Healing Hands Chiropractic Center, Dr. Tristin R. Thompson
Patient Name:________________________________________________________Date:__________________________
Address_____________________________________City________________State__________Zip Code _____________
Cell Phone_________________________H. Phone_________________________W. Phone________________________
Email Address: _____________________________________________________________________________________
Sex M F Marital Status M S D W Date of Birth_________________ Age________________
Social Security #_______________________________________________________
Spouse’s Name:_______________________________________________# of Children/Ages:______________________
Occupation________________________________________________________________________________________
Employer__________________________________________________________________________________________
Referred by: _______________________________________________________________________________________
Have you ever received Chiropractic Care? Yes No If yes, when? ___________________________
Name of most recent Chiropractor: _____________________________________________________________________
1. Current Reasons for seeking chiropractic care:
Primary reason: _____________________________________________________________________________________________
Secondary reason: _______________________________________________________________________________________________
2. Previous interventions, treatments, medications, surgery, or care you’ve sought for your complaint(s) above: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3. Past Health History:
A. Please indicate if you have a history of any of the following:
□ Pacemaker □ Heart problems/high blood pressure/chest pain □ Stroke/TIA’s
□ Lung problems/shortness of breath □ Cancer □ Diabetes □ Psychiatric disorders
□ Bipolar disorder □ Major depression □ Neurologic Problems □ Scoliosis
□ Other ________________________________________________________________________
□ None of the above
B. Previous Injury or Trauma/Date: _________________________________________________________________________________________________
Have you ever broken any bones? Which/When? _________________________________________________________________________________________________
C. Allergies: _______________________________________________________________________________________
D. Medications: (if more than space provided below, write on back of this paper)
Medication Reason for taking
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
E. Surgeries: (most recent first)
Date Type of Surgery
____________________ _________________________________________________________________ ____________________ _________________________________________________________________
____________________ _________________________________________________________________ ____________________ _________________________________________________________________ ____________________ _________________________________________________________________
F. Family Medical Doctor:___________________________________________________________________
Reason for visits in the past year/when____________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________
4. Family Health History:
Do you have a family history of? (Please indicate all that apply) Adopted/Unknown__________________
□ Cancer □ Strokes/TIA’s □ Headaches □ Cardiac disease □ Neurological diseases
□ Diabetes □ Arthritis/Scoliosis □ Genetic Spinal Condition
□ Other _________________________________________________ □ None of the above
Deaths in immediate family and Cause:
Age at death
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Social and Occupational History:
A. Job description:
_____________________________________________________________________________________
B. Work schedule: ______________________________________________________________________________________
C. Recreational activities (hobbies & types/level of exercise): ______________________________________________________________________________________
D. Lifestyle (alcohol, tobacco and drug use, diet):
_______________________________________________________________________________________
Review of Systems
Have you had any of the following pulmonary (lung-related) issues?
□ Asthma/difficulty breathing □ COPD □ Emphysema □ Other _________________________ □ None of the above
Have you had any of the following cardiovascular (heart-related) issues or procedures?
□ Heart surgeries □ Congestive heart failure □ Murmurs or valvular disease □ Heart attacks/MIs □ Heart disease/problems □ Hypertension □ Pacemaker □ Angina/chest pain □ Irregular heartbeat □ None of the above
□ Other___________________________________________________________________________________________
Have you had any of the following neurological (nerve-related) issues?
□ Visual changes/loss of vision □ One-sided weakness of face or body □ History of seizures □ One-sided decreased feeling in the face or body □ Headaches □ Memory loss □ Tremors □ Vertigo □ Loss of sense of smell
□ Strokes/TIAs □ Other _________________________________________________________ □ None of the above
Have you had any of the following endocrine (glandular/hormonal) related issues or procedures?
□ Thyroid disease □ Hormone replacement therapy □ Injectable steroid replacements □ Diabetes
□ Other _______________________________________________________________________ □ None of the above
Have you had any of the following renal (kidney-related) issues or procedures?
□ Renal calculi/stones □ Hematuria (blood in the urine) □ Incontinence (can’t control) □ Bladder Infections
□ Difficulty urinating □ Kidney disease □ Dialysis □ Other ___________________________ □ None of the above
Have you had any of the following gastroenterological (stomach-related) issues?
