©Take 2, LLC 2/12/2020 Fruita Chiropractic & Massage – PAGE 1 OF 4

Welcome to Fruita Chiropractic & Massage PERSONAL INFORMATION

PLEASE PRINT CLEARLY

LAST Name FIRST Name Middle Name/Initial

Birthdate Age: SSN Gender

☐ MALE ☐ FEMALE ☐ Other

Mailing Address City State & Zip

Home Phone Cell Phone Best Contact Method:

☐ Home ☐ Cell ☐ E-mail

E-Mail Address for newsletter, occasional practice

updates, and info on massage services

MARITAL STATUS ☐ Single ☐ Married ☐ Divorced ☐ Widowed LANGUAGE ☐ English ☐ Spanish ☐ Other______________

RACE/ETHNICITY ☐ White/Caucasian ☐ American Indian or Alaskan Native ☐ Asian ☐ Native Hawaiian/Other Pacific Islander

☐ Black/African American ☐ Hispanic/Latino ☐ Decline to Answer ☐ Other __________________________

Employment Status: ☐ Full Time ☐ Part Time ☐ Unemployed ☐ Retired ☐Self-Employed ☐Student

☐ Other:_____________________________________________________________________

Occupation Employer Telephone

Emergency Contact – a friend or family member in the event you cannot be contacted. Name Primary Phone ☐ Home ☐ Cell Relationship to you:

HOW DID YOU HEAR ABOUT US? __________________________________________________________________________________

INSURANCE INFORMATION – Please present your photo ID and Insurance Card to Font Desk.

PRIMARY INSURANCE SECONDARY INSURANCE

Insurance Company Patient is Primary Member? ☐ YES ☐ NO ☐ YES ☐ NO IF NO – COMPLETE INSURED (POLICY HOLDER) INFORMATION

Who is the policy subscriber?

Birthdate

Social Security Number Relationship to Patient ☐ Spouse ☐ Parent ☐Other:

_____________________________________

☐ Spouse ☐ Parent ☐Other: ____________________________________

OFFICE: ❑ CHECKED NAMES AND COPIED/SCANED PHOTO ID AND INSURANCE CARD __________

I certify that I, and/or my dependents, have insurance with the above-named insurance company(s) and assign directly to Fruita Chiropractic &

Massage all benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions.

I understand that co pays, unmet deductibles, and/or co-insurance amounts are payable at the time of each visit and that I am financially

responsible for all charges whether or not paid by insurance. The above-named provider’s office may use my health care information and may

disclose such information to the above-named insurance company(s) and their agents for the purpose of obtaining payment for services and

determining benefits payable for related services.

□ Private Pay/Cash: By checking this box, I acknowledge that I do not have insurance and understand that I am financially responsible for

all services at the time they are rendered. Name of person responsible for this account:_________________________________________

□ Workers Comp / Auto Ins Claim By checking this box, I acknowledge that I am responsible for providing all relevant claim information

and I am ultimately responsible for all charges incurred should the Third Party Payor fail to pay per the practice’s Patient Payment Policy.

X Signature (Parent/Guardian) Printed Name Date

©Take 2, LLC 2/12/2020 Fruita Chiropractic & Massage – PAGE 2 OF 4

REASON FOR VISIT

What is the reason for today’s visit? ☐ Headache ☐ Neck Pain ☐ Mid-Back Pain ☐ Lower Back Pain ☐ Other:_____________

_____________________________________________________________________________________________________________

What caused this issue or what made it bad enough to seek treatment for it? ____________________________________________

_____________________________________________________________________________________________________________

Is this condition due to an accident? ☐ Yes ☐ No If yes, do you have: ☐ Worker’s Comp Claim ☐ Auto Ins. ☐ Home Ins.

When did this complaint begin? ____/________/______ Is it getting worse? ☐ Yes ☐ No ☐ Constant ☐ Comes and goes

Have you had this or similar complaint in the past? ☐ Yes ☐ No If “Yes”, when?_________________________________________

What does your complaint (s) feel like? Circle all that apply: Sharp / Dull / Sore / Stiff / Tight / Aching / Spasms / Throbbing /

Stabbing / Shooting / Burning / Cramping / Nagging / Tingling / Numbness / Other___________________________________

←Please Circle or make an “X” on the body diagram to the left where you have pain or other

symptoms.

