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To download a PDF of the Adult Health Record form to print and fill out, click here.

Or you can fill out the online form below:

About You

NAME:
ADDRESS:
CITY:
STATE/ ZIP CODE:
HOME PHONE:
CELL PHONE:
EMAIL ADDRESS:
DATE OF BIRTH:
 / 
 / 
SOCIAL SECURITY NUMBER:
GENDER:
MARITAL STATUS:
NUMBER OF CHILDREN:
EMPLOYER ADDRESS:
WORK PHONE:
POSITION:
PAYMENT METHOD:

About Your Spouse

SPOUSE NAME:
SPOUSE EMPLOYER:
SPOUSE POSITION:

Health Habits

DO YOU SMOKE?
DO YOU DRINK ALCOHOL?
DO YOU DRINK COFFEE, TEA, OR SODA?
DO YOU EXERCISE REGULARLY?
DO YOU WEAR:

Medications You Take

CHECK ANY THAT APPLY

Chiropractic Experience

WHO REFERRED YOU TO OUR OFFICE?
HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF (CHECK ALL THAT APPLY:
HAVE YOU BEEN ADJUSTED BY A CHIROPRACTOR BEFORE?
IF YES, WHAT WAS THE REASON FOR THOSE VISITS?
DOCTOR'S NAME:
APPROXIMATE DATE OF LAST VISIT
 / 
 / 
HAS ANY MEMBER OF YOUR FAMILY SEEN A CHIROPRACTOR

Reason for this visit

DESCRIBE THE REASON FOR THIS VISIT:
CHECK ANY APPLICABLE CAUSES FOR YOUR VISIT:
IF OTHER, PLEASE BRIEFLY EXPLAIN:
WHEN DID THIS CONCERN BEGIN?
HAS THIS CONCERN:
DOES THIS CONCERN INTERFERE WITH:
HAS THIS CONCERNED OCCURRED BEFORE?
HAVE YOU SEEN OTHER DOCTOR'S FOR THIS CONCERN?
IF YES, DOCTOR'S NAME:
TYPE OF TREATMENT:
RESULTS:

Supplements you take

CHECK ALL THAT APPLY:

Many problems and health challenges can start as 'nerve interference' blocking the vital power that operates and heals our body.�

Are you aware that...

DOCTORS OF CHIROPRACTIC WORK WITH THE NERVOUS SYSTEM?
THE NERVOUS SYSTEM CONTROLS ALL BODILY FUNCTIONS AND SYSTEMS?
CHIROPRACTIC IS THE LARGEST NATURAL HEALING PROFESSION IN THE WORLD

Your Concerns

CHECK ANY AND ALL THAT APPLY:

Goals for your Care

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of what is malfunctioning in their body. you Doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Select the type of care preferred:

Health

Please check each of the diseases or conditions that you now have or have had in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

CHECK ANY AND ALL THAT APPLY

For Women Only:

ARE YOU PREGNANT?
IF YES, WHEN IS YOUR DUE DATE?
ARE YOU NURSING
ARE YOU TAKING BIRTH CONTROL
DO YOU EXPERIENCE PAINFUL PERIODS
HAVE IRREGULAR CYCLES?
HAVE BREAST IMPLANTS
SURGERIES: (PLEASE LIST ALL SURGERIES YOU HAVE HAD)

Informed Consent for Chiropractic Treatment

I understand that, as in the practice of medicine, in the practice of chiropractic care there are some risks to treatment, including and not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest.

By checking this box I agree to the above and allow the Doctor affiliated with Active Family Chiropractic, to perform such. This consent will cover the entire course of my treatment.*

Authorization for Care

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, 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.
I agree that I am responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre -existing medically
diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for p rofessional services rendered me will become immediately due and payable.
I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider for services rende red. I understand
and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. I understa nd that the
Doctor’s Office will prepare any necessary reports and forms to assist me in collecting from the insurance company and that any amou nt
authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt.
Ownership of X-ray Films: It is understood and agreed that the payments to the Doctor for X -rays is for examination of X-rays only.
The X-ray negative will remain the property of the office. They are kept on file where they may be seen at any time while I am a patient at
this office.

Check this box to agree to the above.

Notice of Privacy Policy

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health informati on without
authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public hea lth, research, and law
enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made onl y after obtaining
your consent.
   - You may request restrictions on your disclosures.
   - You may inspect and receive copies of your records within 30 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 its staff .
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to priv acy 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 understan d that I can
request, in writing, that you restrict how my personal information is used and or disclosed.

Check to agree to our Privacy Policy