CHIROPRACTIC PATIENT FORM

First Name:

Last Name:

Address:

City:

State:

Zip:

Birthdate:

Age

SSN

Primary Home Phone:

Cell Phone:

Work Phone

Email:

Work Email:

Occupation:

Employer:

Emergency Contact:

Name:

Relationship

Phone #

Family Physician Name:

City:

How were you referred to Dr. Andrew Cherry?

What is the reason for your visit today/what are your complaints?

What caused this complaint(s)?

When did this complaint begin?

If “Yes”, when?

Mark the areas on the image where you are experiencing symptoms

What area(s) does the pain radiate, shoot, or travel to? (if applicable)?

Have you seen other doctors for this complaint?

Yes No

If “Yes”, please provide the following information:

Doctor’s Name:

Date consulted:

Diagnosis

WOMEN ONLY:

Currently Pregnant?

Yes No

FRACTURES (Broken Bones, Sprains, Strains, Major Trauma/Injury

SURGERIES and/or HOSPITALIZATIONS

Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days?

Yes No

List current prescription medications, including frequency and dosage if known

If there are NO current medications, check here

Add Prescription Medications

SOCIAL HISTORY

Do you exercise?

Yes No

Times per week?

Type?

Do you drink alcohol?

Yes No

How many drinks per week?

For how many years?

Do you drink caffeine?

Yes No

How many drinks per day?

What type?

Coffee

Tea

Soft Drinks

Energy Drinks

Do you take pain killers?

Yes No

What type?

Aspirin

Ibuprofen

Tylenol

Other

What do your work duties include?

Sitting

Standing

Light Labor

Heavy Labor

Other:

Have you seen a chiropractor in the past?

Yes No

What are your hobbies?

INFORMED CONSENT

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

The nature of the chiropractic adjustment:

The primary treatment I use, as a Doctor of Chiropractic, is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. This may cause an audible “pop” or “click“, much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis / Examination / Treatment

The material risks inherent in chiropractic adjustment.

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatments. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The availability and nature of other treatment options.

Other treatment options for your condition may include:
1-Self-administered, over-the-counter analgesics and rest 2-Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers 3-Hospitalization 4-Surgery

If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

The risks and dangers attendant to remaining untreated.

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I have read the above explanation of the chiropractic adjustment and related treatment. I have discussed it with the Doctor Andrew Cherry & Associates and have had my questions answered to my satisfaction. I certify that the information I have provided is correct to the best of my knowledge. I will not hold my doctor or any staff member at Doctor Andrew Cherry & Associates responsible for any errors or omissions that I may have made in the completion of this form nor will I hold Dr Cherry responsible for any damages or injuries from treatment. By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.

Patient’s Name

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient, Parent or Legal Guardian (if a minor)

Date:

By signing above, I acknowledge that I understand that I am financially responsible for all services at the time they are rendered.

Your information will be encrypted.