New Client Paperwork - Dr. George L. Kraft · Kra FamilyChiropractic .com 2 of 13 New Client Paperwork Office / Fax: 314-200-6092 Cell 314-397-1682 d [email protected]

New ClientPaperwork

KraFamilyChiropractic.com 2 of 13

New Client PaperworkOffice / Fax: 314-200-6092 Cell: 314-397-1682

[email protected] kraftfamilychiropractic.com

Dear Client,

Welcome! And thank you for choosing HOW THE PROCESS WORKS:

STEP 1:

Fill out the new client paperwork. The single most important criteria for us to help you with your health is a comprehen-

sive and detailed health history. Please answer the accompanying ques�ons with as much detail as possible. It is import-

ant for us to know everything about you and your health. Even when you feel the ques�ons may not be directly relevant

to your situa�on, please do your best to answer them.

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It takes tremendous �me and energy for us to help a complicated health case. Our consulta�on �me is very limited

therefore the case review process is very important. Please schedule the appropriate amount of �me (1-2 hours) needed

to complete the ques�ons. Once you're finished, please email it to drgeorge@kra�familychiropractc.com or fax it to:

(314) 200 - 6092.

STEP 2:

During your ini�al consulta�on I will review your health history and make recommenda�ons for lab tests that are appropriate

for your specific health issues.

STEP 3:

Once you have completed your lab tests, I will explain the meaning of your test results to you in a follow up consulta�on.

I will create an individualized therapeu�c program for you including diet changes, nutri�onal supplements, and exercise,

lifestyle and stress management advice.

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STEP 4:

Subsequent consults are scheduled to monitor your progress.

We invite you to contact us via email should you have any ques�ons during the course of our rela�onship. Please email:

drgeorge@kra�familychiroprac�c.com

We look forward to assis�ng you in achieving your current wellness goals, and to guiding you in maintaining wellness

throughout your life.

In health,

Dr. George L. Kra� D.C. Ac.

Kra� Holis�c Wellness & Diagnos�cs

I will also design an on-going wellness program to be revie-

wed and updated with our staff at no charge every six months.

Name: Date:

Address: Country:

City: State: Zip/Postal Code:

Home Phone: Slype ID: (required for Int’l):

Email: Cell Phone:

Please mark your preference for occasional follow up communication from our of ce: ____Email ____Phone

Age: Birth date: Sex: M F Status: M S W D No. of Children:

Occupation: Employer: Years Employed:

Spouse’s Name: Occupation: Employer:

Person Responsible for this Account: Referred by:

What is your major complaint?

What are your overall health goals once your complaints are resolved?

How long has it been since you really felt good?

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List all diagnoses given to you in a timeline sequence and your personal opinions about them.

What’s your opinion on what has happened to your health?

List any treatments, medications or supplements that have improved your health.

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Please answer all quest ons frankly, to the best of your knowledge. All informat on is conf dent al.

Weight ______ Height _______

1. Are you presently taking any medica�ons, nutri�onal supplements or vitamins? If YES please list Brand names anddosage per day please list (a�ach sheet if necessary) __________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

2. In the past, have you used birth control pills and/or an�bio�cs? _________________________________________

a. For how long?____________________________________________________________________________________

3. If you have fillings, please list material(s) used: : _____________________________________________________

4. Do you presently, or have you ever had any of these condi�ons? (circle)

Anemia Frequent Headaches Skin condition

Arthritis Heartburn Thyroid condition

Asthma High blood pressure Unexplained weight change

Chest pains High cholesterol

Chronic cold/f u symptoms Hypoglycemia

Chronic fatigue Kidney problems

Depression Liver problems

Diabetes Osteoporosis

5. How much sleep do you get each night on average?____________________________________________________

____________________________________________

_____________________________________________________________________________________________

7. Do you smoke, drink alchohol or use recrea�onal drugs?____________________________________________

a. How much, how o�en?__________________________________________________________________________

b. how o�en do you drink caffeinated beverages?____________________________________________________

6. Do you have any food allergies, sensi�vi�es or restric�ons?



KraFamilyChiropractic.com

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_________________

______________________________________________________________________________________________

9. Are there foods that you eat on a daily basis, almost daily basis?________________________________________

______________________________________________________________________________________________

a. Do you “miss” these foods if you do not eat them?_______________________________________________________

b. Please list the foods you’ve eaten over the last 2 days?_______________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

