*Remember to bring completed paperwork: (If paperwork is not completed, arrive 30 min prior to appt.)

First Name: _____________________________ MI: _____ Last Name: _____________________________________
Mailing Address: ________________________________ City: _______________ State: ______ Zip:______________
Gender: ___M ___F ___Trans       Age: _____   DOB: __________________      Marital Status: __S  __M  __W __D __P
Cell Phone: ________________________  Cell phone carrier (for appt text reminders):________________________ 
E-mail: ___________________________________ Occupation/Employer: __________________________________ 
Emergency Contact: ____________________________ Phone: ____________________ Relation: _______________ 
Primary Care Doctor: ________________________ Who may we thank for your referral?______________________
PRIMARY INSURED INFORMATION
If you are the primary insured, mark “self” and move down to “Payment Information”.
Primary insured: ☐ Self  ☐ Spouse  ☐ Parent  ☐ Other: __________________
First Name: ____________________________ MI: _____ Last Name: ______________________________________
Mailing Address: ________________________________ City: ____________________ State: ____ Zip: __________
Gender: ☐M  ☐F   DOB: ___________Cell Phone: ___________________ E-mail: ____________________________
PAYMENT INFORMATION
Please check the following payment methods that apply:   ☐ Cash (Time of Service)   ☐ Health Insurance

Cancellation and No-Show Policy
Scheduling an appointment reserves this time especially for you and no one else. Therefore, our office requires 24 hours’ notice to cancel an appointment. If 24 hours is not given, a charge of $25 will be billed to your account.
If you do not show up for your appointment, you will be responsible for a $25 no show fee. Patients that cancel 24 hours before their scheduled appointment or whose appointment needed to be rescheduled by our office will NOT be subject to a cancellation fee. Thank you, in advance, for giving us 24 hours’ notice. 

Inclement Weather Policy
Please be aware of the local forecast and if you feel that you are unable to come in for your scheduled appointment make sure to cancel 24 hours before. The above policies will be applied.
If we close the office due to weather, you will receive a text or phone call from our reception staff and a cancellation fee will not be applied.

Signature of Patient or Responsible Party __________________________________________________________

 ☐ Workers Compensation   ☐ Auto Insurance (auto injury)  Date of auto injury/accident: _____________________

                  SYMPTOM SURVEY
1.   What is your Primary complaint? ____________________________________
2.   Was there trauma or a known cause?    ☐YES   ☐NO
        If yes, describe:  _______________________
3.    When did your symptoms begin?  _______________            
4.    How often do the symptoms bother you? 
      ☐ Constant   ☐ Frequent   ☐ Intermittent   ☐ Occasional
5.   Has this condition bothered you before?   ☐YES   ☐NO
6.   Would you describe it as (circle all that apply): SHARP, SHOOTING, ACHY,    ELECTRICAL, DEEP, DULL, ACHING, STIFF, THROBBING, NUMBNESS, TINGLING,    CRAMPING, OTHER: __________________________________________________
7.    How severe is you pain/discomfort from 0 (none) to 10 (worst imaginable)? ___________________________________ 
8.     What makes it worse?  ____________What relieves it? ________________________________ 
9.    Any other symptoms associated with this complaint? ________________________________________________ 
10.  Treated for this in the past? ☐YES  ☐NO  When?_____________Where?________________________________
Problem #2 _________________________________________   Was there trauma or a known cause?   ☐YES   ☐NO      
  If yes, describe:  ____________________________________
  When did your symptoms begin?  _______________      ___________________________      
  How often do the symptoms bother you?   ☐ Constant   ☐ Frequent   ☐ Intermittent   ☐ Occasional
  Has this condition bothered you before?  ☐YES   ☐NO    
  Would you describe it as (circle all that apply): SHARP, SHOOTING,  ACHY,  ELECTRICAL, DEEP, DULL, ACHING, STIFF,
  THROBBING, NUMBNESS, TINGLING, CRAMPING, OTHER _______________________________________________
  Where is you pain/discomfort from 0 (none) to 10 (worst imaginable)? __________________________________________ 
  What makes it worse?  _____________What relieves it? ________________________________ 
  Any other symptoms associated with this complaint? __________________________________________________
  Treated for this in the past?  ☐YES  ☐NO  When?_____________Where?__________________________________
Problem #3 ____________________________________ Problem #4 ______________________________________
Special Imaging and/or Tests (MRI, CT, X-Ray, etc):
Year: ____________  Test: ___________________________  Findings: _______________________________
Year: ____________  Test: ___________________________  Findings: _______________________________
Year: ____________  Test: ___________________________  Findings: _______________________________

