Today’s date ____________________

Name: _______________________________________________________________________________________________

Street Address: ________________________________________________________________________________________

City: _____________________________________________ State: ______________________Zip: ____________________

Cell phone: _______________________Home phone: _______________________Work Phone: ______________________

Email:___________________________________________________Birthday:__________________ Age:_______________

Spouse’s Name:________________________________________________________________________________________

Name(s) and Age(s) of Children: __________________ __________________ __________________ __________________

Occupation:___________________________________________________________________________________________

Primary doctor:______________________________________ May we contact that doctor?________________________

Have you had previous chiropractic care? No Yes

If yes, who was your previous Chiropractor?________________________________________________________________

Why did you go? Please circle: Relief care Corrective Care Wellness Care

Have you had spinal x-rays taken and when?_______________________________________________________________

Other Specialists and Healthcare professionals:

Name:__________________________________________________ Profession:___________________________________

Date and reason for last visit:___________________________________________________________________________

Name:__________________________________________________ Profession:___________________________________

Date and reason for last visit:___________________________________________________________________________

To your knowledge was your birth/delivery difficult? No Yes

If yes circle: Forceps Caesarean Vacuum Breech Other___________________________________________________

Were you breast fed? No Yes For how long? ________________________________________________________________

Did you experience trauma as a child? No Yes _______________________________________________________________

Were you given antibiotics as a child? No Yes________________________________________________________________

Did you ever have ear infections as a child? No Yes___________________________________________________________

Any major childhood illness? No Yes _______________________________________________________________________

Rate your current level of personal stress in your life. . . . . . . . . . . . . . . None Low Moderate High

Rate your current level of relationship stress in your life. . . . . . . . . . . . .None Low Moderate High

Rate your current level of financial stress in your life. . . . . . . . . . . . . . . None Low Moderate High

Rate your current level of health stress in your life. . . . . . . . . . . . . . . . .None Low Moderate High

Rate your current level of family stress in your life. . . . . . . . . . . . . . . . . None Low Moderate High

Rate your current level of career stress in your life. . . . . . . . . . . . . . . . .None Low Moderate High

Do you feel you have a supportive network of friends and family?. . . . . . . .YES NO

Do you feel you have healthy strategies for coping with life stress? . . . . . . YES NO___________________________

Dr. Nicole Rothman

399 B Winchester Park Blvd

Boynton Beach, FL 33436

Phone (561) 740-2340

Fax (561) 740-2644

www.DrNicole.com

Wellness Profile

Were you vaccinated as a child? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes__________________________

Any adverse reactions to vaccines? . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes__________________________

Do you choose to have annual flu shots? . . . . . . . . . . . . . . . . . . . . . . . . No Yes__________________________

Do you choose to get any other adult vaccines?. . . . . . . . . . . . . . . . . . . No Yes _________________________

Do you take anti-biotics? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes__________________________

Did you ever have mono (mononucleosis)? . . . . . . . . . . . . . . . . . . . . . . .No Yes__________________________

Have you ever been bitten by a tick? . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes__________________________

Have you traveled to any developing countries?. . . . . . . . . . . . . . . . . . . No Yes__________________________

How many glass of water a day. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 1-3 4-6 7-9 10+

How many glasses of caffeinated beverages/day. . . . . . . . . . . . . . . . . . . 0 1-3 4-6 7-9 10+

How many glasses of cow’s milk, juice or soda/day. . . . . . . . . . . . . . . . . 0 1-3 4-6 7-9 10+

DO you eat gluten?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes Trying to eliminate

Do you eat dairy? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes Trying to eliminate

Do you eat refined sugars/ (white sugar, white bread, pasta). . . . . . . . . . No Yes Trying to eliminate

Do you eat boxed/frozen foods? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes Trying to eliminate

Do you choose organic foods? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes Veg Fruit Meat Grain All

Do you eat artificial sweeteners? (splenda, aspartame, diet soda…). . . . . . No Yes Trying to eliminate

Any food/drink allergies, intolerances or sensitivities? . . . . . . . . . . . . . . No Yes____________________________

How many times do you eat out each week? . . . . . . . . . . . . . . . . . . . . . 0 1-3 4-6 7-9 10+