□ Nausea □ Difficulty swallowing □ Ulcerative disease □ Frequent abdominal pain □ Hiatal hernia □ Constipation
□ Pancreatic disease □ Irritable bowel/colitis □ Hepatitis or liver disease □ Bloody or black tarry stools
□ Vomiting blood □ Bowel incontinence □ Gastroesophageal reflux/heartburn
□ Other ________________________________________________________________________ □ None of the above
Have you had any of the following hematological (blood-related) issues?
□ Anemia □ Regular anti-inflammatory use (Motrin/Ibuprofen/Naproxen/Naprosyn/Aleve) □ HIV positive
□ Abnormal bleeding/bruising □ Sickle-cell anemia □ Enlarged lymph nodes □ Hemophilia
□ Hypercoagulation or deep venous thrombosis/history of blood clots □ Anticoagulant therapy
□ Regular aspirin use □ Other _____________________________________________________ □ None of the above
Have you had any of the following dermatological (skin-related) issues?
□ Significant burns □ Significant rashes □ Skin grafts □ Psoriatic disorders
□ Other ________________________________________________________________________ □ None of the above
Have you had any of the following musculoskeletal (bone/muscle-related) issues?
□ Scoliosis □ Gout □ Osteoarthritis □ Rheumatoid arthritis □ Spinal fracture □ Spinal surgery □ Fibromyalgia
□ Arthritis (unknown type) □ Metal implants □ Other __________________________________ □ None of the above
Have you had any of the following psychological issues?
□ Psychiatric diagnosis □ Depression □ Suicidal ideations □ Bipolar disorder □ Homicidal ideations □ Schizophrenia
□ Psychiatric hospitalizations □ Other _______________________________________________ □ None of the above
Is there anything else in your past medical history that you feel is important to your care here? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Type of Payment:_____Cash _____Medical _____Auto Accident _____Medicare _____Medicaid _____Work Comp
Name of Primary Insurance Co_______________________________Secondary Insurance Co______________________
I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with chiropractic care, in accordance with this state's statutes. If my insurance will be billed, I authorize direct payment of medical benefits to Dr. Tristin R. Thompson, Healing Hands Chiropractic Center for services performed. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors to secure the payment of benefits. I understand that I am responsible for all the costs of chiropractic care, regardless of insurance coverage.
HIPAA Notice of Privacy Practices: The patient understands and agrees to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.
Patient or Guardian Signature _____________________________________________Date________________________
Patient Name:______________________________________________________Date:___________________________
Symptom 1 _______________________________________________________________________________________
• On a scale from 0-10, with 10 being the worst, please circle the number that best describes this symptom most of the time: 0 1 2 3 4 5 6 7 8 9 10 (keep in mind 10 is GOING TO/IN the hospital)
• During the time that you are awake, what percentage of the time do you experience the above symptom at the above intensity:
% 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 %
• When did the symptom begin? ___________________________________________________________
o Did the symptom begin suddenly or gradually? (circle one)
o How did the symptom begin? _____________________________________________________
• What makes the symptom worse? (circle all that apply):
o Bending neck forward, bending neck backward, tilting head to left, tilting head to right,
turning head to left, turning head to right, bending forward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up from sitting position, all movements, lifting, driving, walking, running, sleeping, deep breath, cold, heat, lying, nothing
o other (please describe): __________________________________________________________
o Any pain with: cough sneeze bearing down getting off toilet getting out of car/out of bed
• What makes the symptom better? (circle all that apply):
o Rest, ice, heat, stretching, exercise, massage, pain medication, muscle relaxers, sleeping, reclining, sitting, standing, walking, using ointment, hot shower/bath, nothing
o Other (please describe): __________________________________________________________
• Describe the quality of the symptom (circle all that apply):
o Sharp, stabbing, piercing, shooting, stinging, deep, nagging, dull, achy, burning, tingling, numbness, throbbing, toothache, pressure, stiffness, cramping, grabbing, sore, tender
o Other (please describe):___________________________________________________________
• Does the symptom radiate to another part of your body (circle one): yes no
o If yes, where does the symptom radiate? ______________________________________
• Is the symptom worse at certain times of the day or night? (circle one)
o Morning Afternoon Evening Night/Sleep Unaffected by time of day
