Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net

 

Welcome to Clearview Chiropractic Life Center! Please read this carefully so you will know what to expect during your first 2 visits. Over 90% of our new patients are referred by current members of our practice, which means the world to us!  We look forward to sharing the Chiropractic Lifestyle and How to Get Well & Stay Well with you and your family!

 What to Expect at Clearview Chiropractic Life Center

 Day 1: Consultation & Exam

  •  Today’s visit should take approximately 40 minutes
  • Personal Consultation with the Doctor, Complete Biomechanical Exam, and if necessary X-rays will be performed to help the Doctor know exactly how to best help you.

  • We will discuss your health history to fully understand your current condition as well as to discover hidden events or lifestyle choices that may be impacting your health

  • All fees will be discussed with you in advance. We require payment for today’s services at the end of the appointment

  • At checkout, you will need to schedule your Doctor’s Report

Day 2:  Doctor’s Report and Best Recommendations

  •  You will be given a specific description of the condition of your spine and nervous system and how these findings impact your current and future health
  • The beginning portion of this report may be in a group setting, so please arrive on time. All of your personal information is discussed in private with the Doctor.

  • The Doctor’s report details the solutions available to maximally correct your problems. If Subluxation is confirmed, your first adjustment will be recommended on this visit.

  • This report is scheduled on very specific days/times, and takes approx. 45 mins -1 hour

  • A financial decision regarding your care will need to be made at this time.

Please bring your spouse/significant other if possible. It is critical to the success of your case that your spouse/significant other sees and understands this information so they are able to support you through this process. (A work excuse can be provided if needed for you or your spouse/significant other).

Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
First Name
Last Name
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Shoe Size
Marital Status
Spouse
Names/Ages
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Emergency Contact
Relationship
Phone
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
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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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Who Carries this Policy?
Insured's:
Name
Birth Date
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Who Carries this Policy?
Insured's:
Name
Birth Date
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Address
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Emp. Phone
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
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?
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
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?
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
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:
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Type of Pain
Front Head

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Front Face

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Front Left Jaw

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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

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

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Front Right Upper Arm

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Front Left Upper Arm

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Front Right Elbow

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Front Left Elbow

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Front Right Forearm

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Front Left Forearm

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Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

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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

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Back Left Shoulder

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Mid-Back

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Back Right Ribs

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Back Left Ribs

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Lower Back

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Back Right Hip

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Back Left Hip

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Back Right Glute

Type of Pain
Back left Glute

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Back Right Thigh

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Back Left Thigh

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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

Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Sensory
Integumentary
Endocrine
Genitourinary
General
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Personal Illness History
Surgery/Trauma History
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
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

Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
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.

The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation. I understand that I am responsible for all payment of fees charged in this office of services rendered.

Privacy Act: I consent to the use of my protected health information by Dr. Robertson for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or conduct health care operations. I understand that the Notice of Privacy Practices is posted on www.clearviewchiropractic.net and in the office at the front desk, and I may request a written copy. HIPAA Compliance.

TERMS OF ACCEPTANCE:

When a patient seeks chiropractic care and we accept a patient for such care, it is essential for both to be working for the same objective.

Chiropractic has only one goal. It is important that each patient understands both the objective and the method that which will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: The adjustment is the specific application of forces to facilitate the body’s correction of a vertebral subluxation. Our Chiropractic method of correction is by specific adjustments to the spine.

Health: The state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

We do not offer the diagnosis or treatment of any disease. We only offer to diagnose either vertebral subluxation complex and/or neuro-musculoskeletal conditions. However, if during the course of a chiropractic spinal examination we encounter unusual finding which are outside the scope of practice for a Doctor of Chiropractic, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatments prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body’s innate wisdom. Our only method is the specific adjustment to correct vertebral subluxation. And we may use other procedures to help your body hold those adjustments.

 

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