Do you smoke? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes I used to for ___ years

Are you or have you been exposed to second hand smoke? . . . . . . . . . . . . No Yes

Do you drink alcohol? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-6 6-12 12+

Do you have implants of any kind (dental, breast…) . . . . . . . . . . . . . . . . No Yes_____________________________

Do you have dental amalgams (metal fillings) . . . . . . . . . . . . . . . . . . . . No Yes

Do you have root canal(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes How many?________________

Have you have any teeth extracted? . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes_____________________________

Do you take supplements and what dose of each?___________________________________________________________

_____________________________________________________________________________________________________

What medications are you currently taking and what for?____________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Do you have a plan in place to wean yourself off any long term medications? No Yes

What are the 3 healthiest foods you eat in a week?_________________________________________________________

What are the 3 worst foods you eat in a week?____________________________________________________________

Height__________ Weight____________Are you happy with your current appearance and abilities? No Yes

Frequency of exercise each week: Cardio____________ Weight bearing_______________ Other________________

Hours of sleep each night? _________ Are you refreshed upon waking? No Yes

Do you stay asleep all night? No Yes What position do you sleep in?__________________________________________

Number of hours spent commuting/week? 0-2 3-5 6-8 9-11 12+

Number of hours per week on a computer or sitting at a desk? 0 1-5 6-10 11-20 21-40 40+

Number of hours per week on a phone or tablet? 0 1-5 6-10 11-20 21-40 40+

Do you perform repetitive tasks at home or work? No Yes

Have you ever been hospitalized or had surgery? No Yes If yes, why and when?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Have you ever been in a motor vehicle accident even if minor? No Yes, if yes what kind and when?

______________________________________________________________________________________________________

Were you evaluated and treated after each accident? No Yes

Any other accidents or falls? No Yes ______________________________________________________________________

What are your primary reasons for seeking care with us?

1.______________________________________ 2. ________________________________________

3.______________________________________ 4. ________________________________________

How long have you suffered with these problems?____________________________________________________________

Would you like improvement with the following?

Digestion: Reflux, gas, Constipation, diarrhea

Sleep: Falling asleep, staying asleep, waking up refresher

Sense of Well Being

Energy

What have you tried doing to resolve these problems that DID NOT work?_______________________________________

______________________________________________________________________________________________________

Have you become discouraged or stressed about handling this problem?_________________________________________

______________________________________________________________________________________________________

When your problem is at its worse, how does it make you feel?_________________________________________________

______________________________________________________________________________________________________

When your problem is at its worse, how much older does it make you feel?______________________________________

Do you know how this problem may have started?____________________________________________________________

How does this problem interfere with the following areas of your life?

Work: ________________________________________________________________________________________________

Family: _______________________________________________________________________________________________

Hobbies: ______________________________________________________________________________________________

Life: _________________________________________________________________________________________________

What effect does this have on your body functions?__________________________________________________________ ______________________________________________________________________________________________________

Are you here visiting us to:

Resolve my immediate problem

Life style program for optimize living

Both

Other: _____________________________________________________________________________________________

How have you taken care of your health in the past?

Medications Holistic

Routine Medical Vitamins

Exercise Chiropractic

Diet and Nutrition Other:_______________________________

How did the previous methods work for you?________________________________________________________________

______________________________________________________________________________________________________

What are you afraid this might be or will be affecting without change? Please circle

Job Freedom

Kids Future Abilities

Marriage Finances

Sleep Time

Are there any health conditions you are afraid this might turn into?

Stress Arthritis

Weight Gain Cancer

Heart Disease Diabetes

Depression Use of a cane or walker

Bed-ridden Other:____________________________________

Surgery Other:____________________________________

Where do you picture yourself in the next 3-5 years if this problem is NOT taken care of? Please be specific

___________________________________________________________________________________________________

___________________________________________________________________________________________________

__________________________________________________________________________________________________

What would be different of better without this problem? Please circle

Diminished stress Sleep

More energy Work

Self-esteem Outlook

Confidence Family

If we were to sit down and discuss your life 3 years from now and look back at today, what would have to have

happened for you to be happy with your progress? (Please take your time and don’t sell yourself short! Include

anything that is part of your happiness, whether health, family, work, finances, travel, marriage, or bucket list)

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

What potential barriers do you foresee that would prevent these things from happening?