Do you EXERCISE on a regular basis?        ☐YES ☐NO
   How often?_____________ How long?________________
   What types?________________________________________
Do you SLEEP WELL at night?       ☐YES ☐NO

What do your DAILY ACTIVITIES consist of?
  ☐ Heavy Labor	       ☐ Prolonged Sitting
  ☐ Light Labor		       ☐ Prolonged Standing
  ☐ Repetitive Movements  ☐ High Mental Stress

Other:_______________________________________________________________________________________ MEDICAL HISTORY

__ Irritable Bowel Syndrome
__ Kidney or Bladder Disease
__ Liver or Gallbladder Disease (stones)
__ Lyme Disease
__ Seasonal Affective Disorder
__ Migraine Headaches
__ Neurological Problems______________
__ Obesity
__ Osteoporosis
__ Pneumonia
__ Migraine Headaches
__ Skin problems
__ Sinus problems
__ Stroke
__ Thyroid problems
__ Ulcer
__ OTHER ____________________________

__ Diabetes
__ Diverticulitis
__ Drug Addiction
__ Eating Disorder______________
__ Epilepsy
__ Emphysema
__ Eyes, Ears, Nose, Throat problems
__ Environmental Sensitivities
__ Fibromyalgia
__ Food Intolerance ________________
__ Gastroesophageal Reflux Disease
__ Genetic Disorder______________
__ Glaucoma
__ Gout
__ Heart Disease
__ Infection, Chronic
__ Inflammatory Bowel Disease 

Past or Present Concerns:
__ Arthritis
__ Allergies/Hay Fever/Asthma
__ Alcoholism
__ Alzheimer’s/Dementia
__ Autoimmune ___________
__ Blood Pressure problems
__ Bronchitis
__ Cancer_________________
__ Carpal Tunnel Syndrome
__ Celiac Disease
__ Chronic Fatigue Syndrome
__ Cholesterol, High
__ Circulatory Problems
__ Colitis
__ Contact Lenses
__ Dental problems
__ Depression

Medical (Men)				Medical (Women)
__ Benign Prostatic Hyperplasia		__ Menstrual Irregularities	__ Pelvic Inflammatory Disease
__ Prostate Cancer			__ Endometriosis			__ Vaginal Infections
__ Decreased Sex Drive			__ Infertility			__ Decreased Sex Drive
__ Infertility				__ Fibrocystic Breasts		__ C-Section
__ Sexually Transmitted Disease		__ Fibroids/Ovarian Cysts		__ Menopause
__ OTHER____________________		__ Premenstrual Syndrome	__ Breast Cancer

__ Arthritis
__ Allergies/Hay Fever/Asthma
__ Alcoholism
__ Alzheimer’s Disease
__ Autoimmune _____________
__ Blood Pressure problems
__ Bronchitis
__ Cancer___________________
__ Carpal Tunnel Syndrome
__ Celiac Disease
__ Chronic Fatigue Syndrome
__ Cholesterol, 

Family Health History- Parents/Grandparents/Siblings: 
__ Autoimmune			__ Eating Disorder___________________     __ Obesity
__ Arthritis		         	__ Genetic Disorder		         	__ Osteoporosis
__ Alcoholism			__ Glaucoma 	                                               	__ Stroke
__ Alzheimer’s/Dementia		__ Heart Disease	                               		__ Mental Illness
__ Celiac Disease		              	__ Cancer ________________________   	__ Diabetes

Medications/Supplements
Med/Sup	Dosage		Reason

			

			

