Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com

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Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
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Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
How did you hear about us?
Family Physician

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Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
The symptoms that have prompted you to seek care today include:
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Does the pain radiate or travel to other parts of the body?
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@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?
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

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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:
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@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

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Front Right Chest

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Front Right Ribs

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Front Left Ribs

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Front Abdomen

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Front Pelvis

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Front Right Hip

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Front Left Hip

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Front Right Thigh

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Front Left Thigh

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Front Right Knee

Type of Pain
Front Left Knee

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Front Right Lower Leg

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Front Left Lower Leg

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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

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Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

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Front Right Upper Arm

Type of Pain
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

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Front Left Hand

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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

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

Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
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Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
Sensory
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Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
Surgery/Trauma History
Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
Social History

Steinke Family Chiropractic
1022 W. Auglaize St., Suite 102
Wapakoneta, OH 45895
(419) 738-1145
chirosteinke@gmail.com
What is the most significant thing you can do to improve your health?
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Please read the following carefully before signing.

Consent to Initiate Care

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Starting care in our office will consist of at least 2 appointments: Your initial visit and a follow up report of findings.  More care may be suggested at your Report of Findings depending on your case. 

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

ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxations. At Steinke Family Chiropractic the main method of adjusting is gentle and specific using an instrument called the Integrator.  Our specific adjusting style is call Torque Release Technique. Our chiropractic method of correction is by specific adjustments to 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 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 to diagnose or treat any disease or condition other than vertebral subluxations. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual finding, 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 a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. 

I acknowledge that I have read and fully understand the above statements. I give consent to Steinke Family Chiropractic to move forward with a chiropractic evaluation, any needed Radiologic Examinations, and any needed chiropractic adjustments at this time. I understand that I am not obligated to move forward with any further care unless I agree to such care at my report of findings.

 

Cost of Nerve Assessment/Initial Evaluation-                  $50

Cost of X-rays-                                                             $50 per set (typically two sets are taken)

Total Maximum Cost per person for Initial Evaluation:     $150

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my protected health information, under the Health

Insurance Portability & Accountability Act of 1996. (HIPAA). I understand that this information can and will be used to:

1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who

may be involved in that treatment directly and indirectly.

2. Obtain payment from third-party payers.

3. Conduct normal healthcare operations,

* Please read and agree to the terms
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Today's Date: 25 Apr 2019