New Patient Application Form Date* Date Format: MM slash DD slash YYYY Name* First Middle Last Age*Birth Date*Gender* Male Female Height*Weight*Social Security #*Marital Status* S M D W Race/Ethnicity* White/Caucasian Black/African American Asian American Indian Native Hawaiian Hispanic/Latino/Spanish Origin Home Address*Home Phone*City, State, ZIP*Work Phone*Email* Cell Phone*Occupation*Employer Name*Language* English Spanish Chinese Other Other LanguageNames and Ages of Children*Spouse's NameWork PhoneCell PhoneSpouse's EmployerOccupationHow were you referred to this office?*Purpose of This VisitReason for this visit – Main Complaint*Is this purpose related to an auto accident / work injury?* Yes No If so, whenWhen did this condition begin?*Did it begin* Gradual Sudden Progressive over time What activities aggravate your symptoms?*Is there anything, which has relieved your symptoms?* Yes No Describe DescribeType of pain* Sharp Dull Ache Burn Throb Spasm Numb Tingling Shooting Does the pain radiate into your* Arm Leg Does not radiate Is this condition getting worse?* Yes No How often do you experience these symptoms throughout the day?* 100% 75% 50% 25% 10% Only with activity Does complaint(s) interfere with Work Sleep Hobbies Daily Routine ExplainHave you experienced this condition before?* Yes No If so, please explainWho have you seen for this?*What did they do?*How did you respond?*Experience with ChiropracticHave you seen a Chiropractor before?* Yes No Who?When?Reason for visitsHow did you respond?Did your previous chiropractor take before and after x-rays? Yes No Did you know posture determines your health?* Yes No Are you aware of any of your poor posture habits?* Yes No ExplainAre you aware of any poor posture habits in your spouse or children?* Yes No ExplainThe most common postural weakness is Forward Head Syndrome (head and neck starting to bend forward and progressively moving downward weakening your whole body). Even less severe forms of this posture can cause many adverse affects on your overall health.Have you ever been told or felt like you carry your head forward, noticed a rounding of your shoulders or a developing “hump” at the base of your neck?* Yes No Health LifestyleDo you exercise?* Yes No How Often?* 1x per week 2x per week 3x per week 4x per week 5x per week What activites?* Running Jogging Weight Training Cycling Yoga Pilates Swimming Have you ever smoked?* Yes No Do you currently smoke?* Yes No How much?If yes would you like information on quitting?Do you drink alcohol?* Yes No How much / weekDo you drink coffee?* Yes No How many cups / dayDo you take any supplements (i.e. vitamins, minerals, herbs)?*HEALTH CONDITIONS Abnormal postural habits or distortions are the result of trauma or stress to the body that have misaligned the vertebrae in your spine. When these vertebrae are twisted from their normal position, they will cause stress to the spinal cord and the delicate nerves that pass between the vertebrae. These misalignments are called Subluxations (sub-lux-a-shuns). It has been extensively documented that subluxations, causing stress to your nerves, will weaken and distort the overall structure of your spine. This results in a weakened and distorted POSTURE. Postural distortions have many serious and adverse affects on your overall health. The most common and detrimental postural distortion is called Forward Head Syndrome (a “hunched forward” posture starting in the neck and progressively moving down your spine weakening the entire body). Please check any health condition you may be experiencing, now or in the past. CERVICAL SPINE (NECK): Postural distortions from subluxations, (causing Forward Head Syndrome), in your neck will weaken the nerves into your arms, hands and head affecting these parts of your bodyDo you experience...? Neck Pain Pain into your shoulders/arms/hands Numbness/tingling in arms/hands Hearing disturbances Weakness in grip Headaches Dizziness Visual Disturbances Coldness in hands Thyroid conditions Sinusitis Recurrent colds/Flu Low energy/Fatigue TMJ/Pain/Clicking Allergies/Hay Fever Other Other/ExplainTHORACIC SPINE (UPPER BACK): Postural distortions from subluxations (resulting from Forward Head Syndrome) in the upper back will weaken the nerves to the heart and lungs and affect these parts of your body.Do you experience...? Heart Palpitations Heart Murmurs Tachycardia Heart Attacks/Angina Recurrent Lung Infections/Bronchitis Asthma/Wheezing Shortness Of Breath Pain On Deep Breathing THORACIC SPINE (MID BACK): Postural distortions from subluxations (resulting from Forward Head Syndrome) in the mid back will weaken the nerves into your ribs/chest and upper digestive tract, and affect these parts of your body. Do you experience...? Mid Back Pain Pain Into Your Ribs/Chest Indigestion/Heartburn Reflux Nausea Ulcers/Gastritis Hypoglycemia Tired/Irritable after eating or when you haven’t eaten for a while LUMBAR SPINE (LOW BACK): Postural distortions from subluxations in the low back (resulting from Forward Head Syndrome) will weaken the nerves into your legs/feet and pelvic organs and affect these parts of your body.Do you experience...? Pain into your hips/legs/feet Numbness/tingling in your legs/feet Coldness in your legs/feet Muscle cramps in your legs/feet Costipation/Diarrhea Weakness/injuries in your hips/knees/ankles Recurrent bladder infections Frequent/difficulty urinating Menstrual irregularities/cramping (females) Sexual dysfunction Low back pain Please list any health conditions or allergies not mentionedPlease list any medications currently taking and their purposePlease list all past surgeriesPlease list all previous accidents and fallsGoals For My CareIndicate all statements that apply to you* I have a specific health concern I want to ensure that my health concerns do not become an ongoing problem I am interested in learning how to improve my quality of life Are you healthier now than you were 1 year ago?* Yes No If yes, what did you do to accomplish this?Is it your goal to be healthier 1 year from now than you are today?* Yes No Do you have a plan on improving your health?Have you ever been advised on lifestyle choices for good health?* Yes No Terms of AcceptanceWhen a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. Health is a state of optimal physical, mental and social well being, not merely the absence of disease/symptoms. Vertebral Subluxation is a misalignment of one or more of the joints of the body. This may or may not cause pain. This also will result in alteration of nerve function and interference of the transmission of nerve impulses, lessening thebody’s innate ability to heal and achieve optimal health. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. One method is specific adjusting to the correct vertebral subluxation. I have read and fully understand the above statement.*Any questions regarding the Doctor’s objectives pertaining to care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.Patient's Signature*Date*CA SignatureDateAuthorization For CareI hereby authorize the Doctor(s) to work with my condition through the use of spinal adjustments, as he or she deems appropriate. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. The Doctor(s) will not be held responsible for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees will become immediately due and payable. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I understand that Stucky Chiropractic Center, S.C. will prepare any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to Stucky Chiropractic Center, S.C. will be credited to my account on receipt. Patient or Guardian Signature*Date*Notice of Privacy PolicyProtecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research and law enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures You may inspect and receive copies of your records for a fee within 14 days with a request. You may request to view changes to your records. In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and it’s staff. I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician’s certifications. I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and/or disclosed. Patient Name*Patient or Guardian Signature*Date*CA SignatureDate
