Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you.

New Patient

Patient Information

Full Legal Name *

Date of Birth *

Gender

Male

Female

Phone *

Email *

Address *

City *

State *

Postal code *

Today's Date *

Whom may we thank for referring you to us?

Is this injury/illness related to an automobile accident?

Have you ever had Chiropractic Care before? If so when and by whom?

Do you have insurance? *

Yes

Picture: Front + Back of Insurance Card

Initial Problem Record

What is your main complaint or problem?

Rate your pain (0-10); 0=no pain, 10=worst

How did this begin?

When did this begin?

Has this happened before?

What time of day is it the worst?

Is It?

What makes your problem better?

What makes your problem worse?

Complaint #2

Complaint #2: Rate your pain (0-10); 0=no pain, 10=worst

Complaint #2 - When did this begin?

Complaint #2 - How did this begin?

Complaint #2: What time of day is it the worst?

Complaint #2: Is It?

Complaint #2: What makes your problem better?

Complaint #2: What makes your problem worse?

Complaint #2: Has this Happened Before?

Complaint #3

Complaint #3: Rate your pain (0-10); 0=no pain, 10=worst

Complaint #3 - How did this begin?

Complaint #3 - When did this begin?

Complaint# 3: Has this Happened Before?

Complaint #3: Is It?

Complaint #3: When is it the worst?

Complaint #3: What makes your problem better?

Complaint #3: What makes your problem worse?

Complaint #3: Have you ever had this before?

Complaint #4

Complaint #4: Rate your pain (0-10); 0=no pain, 10=worst

Complaint #4 - When did this begin?

Complaint #4 - How did this begin?

Complaint #4: When is it the worst? Morning Afternoon Night Overnight

Complaint #4: Is It?

Complaint #4: What makes your problem better?

Complaint #4: What makes your problem worse?

Complaint #4: Have you ever had this before?

Do you have any other related or unrelated complaints you would like to address?

List Doctors (name, practice & phone number or email if possible) consulted for above condition(s):

Medical History and Present Medical Condition Questionnaire

Musculoskeletal

Back trouble/pain

Neck trouble/pain

Joint injury/pain/swelling

Carpal tunnel syndrome

Family History (indicate what side of family & what the disease is)

Cancer
Heart issues
Lung issues
Connective tissue disorder
Stroke
Diabetes
Osteoporosis
Thyroid issues
Aneurysm

Additional Health and Lifestyle Questions

Are you experiencing any stresses, mood problems, relationship difficulties, or substance-related problems for which you would like to resource or referral information on a confidential basis?

If yes, please explain:

Do you occasionally use or are you currently taking any prescription or over-the-counter medications?

List name, dosage, and the reason for the medication:

I drink

beers (per week)
ounces of hard liquor (per week)
ounces of wine (per week)

Are you currently or have you ever been a cigarette smoker? If yes, please explain how many packs per day/how many years below.

Please describe any weekly exercise or physical activities including any exercise at work:

Would you consider yourself to have a well balanced diet? Please explain below if indicated.

Trauma History

Have you ever been in an auto accident/fender bender?

If yes, please describe nature of accident and age accident occurred:

Have you ever had any concussions/loss of consciousness?

If yes, please describe nature of concussion/loss of consciousness and at what age:

Have you ever had any surgeries? Please list below:

Please Identify how your current condition is affecting your ability to carry out routine activities

What are some goals you would like to accomplish here? Please list 4 or more goals.

Be specific with the goals by putting time, distance, or weight to accomplish

Informed Consent for Chiropractic Care

Chiropractic care, like all forms of health while offering considerable benefits, may also provide some level of risk. This level of risk is most often very minimal, yet in 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 rarest complications associated with chiropractic care occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral injury that could lead to a stroke. Therefore, before any services are provided, Destination Chiropractic, LLC will perform all necessary diagnostic testing to identify and assess any risk factors prior to treatment. All specific findings will be discussed with the patient upon completion of examination and prior to beginning care.

I understand and accept that there are risks associated with chiropractic care and I give my consent to Destination Chiropractic, LLC to perform all examinations, tests, treatment, physical therapy and other reasonable measures it deems necessary to diagnose and treat my condition prior to treatment and I will be made aware of any and all recommended care before services are rendered.

My signature affirms I understand and do not have any questions on all of the statements made above.

Your Name and Today's Date:

Informed Consent Signature:

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Informed Consent for Minor/Child

As parent or guardian of named child, I do hereby consent to any chiropractic care, including diagnostic procedures, x-rays and treatment given by the staff at Destination Chiropractic, LLC. As of this date, I have the legal right to select and authorize any health care services for my minor/child and inform Destination Chiropractic, LLC of any and health care changes immediately.

I understand I have the right to discontinue care for the below-named minor at any time.

Name of minor receiving care:

Parent or Guardian Signature

Clear

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my personal health information, under the HIPAA Act of 1996. I understand that my information can be and will be used to:

1. Assist in the diagnosis and treatment among other healthcare professionals who may be involved in my treatment directly or indirectly.

2. Obtain payment from 3rd party payers.

3. Conduct healthcare operations, such as quality assessments and physician certifications.

In all other situations (situations that are not treatment, payment, health systems operations or special situations, as we told you about above), we may only share information with your specific written authorization. You may revoke that authorization, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent that we already have used or disclosed your information. You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care.

You must submit your request for your medical information in writing to the office manager of the office where you received your care. If you request a copy of the information, you may be subject to a fee charge for the costs of copying, mailing, or other supplies associated with your request.

Privacy Practices Signature and Date

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X-Ray Authorization

This form will confirm that Tanner Kurz, D.C. associated with Destination Chiropractic, LLC has recommended that I undergo spinal X-rays in connection with my chiropractic evaluation and treatment of my condition. At my request, I will be provided with a copy of my x-rays within 48 hours of my initial request.

Please note that x-rays are used to help locate and analyze your spinal health. The doctor of Destination Chiropractic does not diagnose or treat medical conditions. However, if any abnormalities are found you will be informed, so that you may seek additional and proper medical advice.

Patient Name *

Signature of Patient or Person Acting on Patients Behalf *

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WOMEN ONLY: I hereby expressly acknowledge that I am NOT pregnant at the present time and that Tanner Kurz DC of Destination Chiropractic, LLC is hereby expressly authorized and directed to complete a radiologic examination (x-rays) in connection with my chiropractic treatment.

I authorize that I am not pregnant - Sign and Date

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I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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