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Do you feel it is possible to eliminate these potential barriers?

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

What are your strengths that will enable you to accomplish your goals?

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Do you agree that your previous efforts have not gotten you to your goals and you need help? __________________

___________________________________________________________________________________________________

Rate on a scale of 1-10 for EACH

__________How important is it for you to resolve your health concerns?

__________Do you feel that you are coachable and would enjoy a mentor in helping you?

__________Are you prepared to make the appropriate lifestyle changes that may be necessary in order for you to

achieve your goals?

In our practice, we are not only interested in your health and wellness, but also in the health and wellness of the

important people in your life. Please mention below any health conditions or concerns you may have about your:

Children:__________________________________________________________________________________________

Spouse:____________________________________________________________________________________________

Mother:____________________________________________________________________________________________

Father:____________________________________________________________________________________________

Brothers/Sisters:____________________________________________________________________________________

Friend(s):__________________________________________________________________________________________

Co-worker(s):_______________________________________________________________________________________

Metabolic Assessment Form Please circle the appropriate number to all questions below and then tally your score.

If you never experience the symptom, leave it blank. Rank the system in terms of frequency and severity with 1 being the lowest and 3 the highest.

If you have a certain diagnosis, some of these will give you an automatic 5 points.

Category I: GI

A. Leaky Gut

Diagnosis of Celiac, Crohn’s, Colitis or IBS (5 points) 5

Diarrhea 1 2 3

More than 3 bowel movements a day 1 2 3

Stools that are green or clay colored 1 2 3

Mucous on the stool 1 2 3

Bloating 1 2 3

Constipation 1 2 3

Hard, Dry, or small stool 1 2 3

Sense of Fullness with little food 1 2 3

Difficulty with fatty foods 1 2 3

GERD/Reflux 1 2 3

Belching, burping 1 2 3

Frequent use of antibiotics 1 2 3

Stomach Pain 1 2 3

Total

B. Dysbiosis/Candidiasis

Gas 1 2 3

Bloating with carbohydrates/sugar 1 2 3

Sugar Cravings 1 2 3

White Tongue 1 2 3

Worse with sugar or carbohydrates 1 2 3

Brain Fog 1 2 3

Foul Smelling Gas 1 2 3

Rectal Itching 1 2 3

Toe fungus, jock itch, athletes foot 1 2 3

Bad breath 1 2 3

Worse with vegetables/fruit/fiber 1 2 3

Total

Category II: Toxicity

Gallbladder removal 5

Sensitive to Smells 1 2 3

Can’t have caffeine late in the day 1 2 3

Often have opposite reactions to medications and supplements 1 2 3

Use or around pesticides 1 2 3

Frequent dry cleaning 1 2 3

Leakage, wet carpets, or water damage 1 2 3

Feel better when I leave my home 1 2 3

Bitter metallic taste in the mouth 1 2 3

History of gallbladder attacks or stones 1 2 3

Never sweat or sweat very easily 1 2 3

Itchy Skin 1 2 3

Reddened skin 1 2 3

Yellowish cast to eyes 1 2 3

Eat fish 3 or more times a week 1 2 3

Total

Category III: Inflammation/Pain/Musculoskeletal

Fibromyalgia 1 2 3

Headaches/migraines (non-hormonal) 1 2 3

Joint Pain 1 2 3

Muscle Aches 1 2 3

Early morning stiffness 1 2 3

Swelling 1 2 3

Frequent use of NSAIDS 1 2 3

Decreased range of motion 1 2 3

Total

Category IV: Cognitive

Diagnosis of or feelings of: Depression, Anxiety, Cognitive Decline (5 points for one)

5

Poor memory 1 2 3

Poor concentration 1 2 3

Mood Swings 1 2 3

Total

Category V: Nervous System

Numbness 1 2 3

Tingling 1 2 3

Diminished Sensation of hot or cold 1 2 3

Loss of smell 1 2 3

Diminished hearing 1 2 3

Total

Category VI: Hormones (female)