__ Migraine Headaches		__ Neurological Disorders_____________________________________________________

Traumatic Injury/Surgery
Year		Trauma/Surgery	

		

 Do you have a Primary Care Provider? 	☐YES  ☐NO
 When was your Last Physical?___________________

MSQ -MEDICAL SYMPTOM/TOXICITY QUESTIONNAIRE
Name: _____________________________________  Date: _______________Height______ Weight_____________

Point	0 -  Never or almost never have the symptom	3 -  Frequently have it, effect is not severe	
Scale	1 -  Occasionally have it, effect is not severe	4 -  Frequently have it, effect is severe	
 	2 -  Occasionally have it, effect is severe	 	 	
				
Head	____ Headaches	Digestive	____ Nausea, vomiting	
 	____ Faintness	Tract	____ Diarrhea	
 	____ Dizziness	 	____ Constipation	
 	____ Insomnia	 	____ Bloated feeling	
 	____ TOTAL	 	____ Belching, passing gas	
Eyes	____ Watery or itchy eyes	 	____ Heartburn	
 	____ Swollen, reddened or sticky eyelids	 	____ Intestinal/stomach pain	
 	____ Bag or dark circles under eyes	 	____ TOTAL	
 	____ Blurred or tunnel vision	Joints/	____ Pain or aches in joints	
 	         (does not include near or far-sidedness)	Muscle	____ Arthritis	
 	____ TOTAL	 	____ Stiffness or limitation of movement	
Ears	____ Itchy Ears	 	____ Pain or aches in muscles	
 	____ Earaches, ear infections	 	____ Feeling of weakness or tiredness	
 	____ Drainage from ear	 	____ TOTAL	
 	____ Ringing in ears, hearing loss	Weight	____ Binge eating/drinking	
 	____ TOTAL	 	____ Craving certain foods	
Nose	____ Stuffy Nose	 	____ Excessive weight	
 	____ Sinus problems	 	____ Compulsive eating	
 	____ Hay fever	 	____ Water retention	
 	____ Sneezing attacks	 	____ Underweight	
 	____ Excessive mucus formation	 	____ TOTAL	
 	____ TOTAL	Energy/	____ Fatigue, sluggishness	
Mouth/	____ Chronic coughing	Activity	____ Apathy, lethargy	
Throat	____ Gagging, frequent need to clear throat	 	____ Hyperactivity	
 	____ Sore throat, hoarseness, loss of voice	 	____ Restlessness	
 	____ Swollen or discolored tongue/gums/lips	 	____ TOTAL	
 	____ Canker sores	Mind	____ Poor memory	
 	____ TOTAL	 	____ Confusion, poor comprehension	
Skin	____ Acne	 	____ Poor concentration	
 	____ Hives, rashes, dry skin	 	____ Difficulty in making decisions	
 	____ Hair loss	 	____ Stuttering or stammering	
 	____ Flushing, hot flashes	 	____ Slurred speech	
 	____ Excessive sweating	 	____ Learning disabilities	
 	_____ TOTAL	 	____ TOTAL	
Heart	____ Irregular or skipped heartbeat	Emotions	____ Mood swings	
 	____ Rapid or pounding heartbeat	 	____ Anxiety, fear, nervousness	
 	____ Chest pain	 	____ Anger, irritability, aggressiveness	
 	____ TOTAL	 	____ Depression	
Lungs	____ Chest congestion	 	____ TOTAL	
 	____ Asthma, bronchitis		<10 – Optimal                              10-50 – Mild Toxicity	
 	____ Shortness of breath		50 – 100 Moderate Toxicity      >100 – Severe Toxicity	
 	____ Difficulty breathing			
 	____ TOTAL		        GRAND TOTAL: ______	
				
INTERESTS AND GOALS

To allow us to better address your healthcare goals & priorities, please check what applies to you and your interests. 

What types of care are you open to?

___ Chiropractic/Sports Medicine: This approach involves addressing musculoskeletal and neurological function through addressing postural or biomechanical imbalances. Injury treatment and prevention are often achieved through joint manipulation, active and passive stretching, soft tissue techniques, traction, physical therapy modalities, and therapeutic home exercise programs.