___________________________________________________

______________________________________________________________________________________________

a. What do you feel triggered your weight fluctua�on? (circle) heredity stress ea�ng habits boredom

b. Was your weight gain/loss: (circle) sudden gradual problem since childhood

___________________________________

______________________________________________________________________________________________

12. What methods have you tried to lose/gain weight_________________________________________________

_____________________________________________________________________________________________

13. How is your energy level?_____________________________________________________________________

_______________________worst?_________________________

14. Are you happy in your life right now?________________________________________________________________

15. What are your main sources of stress________________________________________________________________

_________________________________________________________________________________________________

16. How do you deal with your stress? __________________________________________________________________

_________________________________________________________________________________________




8. Please list foods you tend to overeat or crave (Sweets, breads, fa�y foods, meats, milk, etc.):

10. Write briefly about your weight gain/loss history:

11. Please list close rela�ves that have diabetes, heart disease or obesity:

a. Are there �mes in the day that you feel best?

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17. Please answer the following ques�ons Yes or No:

a. If I'm feeling down, a snack makes me feel be�er. Yes_____ No_____

Yes_____ No _____

Yes_____ No_____

Yes_____ No _____

e. Now and then I think I am a secret eater. Yes _____ No_____

f. At a restaurant, I almost always eat too much bread before the meal is served. Yes_____ No_____

Yes_____ No_____

h. I experience cravings for sugar, breads, pasta and baked goods. Yes _____ No_____

Yes_____ No_____

Yes_____ No_____

18. Check of any of the following that have applied to you within the last 30 days:

_____Do you feel nauseous? _____Do you have abdominal/intestinal pain?

_____Do you have bloating? _____Do you get bloated after meals?

_____Do you get heartburn? _____Do you have diarrhea?

_____Do you have constipation? _____Do you travel outside of the U.S.?

_____Do you have gas? _____Are your stools compact/hard to pass?

_____Do you belch following meals? _____Do you have gurgles in your stomach?

_____Do your bowel movements alternate between

constipation and diarrhea?

For each of the above checked symptoms, please answer the following:

________________________________________________________

__________________________________________________________________________________________




b. I some�mes have a hard �me going to sleep without a bed�me snack.

c. I get �red and/or hungry in the mid-a�ernoon.

d. I get a sleepy, almost "drugged" feeling a�er ea�ng a meal containing bread, pasta or dessert.

g. I have difficulty concentra�ng, or frequent fuzzy or spacey thinking pa�erns.

i. I feel shaky if I don't eat on �me or if I don't snack.

j. I o�en find myself irritable or angry.

a. How long does it occur a�er they eat?

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____________________________________

__________________________________________________________________________________________

c. Are there any other symptoms, pain, or feelings you experience during or a�er you eat that were not

addressed here?_____________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

24. In your es�ma�on, how physically fit are you right now?

Very fitUnfit_____ Below average_____ Average _____ Above average_____ _____

_______________________________________________________________________

a. What is your regimen?___________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

26. If you do not currently exercise, what types of exercise have you enjoyed doing in the past? ____________________

__________________________________________________________________________________________________

27. What are your f tness goals? (circle all that apply)

_____ General f tness endurance_________ Muscle toning

_____ Weight loss/maintain weight _____ Muscle strengthening

_____ Osteoporosis prevention _____ Muscular coordination/balance

_____ Specif c sport enhancement __________________ Other_________________________________________

_____ Flexibility ______________________________________________

28. Surgeries, start ng with most recent:______________________________________________________________

______________________________________________________________________________




b. How o�en does it occur in a day and over the period of a month?

25. How o�en do you exercise?

29. Hospitaliza�ons:

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________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

31. What is your heritage? (Irish, German, Spanish, etc.) _______________________________________________

32. Circle “Now” or “Past” for only those items with which you Ignore anything that does not apply to you.

Is your life: Do you often:

Now Past Satisfactory Now Past Feel depressed

Now Past Boring Now Past Have anxiety

Now Past Demanding Do you often:

Now Past Unsatisfactory Now Past Have irrational fears

Do you worry over: Now Past Feel upset

Now Past Home life Now Past Feel things go wrong

Now Past Marriage Now Past Feel shy

Now Past Children Now Past Cry

Now Past Job Now Past Feel inferior

Now Past Income Have you:

Now Past Money problems Now Past Seriously considered suicide

Now Past Attempted suicide

33. Women please answer the following quest ons.

a. Form of birth control ___________

b. # of children __________________

c. # of pregnancies _______________

d. Age of f rst period _____________

e. Date - last menstrual cycle ______

f. Length of cycle __________ days

g. Interval of t me between cycles_______________________days

h. Any recent changes in normal menstrual f ow (e.g., heavier, large clots, scanty) ____________________

__________________________________________________________________________________________



30. Briefly describe where you have lived since childhood:

iden�fy.

i

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i. Do you persistently experience any of these symptoms within three days to two weeks prior to Please check Yes or No.