A. Menopause

Hot flashes 1 2 3

Brain fog 1 2 3

Insomnia 1 2 3

Osteopenia or Osteoporosis 1 2 3

Diminished quality of life 1 2 3

Change in voice 1 2 3

Change in skin 1 2 3

Total

B. Menstruation

Diagnosis of Endometriosis, PCOS or Fibroids 5

Fertility issues 1 2 3

Cramps 1 2 3

Breast Tenderness 1 2 3

Cycles greater than 32 days or less than 24 days 1 2 3

Pain with period 1 2 3

Scanty or heavy blood flow 1 2 3

Irritability with period 1 2 3

Headaches with period 1 2 3

Acne 1 2 3

Facial hair growth 1 2 3

Hair loss or thinning 1 2 3

Total

Category VII: Hormones (male)

Poor libido 1 2 3

Erectile dysfunction 1 2 3

Fatigue 1 2 3

Irritability/low moods 1 2 3

Poor muscle mass 1 2 3

Weak Urine Flow 1 2 3

Total

Category VIII: Adrenal

Fatigue 1 2 3

Dizziness or lightheaded 1 2 3

Shaky or irritable when hungry 1 2 3

Sugar cravings 1 2 3

Salt cravings 1 2 3

Worse with exercise 1 2 3

Better with naps 1 2 3

Get a second wind at night 1 2 3

Wake feeling unrefreshed 1 2 3

Stress makes things worse 1 2 3

Difficulty sleeping at night 1 2 3

Use of steroids 1 2 3

Anxious 1 2 3

Headaches with Stress 1 2 3

Inward trembling 1 2 3

Can’t get over things easily, easily stressed 1 2 3

Total

Category IX: Thyroid

Diagnosis of Hashimoto’s or Graves (5 points) 1 2 3

Fatigue 1 2 3

Weight Gain 1 2 3

Constipation 1 2 3

Thin hair and/or breaking nails 1 2 3

Menstrual irregularities 1 2 3

Cold hands and feet 1 2 3

Feeling blue or depressed 1 2 3

Sleep excessively, 9 hours or more 1 2 3

Thinning eyebrows 1 2 3

No body hair 1 2 3

Dry skin 1 2 3

Mental sluggishness 1 2 3

Total

Category X: Cardiovascular

Diagnosis of High blood pressure or high cholesterol (5 points) 5

History of Stroke or TIAs 5

Chest tightness/Angina 1 2 3

Arrhythmia 1 2 3

Palpitations 1 2 3

Pulse higher than 80 1 2 3

Total

Category XI: Immune

Diagnosis of an Autoimmune Disease such as Lupus, RA, MS, Psoriasis, or another (5 points)

