Adult NP Paperwork

Acknledgements

To set clear expectations, improve communications, and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.
I instruct the chiropractor to deliver the care that, in his or her professional judgement, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct healing art from medicine and does not proclaim to cure any named disease or entity.*
I may request a copy of the Privacy Policy and understand it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties.*
I realize that an X ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not pregnant.
Date of last menstrual period (MM/DD/YYYY)

MonthDayYear
Date
I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails or health information to me as an extension of my care in this office.
I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non covered services I receive.
To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern.
Patient (or Guardian's) Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

CONFIDENTIAL HEALTH INFORMATION

Demographic Information

Please describe your Primary Complaint in the space below. Use the Secondary and Additional Complaint boxes if they apply.

Primary Complaint

Secondary Complaint

Additional Complaint

How does your current condition interfere with your:

Review of Systems

Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please select any condtion that you've had or currently have.

Health History

Please identify your past health history, including accidents, injuries, illnesses, and treatments. Please complete each section fully.

Illnesses

Allergies

Operations

Treatments

Injuries

Family History

Some health issues are hereditary. Tell Dr. Jones about the health of your immediate family members.

Mother

Father

Sister 1

Sister 2

Brother 1

Brother 2

Additional Entry

Social History

Tell Dr. Jones about your health habits and stress levels.

Activities of Daily Living

How does this condition currently interfere with your life and ability to function?

Acknledgements

To set clear expectations, improve communications, and help you get the best results in the shortest amount of time, please read each statement and initial your agreement.