Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com

Welcome to Greater Life Chiropractic!

Please take the time to fill out your forms with as much detail as possible.  Forms must be completed prior to your appointment day and time.  Please acknowledge if the forms are not completed prior to your scheduled day and time, this may result in the rescheduling of your appointment.

We encourage you to bring any documentation or recent x-rays you feel would be useful in the Doctors evaluation of your health concerns.  

If you have any questions or concerns prior to your appointment please do not hesitate to contact us, we look forward to assisting you at Greater Life!  

 

 

 

Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
First Name
Last Name
Address
City
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Phone (Home)
Phone (Work)
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  Age
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Spouse's Name
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No. Children
Emergency Contact
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Phone
Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
Who may we thank for referring you?
Physician's Name
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Have you missed work due to this injury?
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Who Carries this Policy?
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Secondary
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Who Carries this Policy?
Insured's:
Name
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Address
City
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Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
Your primary complaint:
Previous Chiropractic Care?
Prior Interventions
Accident Related?
Date of Onset?
Similar condition before?
Does the pain radiate or travel to other parts of the body?
Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
The condition is getting:
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect personal?
Does this condition affect sleep?
Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
Are there any other injuries or problem, minor or major, that the doctor should know about?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@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

Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
Personal Illness History
Surgery/Trauma History
Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@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

Greater Life Family Chiropractic
3689 MIDWAY DRIVE
San Diego, CA 92110
(619) 222-8885
greaterlifechiro@gmail.com
What are your concerns if this problem is not addressed or fixed?
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.

Greater Life Family Chiropractic

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health 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 will be use 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 vertebral subluxation. Our chiropractic method of correction is by specific adjustments of 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 diagnose or treat any disease. We only offer to diagnose either vertebral subluxations or neuro-musculoskeletal conditions. However, if during the course of a chiropractic spinal examination we encounter non-chiropractic or unusual findings, 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 treatment 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 specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustments.

 

I understand and agree that;

·          All first visit charges are payable when services are rendered.

·          Any fee paid for x-rays is for analysis only. The film itself is the property of this office.

·           Health and accident insurance policies are an arrangement between my insurance carrier and me.

I understand Greater Life Wellness Center will prepare any necessary reports and forms to assist in making collection from my insurance company, and that any amount authorized to be paid directly to Greater Life Wellness Center will be credited to my account upon receipt.  However, I clearly understand and agree that all services rendered to me are charged directly to me, I am personally responsible for payment, and I may be charged a finance charge of 1.5% per month on any outstanding balance due to me unless other payment arrangements have been made.  I also agree to pay any and all fees that may be associated with any collection on my account.  I certify that the information I give is true and understand that it is confidential.

 

 

 

I, ______________________________ have read and fully understand the above statements.

(print name)

 

All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction.

 

I therefore accept chiropractic care on this basis.

____________________________________      _______________________________

(Signature)                                                     (Date)

 

Consent to evaluate and adjust a minor child:

 

I, _________________________ being the parent or legal guardian of       ______________________________have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.

 

Pregnancy Release:

 

This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual cycle. ________________________

 

______________________________________

(signature)

 

 

 

* Please read and agree to the terms
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Today's Date: 17 Jul 2018