[A]1. Anxious, irritable or restless Yes_____ No _____

2. Numbness, in hands and feet Yes_____ No _____

3. Easy to anger, Yes_____ No _____

4. Aggressive or toward family/friends Yes_____ No _____

[B]

5. Abdominal , feeling swollen (e.g., feet) Yes_____ No _____

6. Temporary weight gain Yes_____ No _____

7. Breast tenderness, swelling Yes_____ No _____

8. Appearance of breast lumps Yes_____ No _____

9. Discharge from nipples Yes_____ No _____

10. Nausea and/or Yes_____ No _____

11. Diarrhea or Yes_____ No _____

12. Aches and pains (back, joints, etc.) Yes_____ No _____

[C ]13. Craving for sweets Yes_____ No _____

14. Increased or binge Yes_____ No _____

15. Headaches Yes_____ No _____

16. Being easily overwhelmed, shaky or clumsy Yes_____ No _____

17. Heart pounding Yes_____ No _____

18. Dizziness or Yes_____ No _____

[D]19. Confused and to the point that work Yes_____ No _____




menstrua�on?

�ngling

resen�ul

hos�le

bloa�ng

vomi�ng

cons�pa�on

appe�te ea�ng

fain�ng

forge�ul suffers

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20. Overwhelmed with feelings of sadness and worthlessness Yes_____ No _____

21. sleeping or falling asleep Yes_____ No ____

22. Engaging in self- behavior Yes_____ No _____

j. Do you experience any of these symptoms during your period? Please check Yes or No.

1. Cramping in lower abdomen or pelvic area Yes_____ No _____

2. Lower abdominal pain is sharp and/or dull or intermit ent Yes_____ No _____

3. and sense of abdominal fullness Yes_____ No _____

4. Diarrhea or Yes_____ No _____

5. Nausea and/or Yes_____ No _____

6. Low back and/or legs ache Yes_____ No _____

7. Headaches Yes_____ No _____

8. Unusual (take naps) in missed work Yes_____ No _____

9. Painful and/or swollen breasts Yes_____ No _____

10. Scanty blood Yes_____ No _____

k. Do you experience these symptoms in general? Please check Yes or No.

1. Painful or sexual intercourse Yes_____ No _____

2. Low abdominal, back and vaginal pain throughout the month Yes_____ No _____

3. Pelvic pressure or pain while down or standing up, relieved by lying down Yes_____ No _____

4. Vaginal bleeding other than during your period Yes_____ No _____

5. Painful bowel movements Yes_____ No _____

6. (straining) urinat on Yes_____ No _____

7. Abnormal vaginal discharge Yes_____ No _____

8. Of ensive vaginal discharge Yes_____ No _____




Difficulty

destruc�ve

Bloa�ng

cons�pa�on

vomi�ng

fa�gue resul�ng

flow

difficult

si�ng

Difficult

f

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9. Vaginal itching or burning with or without intercourse Yes_____ No _____

10. Pain during periods is progressively worse Yes_____ No _____

11. Profuse or prolonged menstrual bleeding Yes_____ No _____

12. Unable to get pregnant Yes_____ No _____

l. Please explain in detail any relevant history ___________________________________________________

__________________________________________________________________________________________

Personal Opinion Quest ons

**Please do not answer “I don’t know” to any of these quest ons**

1. Why do you think healthcare have failed in your case?_________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

2. What do you consider a window of to see changes in your health speaking with us?_____________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

3. Are you prepared to pay for the laboratory , fees and supplements that may be required

to successfully manage your ? __________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

4. On a scale of 1-10, how are you to recovering your health?_______________________________________

__________________________________________________________________________________________________




ge�ng

prac��oners

realis�c �me a�er

tes�ng nutri�onalcondi�on

commi�ed

consul�ng

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5. What obstacles or beliefs, if any, stand in the way of you recovering your health? ______________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

6. Are there or psychological issues that may be to your health problems? If so, please

explain. ___________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

7. Do you enjoy your work? Do you believe your work contributes to your health problems?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

8. Where else do you support? Friends? Family? Nature? Church or Religion?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

9. How did you feel about answering all of these and the case review process?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________




emo�onal contribu�ng briefly

find

ques�ons

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New Client Paperwork - Dr. George L. Kraft · Kra FamilyChiropractic .com 2 of 13 New Client Paperwork Office / Fax: 314-200-6092 Cell 314-397-1682 d [email protected]