Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com

Thank you for taking the first step to a healthier you! Please take your time to fill this out, as the more detail you provide, the better the doctor can be able to help you!

Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
First Name
Last Name
Address
City
Zip Code
Gender
SSN
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:

Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Please read the following carefully before signing.

I hereby request and consent to the performance of chiropractic procedures, including various modes of physio therapy, diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures.

I further understand and I am informed that, as is with all Healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, or a lack in immediate improvement of symptoms.  In rare cases, fractures, disc injuries, strokes, dislocations and sprains have been reported, but are very unlikely. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests.

I further understand that Chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations allowing the body to return to improved health. It can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures. However, like all other health modalities, results are not guaranteed and there is no promise to cure. 

I further understand that I am financially responsible for any procedures and services rendered in the office.  I understand that if I choose to use health insurance for care in the office that it is my responsibility to pay for all copays and coinsurances that my health insurance does not cover. I further understand that the office of Element Chiropractic Wellness will check for coverage on my behalf and provide me with their most accurate information as a courtesy and it is not a guarantee of coverage. Accordingly, I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment.

I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited self-administered, over the counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

 

 

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 14 Dec 2018