New Patient Questionnaire- Adult Step 1 of 10 10% Patient InformationName: First NameMiddle Name Middle NameLast Name Last NameAddress: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone:Cellular/Mobile Provider:Please Select Your ProviderAlltelAT&TBoost MobileCLEARClearwireMetroPCSQwest WirelessSprint NextelT-Mobile USATracFone WirelessVerizon WirelessVirgin Mobile USAHome Phone:Email: Date of Birth:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender:* Male Female Occupation: Employer or School You Attend: Marital Status:SingleMarriedPartnerSeparatedDivorcedWidowedSpouse/Partner's Name: How were you referred to our practice? Friend/Relative Internet Search Reputation/Word of Mouth Sign Wellness Presentation Website Other Patient ConditionPlease list your first health issue: Additional issues may be listed later, please only list your primary health issue.When did your symptom(s) first appear? Are your symptom(s)? Getting worse Staying the same Getting better How often do you feel it? Constant (76-100%) Frequent (51-75%) Occasional (26-50%) Intermittent (0-25%) Please describe your pain/symptom(s)? Please check all that apply: Achey Burning Cramping Dull Loss of Feeling Numbness Sharp Stiffness Swelling Throbbing Tingling Other Rate the severity of pain (1 least pain to 10 severe pain)0 out of 101 out of 102 out of 103 out of 104 out of 105 out of 106 out of 107 out of 108 out of 109 out of 1010 out of 10Does the pain, numbness or tingling radiate into other areas of your body? Yes No Where does the pain, numbness or tingling radiate? Check All That Apply: Abdomen Arms Around Waist Chest Foot/Feet Hands Head Leg(s) Mid Back Neck Rib Cage Shoulders Sternum Other Please list your second health issue: Additional issues may be listed later, please only list your secondary health issue.When did your symptom(s) first appear? Are your symptom(s)? Getting worse Staying the same Getting better How often do you feel it? Constant (76-100%) Frequent (51-75%) Occasional (26-50%) Intermittent (0-25%) Please describe your pain/symptom(s)? Please check all that apply: Achey Burning Cramping Dull Loss of Feeling Numbness Sharp Stiffness Swelling Throbbing Tingling Other Rate the severity of pain (1 least pain to 10 severe pain)0 out of 101 out of 102 out of 103 out of 104 out of 105 out of 106 out of 107 out of 108 out of 109 out of 1010 out of 10Does the pain, numbness or tingling radiate into other areas of your body? Yes No Where does the pain, numbness or tingling radiate? Check All That Apply: Abdomen Arms Around Waist Chest Foot/Feet Hands Head Leg(s) Mid Back Neck Rib Cage Shoulders Sternum Other Please list your third health issue: Additional issues may be listed later, please only list your third health issue.When did your symptom(s) first appear? Are your symptom(s)? Getting worse Staying the same Getting better How often do you feel it? Constant (76-100%) Frequent (51-75%) Occasional (26-50%) Intermittent (0-25%) Please describe your pain/symptom(s)? Please check all that apply: Achey Burning Cramping Dull Loss of Feeling Numbness Sharp Stiffness Swelling Throbbing Tingling Other Rate the severity of pain (1 least pain to 10 severe pain)0 out of 101 out of 102 out of 103 out of 104 out of 105 out of 106 out of 107 out of 108 out of 109 out of 1010 out of 10Does the pain, numbness or tingling radiate into other areas of your body? Yes No Where does the pain, numbness or tingling radiate? Check All That Apply: Abdomen Arms Around Waist Chest Foot/Feet Hands Head Leg(s) Mid Back Neck Rib Cage Shoulders Sternum Other Other Health ComplaintsPlease check all that you are currently experiencing or have experienced in the past 12 months. Allergies Ankle/Foot Pain Arm Numbness/Tingling Arm Pain Arthritis (other) Arthritis Spine Asthma Bulging Disc(s) Buttock Pain Carpal Tunnel Syndrome Cold Feet Cold Hand(s) Dizziness Frequent Colds/Flu Grating Noises Neck Headaches Herniated Disc(s) High Blood Pressure Irritability Knee Pain Lack of Energy Leg Numbness/Tingling Leg Pain Lower Back Pain Menstrual Difficulty Mid Back Pain Muscle Cramping Muscle Spasms Neck Pain Neck Stiffness Pinched Nerve Seizures Shoulder Blade Pain Shoulder Pain Shoulder Tension Sinus Problems Tailbone Pain Upper Back Pain Other None of the Above Conditions/Disorders/DiseasesPlease check all health conditions and/or complaints that you have. Anxiety Bleeding Disorder Cancer Depression Diabetes Emphysema/COPD Epilepsy Gout Heart Disease Hepatitis High Cholesterol HIV/AIDS Kidney Disease Lung Disease Multiple Sclerosis Osteoporosis Parkinson’s Prostate Difficulty Psychiatric/Emotional