_____________________________________ ______________ __________________________________
Patient Signature Date Doctor Signature
Patient Name:______________________________________________________Date:___________________________
Symptom 2 _______________________________________________________________________________________
• On a scale from 0-10, with 10 being the worst, please circle the number that best describes this symptom most of the time: 0 1 2 3 4 5 6 7 8 9 10 (keep in mind 10 is GOING TO/IN the hospital)
• During the time that you are awake, what percentage of the time do you experience the above symptom at the above intensity:
% 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 %
• When did the symptom begin? ___________________________________________________________
o Did the symptom begin suddenly or gradually? (circle one)
o How did the symptom begin? _____________________________________________________
• What makes the symptom worse? (circle all that apply):
o Bending neck forward, bending neck backward, tilting head to left, tilting head to right,
turning head to left, turning head to right, bending forward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up from sitting position, all movements, lifting, driving, walking, running, sleeping, deep breath, cold, heat, lying, nothing
o other (please describe): __________________________________________________________
o Any pain with: cough sneeze bearing down getting off toilet getting out of car/out of bed
• What makes the symptom better? (circle all that apply):
o Rest, ice, heat, stretching, exercise, massage, pain medication, muscle relaxers, sleeping, reclining, sitting, standing, walking, using ointment, hot shower/bath, nothing
o Other (please describe): __________________________________________________________
• Describe the quality of the symptom (circle all that apply):
o Sharp, stabbing, piercing, shooting, stinging, deep, nagging, dull, achy, burning, tingling, numbness, throbbing, toothache, pressure, stiffness, cramping, grabbing, sore, tender
o Other (please describe):___________________________________________________________
• Does the symptom radiate to another part of your body (circle one): yes no
o If yes, where does the symptom radiate? ______________________________________
• Is the symptom worse at certain times of the day or night? (circle one)
o Morning Afternoon Evening Night/Sleep Unaffected by time of day
_____________________________________ ______________ __________________________________
Patient Signature Date Doctor Signature
Patient Name:______________________________________________________Date:___________________________
Symptom 3 _______________________________________________________________________________________
• On a scale from 0-10, with 10 being the worst, please circle the number that best describes this symptom most of the time: 0 1 2 3 4 5 6 7 8 9 10 (keep in mind 10 is GOING TO/IN the hospital)
• During the time that you are awake, what percentage of the time do you experience the above symptom at the above intensity:
% 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 %
• When did the symptom begin? ___________________________________________________________
o Did the symptom begin suddenly or gradually? (circle one)
o How did the symptom begin? _____________________________________________________
• What makes the symptom worse? (circle all that apply):
o Bending neck forward, bending neck backward, tilting head to left, tilting head to right,
turning head to left, turning head to right, bending forward at waist, bending backward at waist, tilting left at waist, tilting right at waist, twisting left at waist, twisting right at waist, sitting, standing, getting up from sitting position, all movements, lifting, driving, walking, running, sleeping, deep breath, cold, heat, lying, nothing
o other (please describe): __________________________________________________________
o Any pain with: cough sneeze bearing down getting off toilet getting out of car/out of bed
• What makes the symptom better? (circle all that apply):
o Rest, ice, heat, stretching, exercise, massage, pain medication, muscle relaxers, sleeping, reclining, sitting, standing, walking, using ointment, hot shower/bath, nothing
o Other (please describe): __________________________________________________________
• Describe the quality of the symptom (circle all that apply):
o Sharp, stabbing, piercing, shooting, stinging, deep, nagging, dull, achy, burning, tingling, numbness, throbbing, toothache, pressure, stiffness, cramping, grabbing, sore, tender
o Other (please describe):___________________________________________________________
• Does the symptom radiate to another part of your body (circle one): yes no
o If yes, where does the symptom radiate? ______________________________________
• Is the symptom worse at certain times of the day or night? (circle one)
o Morning Afternoon Evening Night/Sleep Unaffected by time of day
_____________________________________ ______________ __________________________________
Patient Signature Date Doctor Signature
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