Office Only LIST AND DETAIL YOUR PRIMARY HEALTH CONCERNS BELOW

Office use only: TCPA

Greater Life Chiropractic Health Profile TP DE: Y N Time:____________

Name_________________________________________Date___/___/___Age____ Male/Female Address_________________________________City____________State____Zip_____ Phone: Home______________ Cell______________ Cell Phone Provider__________________ Email Address_________________________________________________ Date of Birth___/___/_____ Occupation_______________________ Employer's Name _____________________________ Single / Married / Divorced / Widowed Spouse's Name____________________________ Number of Children____ Names, Ages & Gender_____________________________________ ______________________________________________________________________________ Who may we thank for referring you? ______________________________________Office Only______________

LIST AND DETAIL YOUR PRIMARY HEALTH CONCERNS BELOW

Health Concerns: List according to severity

1. __________________

Rate of Severity 1 = mild 10 = unbearable

_______________

When did this episode start?

____________

If you had the condition Did the problem

Are symptoms

before, when?

begin with an injury? constant or

intermittent?

______________ _____________ ______________

2. __________________ _______________ ____________ ______________ _____________ ______________

3. __________________ _______________ ____________ ______________ _____________ ______________

4. __________________ _______________ ____________ ______________ _____________ ______________

5. __________________ _______________ ____________ ______________ _____________ ______________

HAVE YOU EVER SEEN OTHER DOCTORS FOR THESE CONDITIONS? YES / NO

CHIROPRACTOR? ________________ MEDICAL DOCTOR?______________OTHER_________

WHO AND WHEN?______________________________________________RESULT_______________________________

CIRCLE ALL ADDITIONAL OR SECONDARY HEALTH PROBLEMS YOU CURRENTLY HAVE

DIZZINESS HEADACHES VERTIGO EAR INFECTIONS NAUSEA TMJ NECK PAIN MIGRAINES ANXIETY CHRONIC SINUS

THROAT ISSUES THYROID PROBLEMS ASTHMA ULCERS NUMBNESS IN ARMS NUMBNESS IN HANDS MENSTRUAL DISORDER HEART DISORDERS STOMACH DISORDERS BLADDER PROBLEMS

KIDNEY PROBLEMS MID BACK PAIN IRRITABLE BOWEL SCIATICA NUMBNESS IN LEGS NUMBNESS IN FEET LOW BACK PAIN HIP PAIN LEG PAINS KNEE PAIN

LIVER DISEASE SHOULDER PAIN CHRONIC FATIGUE LUPUS FIBROMYALGIA CHEST PAIN ARM PAIN ADD/ADHD ______________ _______________

NERVOUSNESS EPILEPSY DISC PROBLEM INFERTILITY GASTRIC REFLUX

OTHER____________ __________________ __________________ __________________

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CIRCLE ANY CONDITION YOU HAVE NOW/ HAVE HAD:

STROKE CANCER HEART DISEASE

SPINAL SURGERY

SEIZURES SPINAL BONE FRACTURE

SCOLIOSIS DIABETES

LIST ALL SURGICAL OPERATIONS AND YEARS__________________________________________________________

__________________________________________________________________________________________________

LIST ALL Over the Counter & PRESCRIPTION MEDICATIONS YOU ARE ON:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

WHEN WAS YOUR LAST AUTO ACCIDENT_____________________________________________________________

HAVE YOU HAD PREVIOUS CHIROPRACTIC CARE? YES / NO

IF YOU HAVE, DR. & DATE________________________________________________________________________

HAVE YOU EVER BEEN KNOCKED UNCONSCIOUS? YES / NO

FRACTURED A BONE? YES / NO

IF YES, PLEASE DESCRIBE_____________________________________________________________________

OTHER TRAUMA:___________________________________________________________________________

SOCIAL HISTORY

1. Smoking: cigars pipe cigarettes How often? Daily Weekends Occasionally

2. Alcoholic Beverage: consumption occurs

Daily Weekends Occasionally

3. Recreational Drug use:

Daily Weekends Occasionally

4. Hobbies -Recreational Activities- Exercise Regime: How does your present problem affect?

Never Never Never

(See activities of daily living [ADL] form next page)

*PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling

What relieves your symptoms? ____________________________

What makes them feel worse? _____________________________

FAMILY HISTORY: 1. Does anyone in your family suffer with the same condition(s)? No Yes

If yes whom: grandmother grandfather mother father sister(s) brother(s) son(s) daughter(s)

Have they ever been treated for their condition? No Yes I don't know 2. Any other hereditary conditions the doctor should be aware of? No Yes:

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LIST RESTRICTED ACTIVITY

CURRENT ACTIVITY LEVEL

USUAL ACTIVITY LEVEL

EXAMPLE: Sleeping ___________________ EXAMPLE: Can only sleep 2 hours________ EXAMPLE: I normally sleep for 8 hours____

____________________________________ ____________________________________ ____________________________________

____________________________________ ____________________________________ ____________________________________

____________________________________ ____________________________________ ____________________________________

____________________________________ ____________________________________ ____________________________________

____________________________________ ____________________________________ ____________________________________

ACTIVITIES OF LIFE

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

_____ACTIVITIES: Carry Children/Groceries Sit to Stand Climb Stairs Pet Care Extended Computer Use Lift Children/Groceries Read/Concentrate Getting Dressed Shaving Sexual Activities Sleep Static Sitting Static Standing Yard work Walking Washing/Bathing Sweeping/Vacuuming Dishes Laundry Garbage Driving Other: _____________

No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect No Effect

EFFECT: Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits) Painful (can do) Painful (limits Painful (can do) Painful (limits) Painful (can do) Painful (limits)

Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform Unable to Perform

Doctor signature_____________________________________ Date_________________

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Practice Member Information (Must be Completed Before Services Can Be Rendered)

NAME: __________________________________________________________________________________

FIRST

MIDDLE

LAST

PHONE: Home______________________ Cell______________________ Work__________________

SOCIAL SECURITY NUMBER: _____________________

MARITAL STATUS: ____________

DATE OF BIRTH: _____________________

CONTACT IN CASE OF EMERGENCY: _________________________ Phone #: _________________

NAME OF PRIMARY INSURANCE CARRIER: ________________________________________________

Name of Insured_________________________

Insured Date of Birth __________________

Insured Social Security Number __________________

NAME OF SECONDARY INSURANCE CARRIER: _____________________________________________

Name of Insured_________________________

Insured Date of Birth __________________

Insured Social Security Number: __________________

Insurance Policies and Fee Schedule

o Consultation- includes practice member history. This service is complimentary o Assessment (new or established practice member)- includes one or more of the following: thermography, surface

electromyography, range of motion, motion and/or static palpation, leg check $50-$75. o Chiropractic Adjustment- The actual re-alignment of the vertebra done by hand. Often a sound will be heard, but if

there is no auditory result, it does not mean that the adjustment has not taken place. $40-$60. o X-rays- Specific x-ray views taken of your spine to determine a misalignment/subluxation of your vertebrae. These can

also be used to indicate progress after period of care. $40 per view.

Release of Authorization/Assignment of Benefits I authorize and request payment of insurance benefits directly to Grant Lisetor, DC I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.

Signed_______________________________________________

Date___________________

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