Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.com
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.com
First Name
Last Name
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SSN
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Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.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
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Policy #
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Who Carries this Policy?
Insured's:
Name
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Patient Address
Phone
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Who Carries this Policy?
Insured's:
Name
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Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.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?
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.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?
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.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:
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.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

Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.com
Personal Illness History
Surgery/Trauma History
Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.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

Schroeder Family Chiropractic
421 E 30th Ave.
Hutchinson, KS 67502
(620) 663-2678
familychirodoc@yahoo.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.

Notice of Privacy Practices Acknowledgement Form
 
 
 
Schroeder Family Chiropractic’s Notice of Privacy Practices provides information about how we may use and disclose Protected Health information about you.  It also provides information on what your rights are regarding your Protected Health Information as outlined by the Health Insurance Portability and Accountability Act of 1996.
 
As provided in our notice, the terms of our notice may change.  If we change our notice, you may obtain a revised copy by making a request.
 
By signing this form, I acknowledge that I have received a copy of the Notice of Privacy Practices or had the opportunity to review the notice.
 
 
 
_____________________________________________ (Print Patient Name)
 
 
_____________________________________________ (Patient or Legal Representative Signature) (Date)
 
 
_____________________________________________ (Witness Signature)    (Date)
 
 
 
 
 
 

 
 
 
www.schroederfamilychiro.com
 
Informed Consent Document
PATIENT NAME: _________________________________________________________
To the Patient: Please read this entire document prior to signing it. It is important you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. 
 
The nature of the Chiropractic Adjustment. The primary treatment used by Doctors of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.
 
Analysis / Examination / Treatment As a part of the analysis, examination, and treatment, you are consenting to the following procedures.  -- spinal manipulative therapy  -- palpation  -- vital signs -- range of motion                      -- ultrasound  -- muscle stim -- muscle strength testing  -- postural analysis -- hot/cold therapy -- basic neurological testing  -- orthopedic testing
 
The material risks inherent in chiropractic adjustment.  As with any healthcare procedure, there are certain complication which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The Doctor will make every reasonable effort during the examination to screen for contraindications to care; however if you have a condition that would otherwise not come to the Doctor’s attention it is your responsibility to inform the Doctor.
 
The probability of those risks occurring.  Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination and X-ray. Stroke and/or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke.
 
 
 
 

 
 The availability and nature of other treatment options.   Other treatment options for your condition may include:  Self-administered, over-the-counter analgesics and rest  Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers,  hospitalization or surgery If you chose to use one of the above noted "other treatment" options you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.
 
The risks and dangers attendant to remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.
 
Dated: ___________________________  Dated: ________________________
 
_________________________________  ______________________________ Patient's Name     Doctor's Name
 
_________________________________  ______________________________ Signature      Signature
 
CONSENT TO TREATMENT (MINOR) I hereby request and authorize Dr. Schroeder to perform diagnostic tests and render Chiropractic adjustments and other treatment to my minor son/daughter: ______________________. This authorization also extends to all other Doctors and office staff members and is intended to include radiographic examination at the Doctor's discretion. 
 
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation, or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify this office.
 
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. 
 
I have read or have had read to me the above explanation of the Chiropractic adjustment and related treatment. I have discussed it with Dr. Schroeder and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.
 
 
 
 
Dated: ___________________________    ________________________________Patient’s Name     
 
_________________________________   Signature of Guardian      
 
 
 
 

 
 
 
 
 
 
www.schroederfamilychiro.com
 
PREGNANCY RELEASE: INFORMED CONSENT TO X-RAY (to be completed on day of x-ray)
    PLEASE READ THIS ENTIRE FORM.  All women of childbearing age must sign this release and check any appropriate category.    

  o I have had a hysterectomy or tubal ligation. 

  o I am presently in menopause or post-menopause.  

  "This is to certify that, to the best of my knowledge, I am not pregnant at this time. I hereby  authorize Schroeder Family Chiropractic to take x-rays as necessary to determine the status of my spine. I will assume all responsibility  for any effects on a fetus potentially present."    

Print name: ___________________________ 

Signature: ______________________________________  

Date: ________________________________  Witness: _____________________________
 
INFORMED CONSENT NOT TO X-RAY (to be completed on day of x-ray)
 
o  I am pregnant. 
 
"This is to certify that, to the best of my knowledge, I am pregnant at this time.  I DO NOT authorize Schroeder Family Chiroprac

* Please read and agree to the terms
Signature
Today's Date: 23 Nov 2017