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
Home Phone
Cell Phone
Other Phone
Email
Gender
SSN
Birthdate
Height
Weight
Shoe Size
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer Address
Have you missed work due to this injury?
Missed work start date
Return or anticipated return date
Extend. Health Cov.

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

Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Sensory
Integumentary
Endocrine
Genitourinary
General
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Personal Illness History
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com

Physical Stresses


Falls

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

Motor Vehicle Accidents

Year
Injuries
Year
Injuries


Sports & Recreation


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

Exercise

Do you participate in aerobic exercise at least 30 minutes per day?
Do you lift weights or do resistance training?
What activities are you involved in that require balance?
How often do you stretch per week?

Posture & Habits

Sleep Position
Hours of sleep per night (1-24)
Do you sit more than 6 hours per day?
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com

Occupational Stresses

Employer
Tasks
Occupation
Work Injuries?
Home Injuries?
My job requires:

Birth Trauma

My delivery was:

Chemical Stresses

Nutrition

Do you feel that you make healthy food choices?
How would you rate your consistency on making good food choices?

Not at all
Very consistent
Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
Do you have a high intake of fruits and vegetables?
Do you have a high intake of lean meat for protein?
Are you at your ideal body weight?
Supplements

Toxic Load

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

Medications

Emotional Stress

Are you currently experiencing, or have you ever experienced significant stress in the following areas?
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

Element Chiropractic Wellness
68 Harold Ave Ste 101
Santa Clara, CA 95050
(408) 246-1738
info@elementchiro.com
How has your condition affected you personally(quality of life, emotionally)?
How has your condition affected your family life and/or relationships?
If left uncorrected, how do you see your condition affecting your life over the next 1-5 years?
What has to happen over the next 12 months to make you feel happy with your progress?
What is your greatest motivation (other than pain) for seeking out a solution for your condition?
Do you believe that this condition can improve?
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
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
Signature
Today's Date: 14 Dec 2018