___ Therapeutic Massage: Several forms of deep tissue massage and other forms of body work are offered. Our licensed massage therapists offer targeted treatments for athletes, work and auto injuries, postural stress, and even pregnancy massage.

___ Functional Medicine: Upstream approach to getting to the root cause of many chronic conditions and health concerns including gastrointestinal dysfunction, autoimmune conditions, chronic fatigue, weight gain, mood disorders, cardiovascular health, and skin complaints. Specialty lab testing, supplements, dietary intervention and lifestyle modifications are the most commonly utilized methods with this approach to best address gut function, sensitivities, toxic burdens, hormone and immune function, and inflammation.

___ Nutrition: Professional guidance with meal planning, shopping, and determining the best diet for an individual’s specific needs or specific condition. Areas of focus include: weight management, athletic performance, food sensitivities/allergies, Celiac and IBD, cancer, and digestive health.

___ Infrared Sauna: We offer the highest quality Full Spectrum Infrared Sauna therapy with our Sunlighten Sauna. Some of the many benefits include: Detoxification, Weight Loss, Pain Relief, Anti-Aging, Immune Enhancement, Relaxation, Cardiovascular and Skin Health.

___ Pulsed Electromagnetic Field (PEMF) Therapy: Through improving the cell membrane potential via charging the cells of the body, improved circulation, oxygen uptake, mitochondrial function, nutrient uptake, and elimination of cellular waste, this modality proves to be quite an impressive therapy. Recommended for improving athletic performance/recovery, strains/sprains/broken bones, post-surgery, neurological complaints, concussions, and in conjunction with Functional Medicine. 

 Specific Health Goals:
    __ Have More Energy	  	      __ Improve Strength		                            	__ Improve Concentration
    __ Sleep Better                                __  Improve Flexibility		           	__ Improve Memory
    __ Be Free of Pain		      __ Improve Balance		                           	__ Neurological Support
    __ Improve Immunity		      __ Reduce Weight		                           	__ Reduce Depression
    __ Heart Health		      __Sport Specific ____________ 	             	__ Reduce Stress

INFORMED CONSENT FOR CHIROPRACTIC TREATMENT

The Nature of Chiropractic Manipulation: The doctor will often use his/her hands or a mechanical device in             order to move your joints. You may feel a “click” or a “pop”, such as the noise when a knuckle is “cracked”, and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound, soft tissue therapies, corrective exercises, or active stretching may also be utilized.

Possible Risks: As with any health care procedure, complications are possible following a chiropractic    
manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocation of joints, or injury to intervertebral discs, nerves, or spinal cord. Cerebrovascular incident could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burn, or minor complications.

Other Treatment Options: May include over-the-counter analgesics, prescription medications, injections, and surgery.

Risks of Remaining Untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

No Warranty: I understand that my doctor at Wellness Doctor, cannot make any promises or guarantees regarding a cure for or improvement of my condition. I understand that my doctor will share with me his/her opinion regarding potential results from chiropractic treatment for my condition and will discuss treatment options with me before I consent to treatment.

I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and herby give my full consent to treatment.

Printed Name: _______________________Signature: ____________________________Date: ________

Consent To Treat A Minor 

 I hereby authorize Wellness Doctor to administer Chiropractic care, as deemed necessary, to my child.

 Name of Child: ______________________________ Age: _______ Date: _______________
              
 Parent /Guardian Signature: ___________________________________________________

 Financial Policy

To ensure your treatments are as stress free as possible we have established a clear financial policy.

Please read and initial next to the policy that applies to you. If you have any questions don’t 
hesitate to ask!