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

___________________________________________________________________________

On the scale below, please circle the severity of your main complaint:

Is your pain: ☐ Constant ☐ Frequent ☐ Intermittent ☐ Occasional

☐ Only when performing certain activities, describe:___________________________________

When is it better/worse? Better Worse No Difference Any numbness or tingling? ☐ Yes ☐ No

Morning ☐ ☐ ☐ Any muscle weakness? ☐ Yes ☐ No

As the day progresses ☐ ☐ ☐ Any? ☐ Stiffness ☐ Swelling ☐ Cramping

Afternoon ☐ ☐ ☐

Evening ☐ ☐ ☐ Since it began, is your condition:

After Activities ☐ ☐ ☐ ☐ Improving ☐ Getting Worse

During Activities ☐ ☐ ☐ ☐ Staying the Same

What makes the pain worse? Check all that apply: ☐ Standing ☐ Sitting ☐ Lying Down ☐ Walking ☐ Bending ☐ Exercise

☐ Other: _________________________________________________________________________________________________

What makes the pain better? Check all that apply: ☐ Standing ☐ Sitting ☐ Lying Down ☐ Walking ☐ Resting ☐ Stretching

☐ Massage ☐ Heat ☐ Ice ☐ Nothing ☐ Unknown ☐ Other_____________________________________________________

How often do you experience your pain? ☐ 25% of Day ☐ 50% of Day ☐ 75% of day ☐ 100% of Day

☐ When performing certain activities, please describe _________________________________________________:_____________

Does your complaint interfere with your daily activities? ☐ Not at all ☐ a little bit ☐ Moderately ☐ Quite a bit ☐ Extremely

Have you seen another provider for this problem? ☐ Yes ☐ No If so whom & when?___________________________________

PRIOR CHIROPRACTIC HISTORY Have you been to see a chiropractor before? ☐ Yes ☐ No If Yes: Dr’s Name ________________________________________

Approximately when was your last adjustment: _____________________________________________________________________

What were the circumstances / injury: ____________________________________________________________________________

Was your experience positive? ☐ Yes ☐ No

Have you had any imaging of your spine performed? X-Ray: ☐ Yes ☐ No CT Scan: ☐ Yes ☐ No MRI: ☐ Yes ☐ No

If so, approximately when ☐ Past Month ☐ Past Three Months ☐ Past Six Months ☐ Past Year ☐ More than a year ago

PRINT NAME:________________________________________________________________ DATE:__________________________

No Pain Mild Pain Moderate Severe

0 1 2 3 4 5 6 7 8 9 10

L R R L

©Take 2, LLC 2/12/2020 Fruita Chiropractic & Massage – PAGE 3 OF 4

GENERAL HEALTH HISTORY

Physician / Primary Care Provider Office / Clinic Telephone

When was your last Physical Exam? _______________________________ Height ________ft ______in Weight: ___________lbs

Are there any health issues the doctor should be aware of? ☐ Yes ☐ No If Yes: ________________________________________

YOUR HISTORY Please check ALL of the health conditions below

that apply to you currently or in the past.

Family History

Mark ALL conditions that run in your family Father, Mother, Sister, Brother,

Maternal Grandmother/Grandfather, Paternal Grandmother/Grandfather)

☐ Whiplash, Date of Injury: ________________________________ Relative: M F S B MGM MGP PGM PGP

☐ Osteoporosis ☐ Headaches Osteoporosis ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Osteoarthritis/Degenerative Joint Disease

☐ Migraines Ostoperosis/Degenerative Joint Disease

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Rheumatoid Arthritis ☐ Concussion Rheumatoid Arthritis ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Fibromyalgia ☐ Disc Herniation Fibromyalgia ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ High Blood Pressure ☐ Epilepsy / Seizures High Blood Pressure ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Heart Disease / Attack ☐ Depression / Anxiety Heart Disease ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Stroke ☐ Blood Clots Stroke ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Diabetes □ Type I □ Type II Was your blood/lab work test for hemoglobin A1c > 9.0%? □ Yes □ No □ Not Sure

☐ Joint Pain: Circle location: Shoulder, Elbow, Wrist, Hip, Knee, Ankle Other:___________

Diabetes Indicate Type 1 (T1) Or Type II (T2)

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Cancer/Tumor Type:

☐ Changes in Urination Cancer Type:

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

☐ Please list any other medical conditions:

Other: ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Are you currently taking any prescription medications? ☐ Yes ☐ No

Name of prescription medication Dosage/Start date Name of prescription medication Dosage/Start date

1. 4.

