General Intake Form

Patient Information

Date

First Name

Last Name

Date of Birth

Address

City

State

zip code

email address

Phone number

Marital Status

Spouse Name

occupatation

Employer

Name of your primary physician

Medical Information

What is the reason for your visit today?

How long have you had these concerns?

How often do you experience your symptoms?

Average Pain Level

Have you experienced any restrictions in your activities of daily living, social or recreational?

If so, is it:

Daily activities I'm having issues with

Is there a certain time of day your pain is better or worse?

Anything that makes your condition better?

Anything that makes your condition worse?

List any medications and/or supplements you are currently taking

Allergies

Have you ever been diagnosed with cancer?

Date of Diagnosis

Type of cancer diagnosed

Still considered active?

Treatment receiving/received

Have you had Covid?

Covid Vaccine?

Booster(s)?

Check all that applyPACEMAKER/DEFIBRILLATORPAIN PUMP/STIMULATORHEART DISEASEEPILEPSYANXIETYCONCUSSIONMEMORY ISSUESTROUBLE SLEEPINGDEPRESSIONSTROKEARTHRITISGOUTVASCULAR DISEASEHIGH BLOOD PRESSUREHIGH CHOLESTEROLGERO/REFLUX/HEARTBURNKIDNEY DISEASECARPAL TUNNELSPINAL FUSIONSEXUAL/ERECTILE DYSFUNCTIONSHINGLESURINARY/BOWEL INCONTINENCE

Please list any surgeries and/or injections:

List three main health goals you would like to accomplish:

Do you exercise regularly?

Do you smoke/vape?

Do you drink alcohol?

How many drinks per week?

What outcome would you like to see for this to be considered a success?

After treatment, if you have to accept some pain, what level of pain would you consider acceptable?

I want to get better because I want to:

My health is an investment or expense:

Wellness Evaluation

In medicine today, leaky gut aka intestinal permeability, isn't typically diagnosed. However that doesn't mean it's not affecting your health. Many health issues related to gut health go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please complete this evaluation to help our doctors determine how we can help your condition.

Let's get started. Please check any that apply to you:

Sub-Clinical Symptoms Including:HeadachesMigraines

Hormone Imbalance Including:PMSEmotional imbalance

Gastrointestinal Issues Including:Abdominal bloating, cramps or painful gasIrritable Bowel SyndromeUlcerative ColitisCrohn's Disease and other intestinal disorders

Respiratory Conditions Including:Chronic sinusitisAsthmaAllergies

Joint Conditions Including:Knee, Shoulder, or Spine

Autoimmune Conditions Including:Diabetes MellitusLupusRheumatoid ArthritisFibromyalgiaChronic Fatigue

Thyroid Conditions Including:HashimotosHypothyroidismHyperthyroidism

Developmental and Social Concerns Including:AutismADD/ADHD

Skin Conditions Including:EczemaSkin rashesHives

Place the number that most closely fits into each field, then add up your results.

0 - None

1 - Mild

2 - Moderate

3 - Severe

Constipation and/or diarrhea

Abdominal pain or bloating

Mucous or blood in stool

Joint pain or swelling, arthritis

Chronic or frequent fatigue or tiredness

Food allergies, sensitivities or intolerance

Sinus or nasal congestion

Eczema, skin rashes or hives (urticaria)

Chronic or frequent inflammations

Asthma, Hayfever, or airborne allergies

Confusion, poor memory or mood swings

Use of NSAIDS (Aspirin, Tylenol. Motrin)

History of antibiotic use

Gluten sensitivity or Celiac's disease

Alcohol consumption makes you feel sick

Nausea

Weight issues

Your total

Patient Informed Consent

I, the undersigned, consent to discussing my personal medical history, full exam, x-rays and potentially care at this clinic. I understand that I have the opportunity to discuss with the medical team and/or with the office personnel, the nature and purpose of chiropractic adjustments, clinic and/or home wellness therapies and regenerative medicine. After examination, if accepted as a patient, I hereby consent to chiropractic treatments including various modes of physiotherapy, diagnostic x-rays and any supportive therapies on myself (or on the patient above, for whom I am legally responsible) by staff.

I understand that as is with all healthcare, treatments/results are not guaranteed, there is no promise to cure, and that there are some risks. Risks include, but are not limited to: aggravating and/or temporary increase in symptoms, muscle spasms, fractures, disc injuries, stroke, dislocations and sprains. I do not expect the staff to be able to anticipate and explain all risks and complications, and I wish to rely on the staff's judgment based upon the facts and/or correct specific conditions to help allow the body to return to improved health.

I have read or have had read to me, this consent. I have also had the opportunity to ask questions about its content and by signing below, I agree to the discussion of my personal medical history with the staff and what options for therapy may/may not be advised based on exam findings.

Patient/Guardian Name

Consent to Treat Minor

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