CONFIDENTIAL INFORMATION FORM

Date:

First Name:

Last Name:

Initial:

Major Complaint Information

What is your complaint(s)?

When did this symptom (s) begin?

Please describe the type and location of any symptoms you are experiencing, such as pain, numbness, tingling, burning, or aching. Be as specific as possible, followed by a number from 1 to 10 indicating the extent of the pain. (1 being minor, 10 being severe)

Add new row

If this is an injury, describe what happened:

Have you experienced these symptoms before?

Yes No

When?

These symptoms developed from?

Auto Accident Work-Related Other

Have you reported this to your:

insurance company

Yes No

employer

Yes No

What aggravates this condition?

What decreases the symptoms/pain?

Have you seen a doctor for this condition?

Yes No

Doctor's Name:

Date consulted:

Diagnosis:

Does this condition interfere with your sleep?

Yes No

If so, how many times do you wake up in pain per night?

In what position do you sleep?

Back Side Stomach

Does it cause pain to cough or sneeze?

Yes No

If so, where?

Does heat affect the pain?

Yes No

If so, how?

Does cold affect the pain?

Yes No

If so, how?

Do you wear a heel lift?

Yes No

If so, which side?

Right Left

Check those activities below during which you experience difficulty or pain:

If other, specify:

Fill out the next three sections as they apply to you

Headaches

Do you have a family history of headaches?

Yes No

Do you get headaches?

Yes No

Frequency

Do you experience the following along with your headaches: Pain or cracking in your jaw?

Yes No

Abnormal blood pressure?

Yes No

High Low

Nausea, Vomiting or Visual disturbances?

Yes No

When was your last eye exam by a doctor?

1-6 months 6-12 months 1-2 years over 2 years

Results:

Lower Back Pain

Do you ever experience ripping or tearing sensations in your back?

Yes No

If so, where?

Does pain radiate to the abdomen?

Yes No

Do you ever have impairment of bowel or urinary function?

Yes No

Explain:

Neck Pain

If you have a neck injury, does it effect: (Check all that apply)

Hearing

Vision

Balance

Cause ringing in your ears

Do you hear grating sounds?

Yes No

Do you feel pressure or pain behind your eyes?

Yes No

Do you feel ripping or tearing?

Yes No

Where?

Do you have difficulty lifting or turning your head?

Yes No

If so, in which direction?

Right Left Up Down

If female, are you pregnant?

Yes No Not sure

If yes, what is your due date:

List all medications you are taking now, including over the counter medication.

Are you allergic to any medications:

Yes No Not Sure

Please list:

Have you ever had any surgeries or hospitalizations?

Yes No

Please List

Add Hospitalization/Surgery:

Have you been x-rayed in the last 12 months?

Yes No

When?

Have you ever been seen by a chiropractor before?

Yes No

Please List

Add Chiropractor:

Do you have a family physician?

Yes No

Name of physician:

Phone

Additional Complaints

Add new row

Please Specify Location:

Numbness

Swelling

Cuts

Bleeding

Broken Bones

Bruising

Add new row

Do you have, or have you ever had, any diseases or medical problems not listed?

Yes No

If so, please list:

Any additional information you would like the doctor to know about before beginning care

Emergency Contact

Name:

Relation:

Home Phone:

Work Phone:

Address:

City

State:

Zip:

Insurance Information

Insurance Company:

Phone #:

Address:

City

State:

Zip:

Insured's Name:

Insured's SS#

Group #

Insured's Birth Date:

Insured's Employer

Personal Information

Address:

City

State:

Zip:

Home Phone:

Work Phone:

Mobile Phone:

Pager:

Email:

Birth Date:

Age:

Sex

Male Female

Spouses Name:

# of Children:

Occupation:

Employers' Name:

Work Address:

City

State:

Zip:

How were you referred

Informed Consent

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment,any fees for professional services rendered me will be immediately due and payable. I will be responsible for any costs of collection, attorney's fees or court costs required to collect my bill.

I hereby authorize physicians and staff at CENTER OF GRAVITY to treat my condition as deemed appropriate. It is understood and agreed the amount paid the doctor for X-rays, is for examination only and the X-ray negatives will remain the property of this office, being on file where they may be seen at any time. The doctor will not be held responsible for any pre-existing medically diagnosed conditions.

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any staff member of CENTER OF GRAVITY Chiropractic office responsible for any errors or omissions that I may have made in the completion ofthis form.

Chiropractic, as well as many other types of health care, is associated with potential risks in the delivery of treatment. Therefore it is necessary to inform the patient ofsuch risks prior to initiating care. While chiropractic treatment is remarkably safe,you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment.

Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal and if the results are not acceptable, we will refer you to another provider who we feel can further assist you.

Specific Risk Possibilities Associated with Chiropractic Care.

Soreness- Chiropractic adjustments and physical therapy procedures are sometimes accompanied by post treatment soreness. This is a normal and acceptable accompanying response to chiropractic care and physical therapy.While it is not generally dangerous, please advise your doctor if you experience soreness or discomfort.

Soft Tissue Injury- Occasionally chiropractic treatment may aggravate a disc injury, or cause other minor joint, ligament, tendon or other soft tissue injury.

Rib Injury- Manual adjustments to the thoracic spine, in rare cases, may cause rib injury or fracture. Precautions such as pre-adjustment xrays are taken for cases considered at risk. Treatment is performed carefully to minimize such risk.

Physical Therapy Burns- Heat generated by physical therapy modalities may cause minor burns to the skin.These are rare, but if it occurs you should report it to your doctor, or a staff member at.

Stroke- Stroke is the most serious complication of chiropractic treatment. The most recent studies (Journal of the CAA, Vol. 37 No. 2, June, 1993) estimate that the incidence ofthis type of stroke is 1 in every 3 million upper cervical adjustments.

Other Problems- There are occasionally other types of side effects associated with chiropractic care. While these are rare, they should be reported to your doctor promptly.

If you have any questions concerning this form or the above statements, please ask your doctor.

Having carefully read the above, I hereby give my informed consent to have chiropractic treatment administered.

Patient Signature:

Date:

Parent/Legal Guardian Signature:

Date:

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