2. 5.

3. 6.

Any FRACTURES? (Broken Bones, Sprains, Strains, Major Trauma/Injury? ☐ Yes ☐ No

Fracture/Trauma/Injury (body part) Date/Time Period Fracture/Trauma/Injury (body part) Date/Time Period

1. 4.

2. 5.

Any SURGERIES and/or HOSPITALIZATIONS? ☐ Yes ☐ No

Surgery Date/Time Period Surgery Date/Time Period

1. 4.

2. 5.

FEMALES ONLY: Are you pregnant? ☐ Yes ☐ No If yes, how far along: ___________________________

ALLERGIES

Do you have any topical (creams/ointments) allergies? ☐ Yes ☐ No If yes, to what_________________________________

Do you have any allergies to medications? ☐ Yes ☐ No If yes, please specify:

_________________________________________________________________________________________________________

Do you have any other known allergies? ☐ Yes ☐ No If yes, please specify:

_________________________________________________________________________________________________________

PRINT NAME:________________________________________________________________ DATE:__________________________

©Take 2, LLC 2/12/2020 Fruita Chiropractic & Massage – PAGE 4 OF 4

SOCIAL & LIFESTYLE HISTORY Exercise/Sports

☐ None

☐ Daily

☐ Weekly

Type: __________

_______________

_______________

_______________

Lifestyle

☐ Smoking ☐ Current ☐ Every day ☐ Some Day

☐ Former Smoker

☐ Alcohol ☐ Casual ☐ Moderate ☐ Heavy

☐ Coffee/Tea/Caffeine - if checked, how many drinks per day?

☐ Under 3/day ☐ 3-6 per day ☐ Over 6/day

Drug Use: ☐ None ☐ Recreational ☐ Addict ☐ Former Addict

Work Habits

☐ Sitting

☐ Standing

☐ Mixed Sitting / Standing

☐ Heavy Computer Use

☐ Light Labor

☐ Heavy Labor

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 used as a Doctor of Chiropractic is spinal manipulative therapy. 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: As part of the analysis, examination, and treatment, you consent to the following procedures:

• spinal manipulative therapy • palpation • vital signs • range of motion testing

• orthopedic testing • basic neurological testing • postural analysis • muscle strength testing

• Electrical Stimulation • ultrasound • hot/cold therapy • radiographic studies

• Graston (a manual therapy technique to mobilize soft tissue

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 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.

ACNOWLEDGEMENT OF RECEIPT OF HIPPA PRIVACY NOTICE

I, the undersigned, have been provided and read a copy of this office’s Notice of Privacy Practices, and have had a copy made available for my records if desired. I understand that I have certain rights to privacy regarding my Protected Health Information (PHI). I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the health care providers who may be directly and indirectly

involved in providing my treatment.

Obtain payment from third-party payers.

Conduct normal health care operations such as quality assessments and accreditation.

I understand and consent to appointment reminders used by the practice by phone and/or leaving a message by voicemail. I have

indicated on Page 1 of this form if there is a preferred contact phone for me.

PATIENT CERTIFICATION & CONSENT

I, the undersigned:

1) Certify that the statements made on this form are complete and accurate to the best of my knowledge.

2) Agree notify the doctor immediately if I have any changes in my health condition.

3) Acknowledge that I have read and understand Fruita Chiropractic and Massage’s Patient Financial/Payment Policy.

4) Acknowledge that I have read and understand Fruita Chiropractic and Massage Protocols and Consent above and agree

to be treated at Fruita Chiropractic and Massage.

X Signature (Parent/Guardian) Printed Name Date

I understand that I am asked to provide 24 hours notice if I need to cancel my appointment, and that I may be charged the following: $25 for chiropractic appointments. (Which will not be covered by your insur-

ance policy.)

50% of massage appointment if cancelled after 24 hours cut off, but 4 hours before your appointment time.

100% of massage appointment if cancelled within 4 hours or less of appoint-ment or missed completely.

We do understand that special circumstances may arise that might cause unfore-seen missed appointments. We may waive the policy if you give us a courtesy call to explain your situation. We strive to give the best quality care and would like to listen and help you the best we can.

Signature: ____________________________________

Date: _________________

CancellationPolicy