WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com

Welcome to WellnessOne,

 

We strive to make your experience as smooth and efficient as possible so here is what you can expect in your visit.

 

PAPERWORK

Please complete this simple personal health history questionnaire form so we have an understanding of your past and current health situation.

CONSULTATION

You will have a one-on-one consultation with the doctor to discuss your health concerns.


EXAMINATION

A comprehensive examination and evaluation including those tests necessary to determine the precise cause of your problem is given. The doctor will advise you if additional laboratory tests or x-rays are needed.


REPORT OF FINDINGS

If we feel we can help you we will tell you. This will include a thorough explanation of how our treatment works and what results we feel can be obtained.  If we feel we cannot help we will provide you with a recommendation and/or referral to another provider that we feel will be of most benefit for you.  


DECISION OF CARE 

Most patients that come to our office have one of two objectives in mind concerning their health care.  Some patients come for symptomatic relief of pain or discomfort (Relief Care).  Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care) and are interested in a more pro-active approach to their health. 

 

EXERCISE PLAN

We find that when patients are empowered to help themselves, they respond faster to care and remain healthier longer. Exercises are a critical part of a long term success program.  We will provide you with a series of exercises that are essential for you to take control of your future.    


Please complete the following pages to save time and help us to serve you better. Thank you.

WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
First Name
Last Name
Address
City
Zip Code
Home Phone
Cell Phone
Other Phone
Email
Gender
SSN
Birthdate
Height
Weight
Shoe Size
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Employer Phone
Occupation
Employer Address
Have you missed work due to this injury?
Missed work start date
Return or anticipated return date
Extend. Health Cov.

Primary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip Code
State
Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip Code
State
Employer
Emp. Phone
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
The symptoms that have prompted you to seek care today include:
Have you seen other doctor(s) for this condition?
Prior Interventions
What is the condition related to?
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect household?
Does this condition affect personal?
Does this condition affect sleep?
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Hours of sleep per night (1-24)
Have you had x-rays in the last six months?
I realize that x ray examinations may be hazardous to an unborn child. I certify to the best of my knowledge I am not pregnant.
Last Cycle:
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

Type of Pain
Front Left Chest

Type of Pain
Front Right Chest

Type of Pain
Front Right Ribs

Type of Pain
Front Left Ribs

Type of Pain
Front Abdomen

Type of Pain
Front Pelvis

Type of Pain
Front Right Hip

Type of Pain
Front Left Hip

Type of Pain
Front Right Thigh

Type of Pain
Front Left Thigh

Type of Pain
Front Right Knee

Type of Pain
Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

Type of Pain
Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

Type of Pain
Back Right Shoulder

Type of Pain
Back Left Shoulder

Type of Pain
Mid-Back

Type of Pain
Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

Type of Pain
Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist

WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Sensory
Integumentary
Endocrine
Genitourinary
General
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Personal Illness History
Surgery/Trauma History
WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
Social History
Family History
Mother
Age
Age at Death
Health
Illness
Father
Age
Age at Death
Health
Illness
Sister
Age
Age at Death
Health
Illness
Brother
Age
Age at Death
Health
Illness

WellnessOne of Bellevue
14700 NE 8th Street, Suite 115
Bellevue, WA 98007
(425) 644-8386
drthain@bellevuewellnessone.com, drthornley@bellevuewellnessone.com
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

Not Interested
Very Interested
How do you want us to handle your problem?
Please read the following carefully before signing.

PLEASE READ CAREFULLY

In order for the Doctor of Chiropractic indicated below to make a
determination on the suitability of my case for chiropractic care,
I acknowledge and understand that I must complete a thorough
chiropractic evaluation, which may include a diagnostic radiographic
examination if clinically indicated. I do hereby request and consent
to the performance of such an evaluation by the Chiropractor indicated 
below, or any party authorized to do so by that Chiropractor.


I understand that Chiropractic care is considered very safe with an extremely low risk rate. I further understand that there are, however, some risks associated with chiropractic care, as there are with any and all healthcare treatments. In healthcare, the matter of whether any treatment is appropriate or not is determined by looking at the level of risk and comparing this with the level of expected benefit. 

In particular, I understand that in rare cases there have been reported incidents of injury to the vertebral artery during the course of care to the cervical spine by medical doctors, physiotherapists, and chiropractors. However, the proposed mechanism of this injury is reproduced by a wide variety of trivial neck movements, including turning your head to look out the back of a car, or having a shampoo at a hair salon. This injury is of concern because it may lead to a stroke.  I understand that while rare, some patients have experienced rib fractures or muscle and ligament sprains or strains following spinal adjustments. I also understand that there have been rare reported cases of disc injuries following cervical and lumbar adjustments although no scientific study has ever demonstrated such injuries are caused or may be caused by chiropractic treatment.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the doctor’s office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the doctor’s office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services rendered me will be immediately due and payable.I have read and understood the above. I do hereby request and consent to all examinations and care as I feel appropriate I also agree to payment for all services rendered.

 

 

 

* Please read and agree to the terms
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Today's Date: 21 Sep 2017