Rheumatoid Arthritis Sexually Transmitted Disease Sleep Difficulty Stroke Thyroid Problems Tremors Tumors/Growths Other None of the Above Medications:* ADD/ADHD Allergies/Sinus Antibiotics Anti-Depressant Anxiety Arthritis Asthma Birth Control Blood Pressure Cholesterol Depression Diabetes Digestion Headaches Heart Muscle Relaxant Osteoporosis/Osteopenia Pain Prostate Sleep Aid Steroids Thyroid Ulcers Other I Take No Medications Please check all conditions and symptoms that you are currently taking medications for.Family Health HistoryDo you have a family history of? (Please indicate all that apply) Adopted/Unknown Cancer Cardiac Disease Diabetes Heart Attack Heart Disease Neurological diseases Psychiatric disease Strokes/TIA’s Social and Occupational HistoryLevel of Exercise None Moderate Exercise: 1-2 days/week; 3-4 days/week Intense Exercise : 1-2 days/week; 3-4 days/week 4+ days a week Activities of Daily LivingDo you have difficulty doing any of the following activities? Check All That Apply: Bathing Bending Bowling Brushing Teeth Carry Objects Climbing Stairs Combing Hair Concentrating Dancing Driving Car Drying Hair Exercise Golfing Hobbies Jogging Kneeling Laundry Leaning Backward Lift from Floor Lift from Table Making the Bed Preparing Meals Prolong Sitting Prolonged Walk Pulling Pushing Putting on Your Pants Putting on Your Shoes Putting the Trash Out Putting on Your Shirt Reaching Sitting Skiing Standing Stooping Swimming Twisting Using Keyboard Walking Washing Dishes Other None of the Above Please rate how the following affect your everyday activities:Frequency of Pain:0- No Pain2- Intermittent Pain (10% of the day)4- Intermittent Pain (25% of the day)6- Occasional Pain (50% of the day)8-Frequent Pain (75% of the day)10-Constant Pain (100% of the day)Lifting:0- No Pain with Heavy Weight2- Intermittent Pain with Heavy Weight4- Increased Pain with Heavy Weight6- Increased Pain with Moderate Weight8- Increased Pain with Light Weight10- Increased Pain with Any WeightPain Intensity:0- No Pain2- Intermittent Pain4- Mild Pain6- Moderate Pain8- Severe Pain10- Worst Possible PainPersonal Care: (dressing, washing, etc.)0- No Pain (No Restrictions)2- Intermittent Pain (Some Restrictions)4- Mild Pain (Need To Go Slowly)6- Moderate Pain (Need Some Assistance)8- Strong Pain (Need 100% Assistance)10- Severe PainRecreation:0- Can Do All Activities2- Can Do All Activities4- Can Do Most Activities6- Can Do Some Activities8- Can Do A Few Activities10- Cannot Do Any ActivitiesSleeping:0- Perfect Sleep2- Intermittently Disturbed Sleep4- Mildly Disturbed Sleep6- Moderately Disturbed Sleep8- Greatly Disturbed Sleep10- Totally Disturbed SleepStanding:0- No Pain After Several Hours2- Increased Pain After Several Hours4- Increased Pain After 2 Hours6- Increased Pain After 1 Hour8- Increased Pain After 30 Minutes10- Increased Pain with Any StandingTravel: (driving, riding, etc.)0- No Pain on Long Trips2- Intermittent Pain on Long Trips4- Mild Pain on Long trips6- Moderate Pain on Long Trips8- Moderate Pain on Short Trips10- Severe Pain on Short TripsWalking:0- No Pain Any Distance2- Increased Pain After Long Distance4- Increased Pain After 1 Mile6- Increased Pain After Half of a Mile8- Increased Pain After Quarter of a Mile10- Increased Pain with All WalkingWork:0- Can Do Usual Work (Plus Unlimited Extra)2- Can Do Usual Work (No Extra Work)4- Can Do 75% of Usual Work6- Can Do 50% of Usual Work8- Can Do 25% of Usual Work10- Can Do 0% of Usual Work Review of SystemsHave you had any of the following pulmonary (lung-related) issues? (Check All that Apply) Asthma/Difficulty Breathing COPD Emphysema Other None of the Above Have you had any of the following cardiovascular (heart-related) issues or procedures? (Check All that Apply) Heart Surgeries Congestive Heart Failure Murmurs or Valvular Disease Heart Attacks/MIs Heart Disease/Problems Hypertension Pacemaker Angina/Chest Pain Irregular Heartbeat Other None of the Above Have you had any of the following neurological (nerve-related) issues? (Check All that Apply) Visual changes/loss of vision One-sided weakness of face or body History of seizures One-sided decreased feeling in the face or body Headaches Memory loss Tremors Vertigo Loss of sense of smell Strokes/TIAs Other None of the Above Have you had any of the following endocrine (glandular/hormonal) related issues or procedures? (Check All that Apply) Thyroid disease Hormone replacement therapy Injectable steroid replacements Diabetes Other None of the Above Have you had any of the following renal (kidney-related) issues or procedures? (Check All