THEOBALD FAMILY CHIROPRACTIC -- Patient Information
Patient Name: _______________________________________________ Case No. ______________
Address: ___________________________________________________ City: __________________
State: _______ Zip Code: ______________ Date of Birth: ___________________ Male/Female
Home Phone: _________________________ Mobile Phone: __________________________
E-mail address: ______________________________________
Marital Status: _______________ Spouse Name: ______________________________________
Children's Names and Ages: ___________________________________________________________
Occupation: __________________________ Employer: ____________________________________
In case of emergency notify: ____________________________ Phone: ________________________
SS No. ___________________________ Referred by: ____________________________________
Past Chiropractic Care (where & when): ___________________________________________________
Reason for office visit: _________________________________________________________________
List prior surgeries, falls, accidents and/or injuries and their dates:
MEDICATIONS DOSAGE PURPOSE
YOUR BIRTH RECORD
Type of birth -- cesarean, natural, etc. ______________________________________________________
Any complications during your birth: _______________________________________________________
Any complications after your birth: ________________________________________________________
How would you describe your current health? _________________________________________________
How would you describe your family's health? _________________________________________________
Do you or any of your family suffer from the following? (circle all that apply)
Headaches Dizziness Nausea Malaise
TERMS OF ACCEPTANCE
When a patient seeks Straight Chiropractic healthcare, and we accept a patient for such care, it is essential for both to be working towards the same goal.
Straight Chiropractic has only one goal. It is important for the patient to understand this goal and the method that will be used to attain it. This will prevent confusion and disappointment.
"Vertebral Subluxations" are mechanical interferences by the spinal bones, to the normal flow of mental impulses traveling over the nerve pathways. The goal of Straight Chiropractic is to locate, analyze and remove these vertebral subluxations.
The Straight Chiropractic method is by specific adjustments of the spine. These adjustments are intended to remove vertebral subluxations, thereby allowing the innate healing abilities of the body to work at maximum efficiency.
With a proper nerve supply restored through Straight Chiropractic adjustments, the body can begin the process of repair, leading to health. In some patients, this happens quickly, in others more slowly. In some patients the repair and maintenance is complete, in others only partial.
Regardless of what the disease is called, we do not offer to treat it, nor do we offer advice regarding treatment prescribed by other healthcare providers. We do not diagnose conditions or diseases other than vertebral subluxations. OUR ONLY GOAL IS TO ALLOW THE BODY TO DO ITS JOB.
I, _______________________________________, have read and fully understand the above statements and accept chiropractic care on that basis beginning on the following date: _____________________.