Please indicate where you areexperiencing pain or discomfort.

CONFIDENTIAL PATIENT INFORMATION

CURRENT HEALTH CONDITIONS

YOUR HEALTH GOALS

First Name:

SS#: - -

Marital Status:

Street Address:

City:

Email:

Emergency Contact:

How did you hear about us?

Who is your primary care physician?

Date and reason for your last doctor visit:

Are you also receiving care from any other health professionals? Yes No

- If yes, please name them and their specialty:

Please note any significant family medical history:

Last Name:

DOB: / /

# of Children:

Cell Phone: - -

Emergency Relation:

Date: / /

Sex: M F

Occupation:

Height: ft. in.

Weight: lbs.

Other Phone: - -

Emergency Phone: - -

State: Zip:

What health condition(s) bring you into our office?

Have you received care for this problem before? Yes No

- If yes, please explain:

When did the condition(s) first begin?

How did the problem start? Suddenly Gradually Post-Injury

Is this condition: Getting worse Improving Intermittent Constant Unsure

What makes the problem better?

What makes the problem worse?

Your top three health goals:

1.

2.

3.

Atone Chiropractic

© 2018 WELL ALIGNED PRODUCTS

TRAUMAS: Physical Injury History

TOXINS: Chemical & Environmental Exposure

ACKNOWLEDGEMENT & CONSENT

Please rate your CONSUMPTION for each:

Please rate your STRESS for each:

CHIROPRACTIC HISTORY

THOUGHTS: Emotional Stresses & Challenges

What would you like to gain from chiropractic care? Resolve existing condition(s) Overall wellness Both

Have you ever visited a chiropractor? Yes No If yes, what is their name?

What is their specialty? Pain Relief Physical Therapy & Rehab Nutritional Subluxation-based Other:

Do you have any health concerns for other family members today?

Ha e you e er had any significant falls surgeries or other in uries as an adult? es o- If yes, please explain:

Notable childhood injuries? Yes No If yes, please explain:

Youth or college sports? Yes No If yes, list major injuries:

Any auto accidents? Yes No If yes, please explain:

Exercise Frequency? None 1-2x per week 3-5x per week DailyWhat types of exercise?

Ho do you normally slee ? ac ide tomach o you a e u : efreshed and ready ti and tired

Do you commute to work? Yes No If yes, how many minutes per day?

ist any roblems ith e ibility. (e . Putting on shoes soc s etc.)

How many hours per day you typically spend sitting at a desk or on a computer, tablet or phone?

Please list any drugs medications itamins herbs other that you are ta ing and hy.

Alcohol

Water

Sugar

Dairy

Gluten

Processed Foods

rtificial eeteners

Sugary Drinks

Cigarettes

Recreational Drugs

None Moderate High None Moderate High

Home

Work

Life

Money

Health

Family

None Moderate High None Moderate High

Date:Patient Name:

Atone Chiropracticinfo@atonechiropractic.com atonechiropractic.com

/ /

Patient Review of SystemsTHE NERVOUS SYSTEM CONTROLS AND COORDINATES ALL ORGANS AND STRUCTURES OF THE HUMAN BODY

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Patient Name:

Please check the corresponding boxes for each symptom or condition you have experienced – including both past and present.

REGIONS FUNCTIONS SYMPTOMS

Cervical

• Autonomic Nervous

System

• ENT System

• Vision, Balance &

Coordination

• Speech

• Immune System

• Digestive System

• Nerve Supply to

Shoulders, Arms

& Hands

• Sympathetic Nucleus

• Metabolism

Colic & Excessive Crying Epilepsy & Seizures

Ear & Sinus Infections Sensory & Spectrum

Allergies & Congestion ADD / ADHD

Immune Deficiency Focus & Memory Issues

Headaches & Migraines Anxiety & Stress

Vertigo & Dizziness Balance & Coordination

Sore Throat & Strep Speech Issues

Swollen Tonsils & Adenoids TMJ / Jaw Pain

Vision & Hearing Issues Stiff Neck & Shoulders

Low Energy & Fatigue Depression

Difficulty Sleeping High Blood Pressure

Pain, Numbness & Tingling

in Arms to Hands

Poor Metabolism &

Weight Control

Upper Thoracic

• Upper G.I.

• Respiratory System

• Cardiac Function

Reflux / GERD Bronchitis & Pneumonia

Chronic Colds & Cough Functional Heart Conditions

Asthma

Mid Thoracic

• Major Digestive

Center

• Detox & Immunity

Gallbladder Pain / Issues Indigestion & Heartburn

Jaundice Stomach Pains & Ulcers

Fever Blood Sugar Problems

Lower Thoracic

• Stress Response

• Filtration &

Elimination

• Gut & Digestion

• Hormonal Control

Behavior Issues Allergies & Eczema

Hyperactivity Skin Conditions / Rash

Chronic Fatigue Kidney Problems

Chronic Stress Gas Pain & Bloating

Lumbar, Sacrum & Pelvis

• Lower G.I.

(Absorption &

Motility)

• Gut-Immune System

• Major Hormonal

Control

Constipation Sciatica & Radiating Pain

Chrohn’s, Colitis & IBS Lumbopelvic / SI Joint Pain

Diarrhea Hamstring Tightness

Bed-wetting Disc Degeneration

Bladder & Urination Issues Leg Weakness & Cramps

Cramps & Menstrual Issues Poor Circulation & Cold Feet

Cysts & Endometriosis Knee, Ankle & Foot Pain

Infertility Weak Ankles & Arches

Impotency Lower Back Pain

Hemorrhoids Gluten & Casein Intolerance

PAST

PRES

ENT

PAST

PRES

ENT

Date: / /

Outcome Assessment Tool Please circle the number that best describes the question asked. If you have more than one complaint, please answer each question for each individual complaint and indicate the score of each complaint.

