100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.com

Introduction to the Office

 

 

Let us extend a warm and personal welcome to you on behalf of the 100% team!  We want to provide you with the finest health care and we’ll offer you many informative and entertaining educational opportunities.

 

First, you will want to make informed decisions regarding your health.  During the course of your care you will be presented with several choices that will affect your ability to reach your individual health objectives.

 

Second, this information will be useful in making decisions about your health for the rest of your life.

 

To begin this process, here are a few important terms and procedures as you begin care:

 

On your first visit we will gather information about you through our Initial Discovery (examination and consultation).  There will be someone here to assist you in each step along the way.  If you’re not sure about what we need, just ask.  Nothing will be done

without your consent and full understanding.

 

 

We will be giving you information and clinical data in the form of literature, personal and media presentations.  These are designed to help you understand your own case and the procedures you’ll experience in this office.  Everything is brief and to the point.  It is recommended that you read the material and keep it together for reference during the course of your care.

 

Just as we need to know about you, you should know about us.  Chiropractic education currently consists of four years of pre-Chiropractic college education in the biological sciences, followed by another five years of Chiropractic education and clinical internship.  Then we are required to attend many hours of post-graduate education each year for license renewal.  On top of this, our office is frequently involved in various seminars to keep abreast of the latest information.

 

We are excited to show you how chiropractic can change your life!  Let's get started!

100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.com
First Name
Last Name
Address
City
Zip Code
Home Phone
Cell Phone
Other Phone
Email
Gender
SSN
Birthdate
Height
Weight
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.com
How did you hear about us?
Previous Chiropractor
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
Worker's Comp

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
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.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?
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.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?
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.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:
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.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

100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.com
Sensory
Integumentary
Endocrine
Genitourinary
General
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.com
Personal Illness History
Surgery/Trauma History
100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.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

100 % Atlanta
1600 Mall of Georgia Blvd. 1110
Buford, GA 30519
(770) 614-1009
drsteve@100percentdoc.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
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How do you want us to handle your problem?
Please read the following carefully before signing.

Terms of Acceptance

 

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. The process if often referred to as “ informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risk associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

 

We may conduct some diagnostic or examination procedures if indicated. Any examinations or test conducted will be carefully performed but may be uncomfortable.

 

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment includes restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

 

It is important that you understand, as with all heath care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscles spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs, and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as and “arterial dissections” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease process, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Stokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

 

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke.

 

The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users.

 

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self- administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

 

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendations to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care form all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

 

* Please read and agree to the terms
Signature
Today's Date: 27 May 2018