Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com

Please fill out this form online prior to coming for your first appointment.

Complete it as thoroughly as possible, and if you have questions we can cover them on your initial visit.

We look forward to your visit.

Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
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Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
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Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
The symptoms that have prompted you to seek care today include:
Have you seen other doctor(s) for this condition?
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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?
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.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?
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
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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:
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.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

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Front Abdomen

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Front Pelvis

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Front Right Hip

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Front Left Hip

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Front Right Thigh

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Front Left Thigh

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Front Right Knee

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Front Left Knee

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Front Right Lower Leg

Type of Pain
Front Left Lower Leg

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Front Right Ankle

Type of Pain
Front Left Ankle

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Top of Right Foot

Please specify specific areas

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Top of Left Foot

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Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

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Front Right Upper Arm

Type of Pain
Front Left Upper Arm

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Front Right Elbow

Type of Pain
Front Left Elbow

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Front Right Forearm

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Front Left Forearm

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Front Right Hand

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Front Left Hand

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Type of Pain
Front Right Wrist

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Front Left Wrist

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Back of Head

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Back Right Neck

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Back Left Neck

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Upper Back

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Back Right Shoulder

Type of Pain
Back Left Shoulder

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Mid-Back

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Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

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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

Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
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Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
Personal Illness History
Surgery/Trauma History
Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
Social History
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Illness
Father
Age
Age at Death
Health
Illness
Sister
Age
Age at Death
Health
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Brother
Age
Age at Death
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Adjust
807 Main Street
Bastrop, TX 78602
(512) 321-9200
info@adjust4life.com
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

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How do you want us to handle your problem?
Please read the following carefully before signing.

Informed Consent

 

We encourage and support a shared decision making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you

can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent.

 

Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health. 

 

Adjustments are made by chiropractors in order to correct or reduce spinal and extremity joint subluxations. Vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and/or does not move properly causing interference and/or irritation to the nervous system. The primary goal in chiropractic care is the removal and/or reduction of nerve interference caused by vertebral subluxation.

 

A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, specialized instrumentation, radiological examination (x-rays), and laboratory testing.

 

The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life.

 

In addition to the benefits of chiropractic care and treatment, 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 treatment 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 chiropractic treatment 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. 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 THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE ADJUST TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.

* Please read and agree to the terms
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Today's Date: 14 Dec 2018