that Apply) Renal calculi/stones Hematuria (blood in the urine) Incontinence (can’t control) Bladder Infections Difficulty urinating Kidney disease Dialysis Other None of the Above Have you had any of the following gastroenterological (stomach-related) issues? (Check All that Apply) Nausea Difficulty swallowing Ulcerative disease Frequent abdominal pain Hiatal hernia Constipation Pancreatic disease Irritable bowel/colitis Hepatitis or liver disease Bloody or black tarry stools Vomiting blood Bowel incontinence Gastroesophageal reflux/heartburn Other None of the Above Have you had any of the following hematological (blood-related) issues? (Check All that Apply) Anemia Regular anti-inflammatory use (Motrin/Ibuprofen/Naproxen/Naprosyn/Aleve) HIV positive Abnormal bleeding/bruising Sickle-cell anemia Enlarged lymph nodes Hemophilia Hypercoagulation or deep venous thrombosis/history of blood clots Anticoagulant therapy Regular aspirin use Other None of the Above Have you had any of the following dermatological (skin-related) issues? (Check All that Apply) Significant burns Significant rashes Skin grafts Psoriatic disorders Other None of the Above Have you had any of the following musculoskeletal (bone/muscle-related) issues? (Check All that Apply) Rheumatoid arthritis Gout Osteoarthritis Broken bones Spinal fracture Spinal surgery Joint surgery Arthritis (unknown type) Scoliosis Metal implants Other None of the Above Have you had any of the following psychological issues? (Check All that Apply) Psychiatric diagnosis Depression Suicidal ideations Bipolar disorder Homicidal ideations Schizophrenia Psychiatric hospitalizations Other None of the Above Is there anything else in your past medical history that you feel is important to your care here? Yes No Explain: Trauma/Injuries/SurgeriesPlease List All That Apply:Have you ever had any broken bones or dislocations? Yes No If yes, please describe:* What Bone, When (Year) & Resolution (Cast, Self Managed, Surgery, Etc.)Have you ever been involved in a motor vehicle collision? Yes No If yes, please describe:* Year & Did you seek medical attention (yes or no).Have you ever experienced a head or neck injury? Yes No If, yes please describe:* Have you ever experienced any significant falls or injuries? Yes No If, yes please describe:* Year & Did you seek medical attention (yes or no).Have you had any surgeries? Yes No Please list all surgeries you have had:* Year & ProcedureFemale OnlyAre you pregnant?* Yes No Maybe X-ray/Imaging Studies Awareness StatementBy clicking the "I have read and accept the above terms." button. I am acknowledging that the above information is correct. I understand the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.X-ray/Imaging Studies Awareness Statement* I have read and accept the above terms. I do not accept the above terms. Your Family Doctor's InformationName of Your Family Doctor: Address of Your Family Doctor's Office: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have any of the following? Flexible Spending Account (FSA) Health Reimbursement Account (HRA) Health Savings Account (HSA) Assignment, Release of Benefits and Guarantee of PaymentBy clicking the button below, I certify that to the best of my knowledge the information on this form is accurate, truthful and current. I certify that I, and/or my dependent(s) have insurance coverage with the aforementioned company(s) and assign directly to Optimal Wellness for Life Chiropractic Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that 1) I am financially responsible for all charges whether or not paid by insurance and 2) I am financially responsible for any legal fees or other fees incurred by Optimal Wellness for Life Chiropractic Center for collection efforts of delinquent balances on my and/or my dependent(s) account(s). I authorize the use of my signature on all insurance submissions.Optimal Wellness for Life Chiropractic Center may use my healthcare information and may disclose such information to the above-named insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. The consent will end when my current treatment plan is completed or one year from the date below. I consent to treatment for myself and/or treatment of my minor dependent(s) and guarantee payment for all services rendered by Optimal Wellness for Life Chiropractic Center whether insurance pays or not.Acceptance of Assignment, Release of Benefits and Guarantee of Payment* I have read and accept the above terms. I do not accept the above terms. Notice of Privacy Practices I acknowledge that I have had the opportunity to review Optimal Wellness