          Insurance: We will bill your insurance as a courtesy for you. If you provide us with your current insurance information we will do our best to verify your benefits prior to receiving care, however insurance companies will never allow a quote of coverage to be a guarantee of payment. We will collect 100% of services not covered by your insurance carrier. If you have a copay, co-insurance, or unmet deductible you will be responsible for payment at time of service. We do offer services that may not be covered by your insurance and you will be responsible for the balance. Please be aware that some patient’s policies are written to where they may have a deductible for certain services and or a copay for certain services. *Insurance is a contract between the patient and their carrier, so it is important that you take responsibility for understanding your benefits. *

           Auto Accident/Personal Injury/Workman’s Compensation: Most Personal Injury and Workman’s Compensation claims are covered 100%. However, it is YOUR responsibility to provide our office with the documentation necessary to prove a valid claim which includes your claim number, as well as the name(s) of any claims adjustor/attorney, etc. handling the case, their phone and fax number and the mailing address to send bills. Failing to provide the documentation needed will result in immediate conversion of your case to cash, and all payment will be due on receipt. We can send any unpaid claims to your personal health insurance if it was in effect during your treatment as long as you provide us with current insurance information. If you miss more than two appointments and do not call within the 24-hr. cancellation period, appointments with our facility may be terminated.

          Cash: Payment is due at the time of service. A prompt pay incentive discount is offered for patients that do not have insurance or choose to not use their insurance. Please speak with our front desk staff to go over those prices.

*Unpaid balances greater than 120 days will be sent to collections and you will be charged an additional
35% to cover the cost of collections (this amount will be added to you bill). *

I have read and understand the above Financial Policy.

Signature of Patient or Responsible Party	Date

HIPAA Acknowledgement of Notice of Privacy Practices

PLEASE REVIEW THE FOLLOWING CAREFULLY AS IT PERTAINS TO THE USAGE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

*My health information may be created or received by Wellness Doctor, LLC and may be in the form of written or electronic records, or spoken words. My health record may include information of my health history, health status, test results, diagnoses, treatments, procedures, prescriptions and similar types of health-related information.

*We may use health information about you to provide you with medical treatment of services. We may disclose health information about you to doctors, nurses, technicians, office staff, personnel or anyone who is involved in taking care of you and your health.

*I understand that I have the right to receive and review a written description of how Wellness Doctor, LLC will handle my health information. This written description is known as a NOTICE OF PRIVACY PRACTICES and describes the uses and disclosures of health information made and the information practices followed by employees, staff and other office personnel of Wellness Doctor, LLC and my rights regarding my health information.

*I understand that the NOTICE OF PRIVACY PRACTICES may be revised periodically. We will not disclose your health information unless we have received written consent. I understand that a copy of summary of the most recent version of Wellness Doctor, LLC’s NOTICE OF PRIVACY PRACTICES in effect will be posted in the waiting/reception area.

Special Permission Request:

I give my permission for Wellness Doctor, LLC to leave messages regarding appointments on my home/cell phone answering machine.

Initial:  	

Date:  	

I give my permission to speak with/leave messages regarding treatment, billing and regarding appointment status left with my spouse, partner, caregiver.

Initial:  	

Date:  	

Name:  	

By signing this agreement, I attest that I understand the information above. Our posted Privacy   Health Information provides more detailed information about the usage and disclosure of your (PHI). You have the right to review and/or request a copy of this policy before signing this consent. This release will revoke by written permission only.

I understand that I must send a written request to Wellness Doctor, LLC to revoke this release. Signature:  	Date:  _____________	

MASSAGE PATIENT WAIVER FORM

Please read and initial the following information if you think you would like/need massage at our clinic.

___ I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular and fascial tension, improvement of circulation and energy flow.

___ If I experience pain or discomfort during the session, I will immediately inform the Licensed Massage Therapist (LMT) so that pressure/strokes can be adjusted to my level of comfort. I will not hold Wellness Doctor or the LMT responsible for any pain or discomfort I experience during or after the session.

___ I understand that the services offered today are not a substitute for medical care. I understand that the LMT, is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

___ I affirm that I have notified the LMT of all known medical conditions, medications, and injuries.

___ I agree to inform the LMT of any changes in my health and medical condition (ex. pregnancy). I understand that there shall be no liability on the LMT should I forget to do so.

___ By signing this release, I hereby waive and release Wellness Doctor and the LMT from all liability, past, present, and future relating to massage therapy and bodywork.

____________________________________________________              ____________________________  
Patient Signature						            Date