COMMITED)

PATIENT WELLNESS ASSESSMENT

Illness-WellnessContinuum_Revised+June+2020 low res

On the arrow diagram above:

What number do you think represents your health today?

In what number is your health currently headed?

What are your health goals?

IMMEDIATE:

SHORT TERM:

LONG TERM:

CHILDREN & PREGNANCY

How many children do you have?

Children’s health concerns?

Are you currently pregnant?

Yes

I am due:

Children’s ages?

HEALTH & ILLNESS HISTORY

Which of the following health issues have you experienced?

AIDS/HIV

Alcoholism

Anxiety

Arteriosclerosis

Arthritis

Asthma/Allergies

Back Pain

Cardiovascular Issues

Cancer

Circulation Issues

Childhood Illness

Depression

Diabetes

Digestive Issues (Constipation/Diarrhea/GERD/IBS)

Elbow/Wrist/Hand Issues

Endocrine Issues/Endocrine

Foot/Ankle Issues

Gout

Headaches / Migraines

Heart Disease

Hepatitis

Hip Issues

Immune Issues

Lymphatic Issues

Multiple Sclerosis

Neck Pain

Reproductive Issues

Ringing in Ears

Scoliosis

Shoulder Issues

Neurological Disorders

TMJ Issues

Urinary Issues

Osteoporosis

Other:

EMOTIONAL HISTORY

Emotional History

Financial Stress

Loss of a loved one

Stress of being sick/ill

Change of job/career

Divorce

Work Stress

Physical Abuse

Sexual Abuse

Verbal Abuse

Other

MEDICATIONS/SUPPLEMENTS

Please List:

CLIENT CONSENT

Client Policies: Our practitioners and staff are dedicated to maintaining the confidentiality of client Health Insurance Portability and Accountability Act (HIPPA). Client records are maintained in conformance with respect for your privacy. Communication is vital for effective practitioner-client sessions. If you have any questions, comments, complaints, or compliments, do not hesitate to bring them to our attention. To maintain a peaceful environment, we ask that you silence your cell phone, and take calls outside of the building. *

Client Consent: I understand that the purpose of Touch Light Chiropractic (TLC Care) is to harmonize the energetic field of the body as well as balance the nervous system, and that sessions are not designed or intended to diagnose, treat, or cure any disease or infirmity. I agree to accept responsibility for my own health and any risk related to receiving a session, and to hold harmless Touch Light Chiropractic, Dr. Ginni Gross and Dr. Tina Tang from any claim resulting from my sessions. I also understand that TLC sessions do not replace services or treatment by other healthcare professions. I acknowledge that the number of sessions recommended, and results obtained will vary for each individual.

Payment Policy: Payment is due at the time of service. Accepted forms of payment include cash, check, and credit card. The client’s signature at the bottom of this page authorizes the use of the credit card information on file for all sessions and products provided by Touch Light Chiropractic. A $25.00 fee will be assessed for any check returned unpaid by the clients’ bank. Touch Light Chiropractic is PRIVATE PAY only and is not a participating provider for any carrier or group. Payment plan options may be arranged with the office manager PRIOR to your session. All outstanding balances are due immediately if a client chooses to terminate services.

Cancellation/Rescheduling: Occasionally, clients are turned away for appointments because practitioner schedules are full. A 24-hour notice is required for canceling or rescheduling an appointment.

Name: *

Date: *

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.