Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@GMAIL.COM

Thank your for choosing Sports and Family Chiropractic. We know that in today’s competitive market place, patients have many choices when seeking care. We appreciate your choosing our office and know you made the best choice. Our continued reputation as one of the top chiropractic offices rests with each and every customer. Sports and Family Chiropractic stands behind our quality service and want to let you know we are here if you need us. Should you, a family member or friend, have need for care, please do not hesitate to have them contact us. Thanks, again.

Please Scroll down and press NEXT.

Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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?
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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?
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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:
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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

Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@GMAIL.COM
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@GMAIL.COM
Sensory
Integumentary
Endocrine
Genitourinary
General
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@GMAIL.COM
Personal Illness History
Surgery/Trauma History
Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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

Sports & Family Chiropractic
50 South Anaheim Blvd Ste 250
Anaheim, CA 92805
(714) 956-2225
714956BACK@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.

HEALTH CARE AUTHORIZATION: The patient identified above authorizes SFC (Sports & Family Chiropractic) to use and or disclose protected health information in accordance with the following Specific Authorizations: Patient Demographics: I give permission to SFC to use my address, phone number and clinical records to contact me with birthday cards, holiday related cards, and newsletters and information about treatment alternatives or other health related information. We do not share this information with others. Open Room Adjustments: I give SFC permission to treat me in an open room where other patients are also being treated.  I am aware that other persons in the office may overhear some of my protected health information during the course of care.  Should I need to speak with doctor at any time in private; the doctor will provide a room for these conversations. Patient Health Information:  By signing this form you are giving SFC   permission to use and disclose your protected health information in accordance with the directives listed above (patient testimonials). Expiration: The Authorization shall renew on the following date: January 1, of each year, unless a written notice of cancellation is given. Right To Revoke Authorization: You have the right to revoke this AUTHORIZATION, in writing, at any time.  However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. How to Revoke Authorization: You may revoke this authorization by mailing or hand delivering a written notice to the Privacy Official of SFC.  The written notice must contain the following information: Your name, Social Security number and date of birth; A clear statement of your intent to revoke this authorization; The date of your request; and your signature. The revocation is not effective until the Privacy Official receives it. Use/Disclosure of Patient Health Information: This authorization is requested by SFC for its own use/disclosure of PHI.  (Minimum necessary standards apply.) You have the right to refuse  to sign this authorization.  If you refuse to sign this authorization, SFC will not refuse to provide treatment. You Have The Right To Inspect Or Copy The PHI To Be Used/Disclosed. *A copy of the signed authorization will be provided to you upon request. Financial Policy: Welcome.  Sports & Family Chiropractic are committed to your care being successful. Payment of your service is considered an integral part of your health benefits.  To ensure the best results and uninterrupted care we appreciate your cooperation with the following: Scheduled Appointments you will be served in the order of your reserved time. When you are in the adjustment room, lie face down, rest and take a few moments to breathe. Releasing some of the stress and strain on your muscles and mental attitude is very helpful before your Chiropractic adjustment.  Changes to an appointment should be made 24 hours in advance to avoid a $28 service fee, including Massage Appointments. Cancellations can be left on our answering machine. Reschedules should be done directly with the front desk. If you need to change the time of your appointment and the same day is not possible, be sure to make up your appointment within the week. Expect to pay your portion at the time service is rendered to avoid processing fees of $5 per day.  An immediate change in your financial arrangement with this office may occur due to changes you make in your treatment plan. When you pay by check, if your check is dishonored or returned for any reason, a processing fee of $25 will be assessed.  The use of a check for payment is your acknowledgment and acceptance of this policy and its terms. $8 late fees per bill, per month is assessed to accounts 30 days past due.  Accounts are delinquent at 45 days.  Accounts will be forwarded to our collections department at 60 days and subject to any and all collection-processing fees. Insurance Policies are not a guarantee or authorization of payment. They are solely contracts between the subscriber and the insurance company.  Ultimate financial responsibility lies with you, the patient. Carefully review your "Explanation of Benefits" when received in the mail. Call your insurance carrier directly to resolve any discrepancies on your claims, to avoid out of pocket expenses. Accepting assignment and/or liens is done so under a pre-qualified understanding between the patient, this office and the third party payor(s).  Establishing an honest ethical working relationship allows this office to continue accepting liens and assisting patients in their goals for better health. Any and all changes of the original partys agreement, independent of this offices knowledge or consideration, immediately disqualifies the terms of that agreement and demands immediate payment on the outstanding balance. Financial arrangements are valid under your present condition.  They are subject to renewal by the start of each New Year. Should changes arise in your medical or financial situation that would affect your current financial agreement, you must notify this office prior to your care. Should you discontinue care or be released from further service, at this office, all outstanding balances are due upon notification. Terms of Acceptance: Chiropractic has only one goal. To eliminate a major interference to the expression of the bodys innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. Adjustment: an adjustment is the specific application of force to facilitate the body’s correction of vertebral subluxation. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Our Happy “Healthy” Hour is a complimentary service mandatory for all Wellness Patients. We offer 1) The Secrets of Optimum Health, 2) The 5 Factors of Health, and 3) Peak Performance. Each hour details how the body functions, things you can do in your daily activities for long-term results and how Chiropractic works. We suggest bringing a partner and/or loved one(s) who may benefit from this information on daily health. Progress Evaluations and Updates:  During your course of care, progress exams are done to measure your progress. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spine causing interference of nerve function and transmission of mental impulses, resulting in a lessening of the bodys innate ability to express it’s maximum health potential. We are here for your health needs. Please speak directly with Dr. Wright, should any upsetting matter occur. Your comments and participation guide us to the best possible care and service we can provide you. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation, and neuromusculoskeletal, (nerve, muscles, and bone). However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you and or refer you to a specialist as needed. I have read and fully understand the above.

* Please read and agree to the terms
Signature
Today's Date: 21 Oct 2018