for Life Chiropractic Center’s "Notice of Privacy Practice" on the practice’s website online. I understand I have a right to review Optimal Wellness for Life Chiropractic Center’s Complete Notice of Privacy Practices prior to accepting this document. The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Optimal Wellness for Life Chiropractic Center The Notice of Privacy Practices is also provided on request at the main administration desk of the practice. This Notice of Privacy Practices describes my rights and Optimal Wellness for Life Chiropractic Center’s duties with respect to my protected health information. Optimal Wellness for Life Chiropractic Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail, email or asking for one at the time of my next appointment. Acceptance of Notice of Privacy Practices* I have read and accept the above terms. I do not accept the above terms. Terms of Acceptance/Informed ConsentWhen we accept you as a patient it’s important that you understand the objectives of our care. Chiropractors provide a unique service that other healthcare providers do not offer. Chiropractors specialize in the location and correction of vertebral subluxations for the purpose of improving the health and function of your spine and nervous system. A vertebral subluxation is a misalignment or distortion of your spinal column and/or related structures that can affect your health and overall body functioning. Chiropractors spend years studying how to locate and correct this destructive condition. The correction is performed using specialized techniques called “chiropractic or spinal adjustments” over a period of time. When your spine is free of the nerve and musculoskeletal stress caused by subluxations your body can function more efficiently and your body’s natural ability to heal can work more optimally. It is not our objective to medically diagnose or treat any disease, symptom or condition. If you desire diagnosis or treatment for a specific symptom or treatment of a specific symptom, disease, or condition or advice on taking or stopping medications, we recommend you consult a healthcare provider who specializes in that area. If we discover unusual findings in the course of our chiropractic examination(s) we will let you know of them. You may then decide whether you wish to investigate further and discuss your healthcare options with other health professionals. Chiropractic, like all forms of health care, while offering considerable benefits may also provide some level of risk. This level of risk is most often very minimal. In very rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the extremely rare complications associated with spinal manipulation, occurring at a rate between one per one million to one per twelve million cervical spine (neck) adjustments is vertebral artery injury. This very rare occurrence could lead to stroke. Prior to receiving chiropractic care from Optimal Wellness for Life Chiropractic Center, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spinal health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a recommended plan of care prior to beginning care. The purpose of chiropractic care is not to treat disease or conditions, nor to suppress symptoms, nor to perform surgery or prescribe medications but rather to improve the health and function of your spine and nerve system to help your body function at it’s optimum health and healing potential. It is our sole objective to improve and maintain the health and normal function of your spine and nerve system to the maximum degree possible for you. Acceptance of Terms of Acceptance/Informed Consent* I have read and accept the above terms. I do not accept the above terms. Consent to Treatment, Payment Guarantee, and Release of InformationI hereby consent to examination and all treatments of myself or my minor dependent(s) for whom I am responsible. I guarantee payment for all services rendered regardless of my results or whether my insurance company(s) contributes or does not contribute toward payment for my care or care of minor dependent(s). I authorize Optimal Wellness for Life Chiropractic Center to release my health and personal information for the purposes of billing, insurance submission, doctor referrals, insurance requests, employer test results, governmental agencies, etc. as required by law and allowed by law.Acceptance of Consent to Treatment, Payment Guarantee, and Release of Information* I have read and accept the above terms. I do not accept the above terms. CommentsThis field is for validation purposes and should be left unchanged.