5

Low White Blood Cell Count 1 2 3

Takes more than 3-4 days to recover from a cold 1 2 3

Migratory pain 1 2 3

Lymph nodes that swell and remit 1 2 3

Periodic sweating (when not working out) 1 2 3

Fatigue that had a sudden onset 1 2 3

Frequent or recurrent infections 1 2 3

Frequent use of antibiotics 1 2 3

Total

Category XII: Allergies

Seasonal Issues 1 2 3

Sensitivities to foods 1 2 3

Hives 1 2 3

Headaches 1 2 3

Itching 1 2 3

Rashes 1 2 3

Eczema 1 2 3

Worse in moldy buildings 1 2 3

Shortness of Breath 1 2 3

Chest Tightness 1 2 3

Total

Category XIII: Metabolic

Diagnosis of Diabetes type II, Metabolic Syndrome or PCOS (5 points) 1 2 3

Weight gain 1 2 3

Frequent thirst and urination 1 2 3

Numbness or Tingling 1 2 3

Poor wound healing 1 2 3

Reoccurring yeast infections 1 2 3

Fatigue after meals 1 2 3

Crave sugar 1 2 3

Eat sugar daily 1 2 3

Gain weight around the middle 1 2 3

Gain weight easily even with minimal carbohydrate/sugar intake 1 2 3

Total

Rothman Health Solutions

When a person seeks health care from us and we accept that person for such care, it is essential for us both to be working towards the same objective. OUR FUNCTIONAL WELLNESS CURRICULUM has only one goal: to educate the practice member in order to help them optimize the functions of their body by changing their lifestyle and by becoming self-empowered. Any nutritional advice or supplements given are not used to treat disease or symptoms but to address the underlying dysfunction of the body and how it relates to interference in the nervous system and impacts their overall health. CHIROPRACTIC has only one goal: TO ELIMINATE VERTEBRAL SUBLUXATIONS WITHIN THE SPINAL COLUMN WHICH INTERFERE WITH THE EXPRESSION OF THE BODY’S INNATE WISDOM. It is important that each practice member understand both the objective and the method that will be used to attain our goal. This will prevent any disappointment. HEALTH: A complete state of physical, mental and social well-being, not merely the absence of disease or infirmity. Health = 100% Function. NERVOUS SYSTEM: Brain, spinal cord and nerves which are the master control system, controlling all function of your entire body, every cell, organ, gland, tissue, muscle, and system. VERTEBRAL SUBLUXATION: A misalignment of one or more vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a decrease in the body’s innate ability to express its maximum health potential, and thereby lowering the body’s resistance. ADJUSTMENT: The specific application of gentle forces to facilitate that body’s correction of vertebral subluxation. Our chiropractic method of correction is specific adjustments of the spine which may be done by hand or by instrument. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life. We do not offer to diagnose or treat any disease or condition. Our chiropractic adjustments only address vertebral subluxation. Our wellness recommendations only address changes in lifestyle that trigger the healing process of the body. However, if during the course of any test or examination we encounter non-chiropractic or unusual findings, we will advise. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Any lifestyle or nutritional advice given is to reduce causes of subluxation. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatments prescribed by others. OUR ONLY PRACTICE OBJECTIVE IS TO ELIMINATE MAJOR INTERFERENCE TO THE EXPRESSION OF THE BODY'S INNATE WISDOM, THEREBY RELEASING THE BODY’S INNATE HEALING POTENTIAL TO ACHIEVE OPTIMAL HEALTH AND WELL-BEING. Our only method to correct vertebral subluxation is a specific adjustment. I, _________________________________Have read and fully understand the above statements. (Print name) All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore, accept chiropractic care on this basis. X __________________________________________ _________________________ Signature of Practice Member or Legal Guardian Date

Rothman Health Solutions

Receipt of Notice of Privacy Practice Written Acknowledgement:

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.

List below the names & relationships of people to whom you authorize us to release your private health information.

______________________________ ________________________________

______________________________ ________________________________

Authorizations to release records and financial responsibility:

I understand that Rothman Health Solutions does not accept assignment for any insurance carriers including Medicare and all fees for services shall be paid when services are rendered. I authorize Rothman Health Solutions to release any medical records regarding my case to my insurance carrier and/or attorney if requested but will hold no

liens for care or bill my auto or workman’s comp for any services received. I agree to pay all of my medical bills directly to Rothman Health Solutions. Any fees for collection procedures

by an attorney or third party are my responsibility.

Informed Consent:

A chiropractic examination and specific wellness testing will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, specialized instrumentation, and laboratory testing. X-rays may be recommended and taken by Diagnostic Centers of America. In addition to the benefits of chiropractic care, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them. Risks associated with some chiropractic adjustments may include soreness, musculoskeletal sprain/strain, and fracture. In addition there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between medical or chiropractic care and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. A recent study by United Health Care Optum Health says there is no causal relationship between the adjustment and stroke but we are required to inform you anyway. However, you are being informed of this reported association because a stroke may cause serious neurological impairment. I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and

the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment. I HAVE READ ALL OF THE ABOVE PARAGRAPHS. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE DR. NICOLE ROTHMAN TO PROCEED WITH CHIROPRACTIC ADJUSTMENTS.

DATED THIS ____ DAY OF _____________, 20___

X ___________________________________________ __________________________ Signature of Practice Member or Legal Guardian Doctor’s Signature

Permission to use name and picture:

I give Rothman Family Chiropractic permission to use my name and picture on practice materials used inside and outside the office (i.e. brochures, newsletters, testimonials, internet, advertisements) and on the walls of our office (i.e. our welcome board). Please circle one: INSIDE ONLY OUTSIDE ONLY BOTH INSIDE AND OUTSIDE NONE

X____________________________________________ _______________________ Signature of Practice Member or Legal Guardian Date