100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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!

 

Team 100%

 

100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Sensory
Integumentary
Endocrine
Genitourinary
General
100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@100percentdoc.com
Personal Illness History
Surgery/Trauma History
100 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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 % Lakewood
455 S Teller Street
Lakewood, CO 80226
(303) 922-1007
drdarby@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
Very Interested
How do you want us to handle your problem?
Please read the following carefully before signing.

When a person seeks Chiropractic care and we accept a person for such care it is essential for both to be working towards the same objective.  Chiropractic has only one goal.  It is important that each person understand both the objective and the method that will be used to attain it.  This will prevent confusion.

Adjustment:  A specific application of forces to facilitate the body’s correction of the vertebral subluxation.  Our chiropractic method of correction is by specific adjustments of the spine.

Health:  A 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 vertebrae in the spine resulting in nerve dysfunction, resulting in the lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease.  Our focus in this office is the vertebral subluxation.  However, if we encounter non-chiropractic or unusual findings we will advise you.  If you desire advice, diagnoses or treatment for those findings we recommend that you seek another healthcare provider.

Regardless of what the disease is called, we do not offer to treat it.  Nor do we offer advice regarding treatment prescribed by others.  Our ONLY practice objective is to locate, analyze and correct vertebral subluxation by specific adjustments.


I have read and fully understand the above statements. All questions regarding the chiropractor's objectives to my care in this office have been answered to my complete satisfaction.  I therefore accept care on this basis.

 

* Please read and agree to the terms
Signature
Today's Date: 17 Oct 2017