Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.com
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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?
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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?
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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:
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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

Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.com
Personal Illness History
Surgery/Trauma History
Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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

Eade family Chiropractic
575 Lincoln Ave
Napa, CA 94558
(707) 255-6888
drdeade@gmail.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.

 Instructions for the Informed Consent for Chiropractic Care form for the Doctor

  

                As of Oct. 7, 2011 in California, all licensed chiropractors in this state are required to discuss and obtain signed, written informed consent from all of their patients.  The most important part of informed consent is the verbal discussion, and the signed statement by the patient (or their parent, legal guardian, conservator, or agent) is not only also required by law but is evidence that the discussion actually occurred.  Make sure you have this discussion with your patient or patient to be (or their parent, guardian, conservator, or agent) prior to having them sign this form, and make sure they actually sign the form.

 

                 Informed consent must include the following:

 

                                a) the proposed procedures,

 

                                b) the material risks of the proposed procedures,

 

                                c) the potential benefits of the proposed procedures,

 

                                d) common alternatives to the proposed procedures/care, including refusal of

         care and the associated risks of the refusal of care

 

                 Make sure that you list all proposed procedures that the patient will receive not only from you (the doctor) directly, but also those procedures recommended by you to the patient (e.g. exercise, etc.), and those procedures to which you refer a patient (e.g. radiology, massage therapy, referrals to other doctors, etc.).

 

                 Material means known risk of serious bodily harm.  It is not necessary to discuss every known risk, but a sufficient variety of significant known risks is necessary.  The possibility of the occurrence of known risks should be mentioned with the associated known risk.

 

 

                Although the driving force for this new law was probably that of those opposed to chiropractic, this is an opportunity to turn the situation in a positive one where patients will feel comfortable with your care.  To this effect, included is a perspective on risks associated with chiropractic as compared to medicine based on the premiums paid for a $1,000,000 malpractice liability policy.

 

                 Keep this as a separate form in every patient's file as required by law. 

* Please read and agree to the terms
Signature
Today's Date: 19 May 2019