EXAMPLE:

No pain Worst possible pain 0 1 2 3 4 5 6 7 8 9 10

1. How would you rate your pain RIGHT NOW?

0 1 2 3 4 5 6 7 8 9 10

2. What is your typical or AVERAGE pain?

0 1 2 3 4 5 6 7 8 9 10

3. What is your pain level at its BEST? (How close to 0 does your pain get at its best?)

0 1 2 3 4 5 6 7 8 9 10

4. What is your pain level at its WORST? (How close to 10 does your pain get at its worst?)

0 1 2 3 4 5 6 7 8 9 10

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

ACTIVITY: EFFECT: Sit to Stand □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Walking □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Running □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Climbing Stairs □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Driving □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Extended Computer Use □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Household Chores □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Lifting Objects □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Sleep □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Sitting for Long Periods □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Standing for Long Periods □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Dressing □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Concentration (Reading) □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Other: ___________ □ No Effect □ Painful (can do) □ Painful (limits) □ Unable to Perform

Informed Consent for Chiropractic Care

Chiropractic care, like all forms of health care while offering considerable benefits may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases, injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include: sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the rarest complications associated with chiropractic care occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral injury that could lead to a stroke.

Prior to receiving chiropractic care in the chiropractic office, a health history and physical examination will be completed. These procedures are performed to assess your specific conditions, your overall health and in particular your spinal health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, this will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care.

• I understand and accept that there are risks associated with chiropractic care, and give consent to the examination and chiropractic care that the doctor deems necessary, including spinal adjustments, as reported following my assessment.

Print Name: ___________________________________________________ Signature: ________________________________________________ Date: ___________________

If This Health Profile Is for a Minor/Child, Please Fill Out and Sign Below

Written Consent for a Child Name of Practice Member who is a Minor/Child:___________________________________________ I authorize Dr. Joseph Benne and any and all Atone Chiropractic staff to perform diagnostic procedures, radiographic evaluations, render chiropractic care and perform chiropractic adjustments to my minor/child. As of this date, I have the legal right to select and authorize health care services for my minor/child. If my authority to select and authorize care is revoked or altered, I will immediately notify Atone Chiropractic.

Guardian Signature: ______________________________________ Date: ______________________

Relationship to Minor/Child: ____________________________________

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA). I understand that this information can and will be used to: 1. Conduct, plan and direct my care and follow-up among the multiple healthcare providers who may be involved in that care directly and indirectly. 2. Obtain payment from third-party payers. 3. Conduct normal healthcare operations, such as quality assessments and physicians’ certifications. I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my private information is disclosed to carry out care, payment, or healthcare operation. Release of Information: □ I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:

□ Spouse ______________________________________________

□ Child(ren) ____________________________________________

□ Other ________________________________________________

□ Information is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing. Signature: ___________________________________________________Date: _____________________

X-Ray Authorization

As your healthcare provider, we are legally responsible for your chiropractic records. We must maintain a record of your x-rays in our files. At your request, we will provide you with a copy of your x-rays. Digital x-rays on a CD will be available within 72 hours of any regular practice hour day. Please note: X-rays are utilized in this office to help locate and analyze vertebral subluxations. The doctor of Atone Chiropractic does not diagnose or treat medical conditions; however, if any abnormalities are found, we will bring it to your attention so that you can seek proper medical advice. Print Name: _____________________________________________ Date of Birth: _________________ Signature: _________________________________________________ Date: _______________________ FEMALE PRACTICE MEMBERS ONLY: To the best of my knowledge, I BELIEVE I AM NOT PREGNANT at the time the x-rays are taken at Atone Chiropractic. Signature: __________________________________________________ Date: _______________________

Financial Policy Agreement We are committed to providing you and your family the best neurologically-based chiropractic care possible in a loving and caring environment. We have established our financial policies to assist us in achieving that goal. We offer a variety of payment options and have a federal discount program available which maximizes your savings whether you have health insurance or not. All payments are due at or before the time of your service. We are happy to provide RECEIPTS for your flexible spending accounts, health savings accounts, health insurance reimbursement, and end of year income tax statements.

• I understand that payment is due at the time of my service: We appreciate the commitment you are making to your health. If you have insurance that reimburses for chiropractic or would like to apply your care towards your deductible, we can supply you with the receipts/statements that you’ll need to send to your insurance company. If they cover the service, they will reimburse you directly. They are responsible to you, as the subscriber, not to us, the provider.

**If you have Medicare insurance*- We are a NON-PARTICIPATING office with Medicare. Government regulations restrict our team from providing Medicare covered individuals the standard of care that we hold for ourselves. If you would like to use your Medicare benefits, we can help you find an office that is able to work with you and your needs. **NOTE: If you are in any Medicare HMO, the Medicare restrictions apply.

Print Name: ___________________________________________________ Signature: ____________________________________________________ Date: ___________________

Photo Release Agreement

I grant Atone Chiropractic and its employees the right to take photographs of me with connection to the promotion of chiropractic via websites, social media, and any other avenues. I agree that Atone Chiropractic may use such photographs of me and for any lawful purpose, including such purposes as publicity, illustration, advertising, and web content. By signing below you are agreeing to the above statement (IF UNDER 18, legal guardian must sign)

Print Name: ___________________________________________________ Signature: ____________________________________________________ Date: ___________________