Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.com

Welcome! This is what you can expect in your upcoming visits.

PAPERWORK

Please complete this simple admittance Form so we have an
understanding of your past and current health situation.

CONSULTATION

 You will meet the doctor and discuss your health concerns.

EXAMINATION

We will conduct a thorough examination to locate the cause
of your problem and determine if you are a candidate for
chiropractic care. This includes a computerized assessment
of how well your nervous system is communicating with your
body. The assessment will include range of motion, surface
electromyography, which evaluates muscle function and balance
and an orthopaedic assessment. The doctor may also need additional
procedures, such as x-rays. If yours is a chiropractic case,
we will develop a plan to help you.

REPORT OF FINDINGS

At your second visit, the doctor will explain the
 results of your examination. If we think that we can help you,
we will recommend a schedule of care created just for you. During
this time we will also explain our financial policies and determine
your insurance coverage, if applicable.

HEALTH TALK

We find that when patients are empowered to help themselves,
they respond faster to care and remain healthier longer.
If we decide to accept your case part of your care involves an
opportunity to attend our health talk entitled health and healing
and inside out approach.  

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

Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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 #
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Who Carries this Policy?
Insured's:
Name
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Patient Address
Phone
Address
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Secondary
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Who Carries this Policy?
Insured's:
Name
Birth Date
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Patient Address
Phone
Address
City
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State
Employer
Emp. Phone
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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?
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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?
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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:
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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

Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.com
Personal Illness History
Surgery/Trauma History
Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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

Family First Chiropractic
800 HWY 290 West Bldg F
Dripping Springs, TX 78620
(512) 858-9355
ask@ffchiro.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 have had the opportunity to discuss with the Doctor of Chiropractic
indicated below, or with any party authorized to do so by that Chiropractor,
 about the nature and purpose of Chiropractic adjustments and other procedures.
 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. The risk of stroke after
 cervical adjustment is estimated at 1 in 1,000,000, substantially lower
 than that associated with any medical or other treatment medications or
 procedures for the same symptoms. To put this in perspective, studies
that have assessed the risk from interventions a non-Chiropractor
commonly uses for the same complaints have found the following:

Risk of paralysis or stroke from surgeries for neck pain:    15,600 per million   
Risk of death from surgeries for neck pain:             6,900 per million
Risk of serious gastrointestinal event from non-steroidal
anti-inflammatory drugs:                      1,000 per million

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, and I have had sufficient opportunity to discuss
 its content with the Doctor of Chiropractic indicated below. I do hereby request and
 consent to all examinations and care as deemed appropriate by the Doctor of Chiropractic
 indicated below, for my present condition and for any future conditions for which I
may seek care. I also agree to payment for all services rendered.

* Please read and agree to the terms
Signature
Today's Date: 17 Jan 2018