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HOME
OUR STORY
WHO WE ARE
WHAT TO EXPECT
CONTACT
HOME
Please complete the form below
Personal Information
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Main (Cell/Home) Phone Number
*
Email Address
*
Date of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Primary Care Physician
Occupation
*
Employer
Marital Status
*
Single
Married
Divorced
Widowed
Spouse's Name
Emergency Contact
Emergency Contact Phone Number
Names of Children
Are you a veteran or active military?
*
Yes
No
How did you hear about our office (please check all that apply)?
*
Family
Friend
Website
Google
Facebook
Instagram
Evolved CrossFit
Insurance
Other
Whom may we thank for referring you to our office?
First Name
Last Name
Height (inches)
*
Weight (pounds)
*
Have you been hospitalized within the past six months?
Yes
No
If yes please explain reason for hospitalization
Have you had a complete spinal examination (including x-rays) within the past year?
*
Yes
No
If yes, please explain who performed the exam and what was done.
Have you ever been to a chiropractor before?
*
Yes
No
If you answered yes, how was your experience?
Good
Bad
Indifferent
How do you prefer we contact you to schedule your consultation and examination?
*
Phone
Email
Reason for visit
*
Wellness and improved health/function
Health concern/challenge
Do you have a preference of which doctor you see?
Dr. Matt
Dr. Lynn
No preference
Is your reason/injury/condition related to an auto accident or work related injury?
*
Work
Auto
Neither
If yes, please explain how the injury occurred.
Claim Number (Only applies to auto or work related injury)
History of Complaint
First Complaint
*
In your words, how would you describe the pain? (examples: ache, burning, numbness)
*
On a scale from 0 to 10 with 10 being the worst pain you have ever felt and 0 being no pain, how would you rate your discomfort?
*
Date of Onset (when did it begin)
*
MM
DD
YYYY
How often do you experience the pain?
*
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
*
AM
Mid-day
PM
Late PM
No specific time of day
Does the pain/discomfort radiate into your extremities?
*
Yes
No
If yes please explain
Second Complaint
In your words, how would you describe the pain? (examples: ache, burning, numbness)
On a scale from 0 to 10 with 10 being the worst pain you have ever felt and 0 being no pain, how would you rate your discomfort?
Date of Onset
MM
DD
YYYY
How often do you experience the pain/discomfort?
Constant
On/off throughout the day
Comes and goes throughout the week
What time of day is the problem the worst?
AM
Mid-day
PM
Late PM
Does the pain/discomfort radiate into your extremities?
Yes
No
If yes please explain:
Do you have more than two complaints?
*
*If yes, we will discuss in-person with the doctor.
Yes
No
In the past 6 months have you experienced any of the following health challenges? Please check all that apply.
General
Fatigue
Fever(s)
Unexplained weight loss
Insomnia
Ears, Eyes, Nose & Throat
Visual changes
Hearing loss
Sore throat
Trouble swallowing
Nasal congestion
Ear pain
Respiratory
Prolonged cough
Unable to catch breath
Wheezing
Snoring
Cardiovascular Issues
Irregular heartbeat
Racing heart
Chest pain
Swelling of legs or feet
Shortness of breath
Musculoskeletal
Joint pain
Muscle pain
Neurologic
Headaches
Dizziness
Difficulty walking
Numbness or tingling in face
Seizures
Gastro-Intestinal Issues
Abdominal pain
Constipation
Diarrhea
Gas
Heartburn
Nausea
Vomiting
Genitourinary
Painful urination
Bloody urine
Increased urination
Leaking urine
Females Only Section
Ionizing radiation can be hazardous to an unborn child.
To the best of my knowledge I am not pregnant and the doctor has my permission to perform an x-ray evaluation.
I am currently, pregnant and therefore I am unable to receive ionizing radiation at this time.
Are you trying to become pregnant?
Yes
No
If yes, have you had trouble conceiving?
Yes
No
Do you suffer with any of the following?
Check all that apply
PMS
Painful monthly cycle
Absent monthly cycle
Heavy menstrual cycle
Abnormal vaginal discharge
Polycystic Ovarian Syndrome
If you are pregnant
How many weeks pregnant are you?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Have you been diagnosed with gestational diabetes?
Yes
No
Have you been diagnosed with preeclampsia?
Yes
No
Is your baby breech?
Yes
No
NA
Do you have a mid-wife?
Yes
No
Where do you plan on having baby?
Home
Birthing Center
Hospital
Mental Health History
Have you been officially diagnosed with a mental health condition?
*
Yes
No
If you answer yes, please explain
Are you currently experiencing any of the following
Check all that apply
Eating related concerns
Overwhelming sadness
Worry and fear affecting your ability to function
Unusual or extreme shifts in mood or energy
Issues with attention or behaviors
Feel like your brain is playing tricks on you
Bothered by a traumatic life event
Nothing
Have you attempted or have had thoughts about suicide?
Attempted
Thoughts
Both
Neither
Do you self harm?
Yes
No
Past History
Have you suffered with this pain/symptom/condition/injury/illness in the past?
*
Yes
No
When was the last episode?
Have you (in the past or currently) received care for this condition?
*
Yes
No
If you answered yes please explain:
Please List any surgeries you have had in the past (or present)
*
If no surgeries in past say "none"
Have you broken any bones in the past (please list)?
*
If no broken bones say "none"
Have you suffered with any major illnesses or are you currently suffering with (for example: diabetes)
*
If no major illnesses say "none"
Family History
Has anyone in your family suffer with or is currently suffering with similar condition(s)?
*
Yes
No
If yes whom?
Mother
Father
Sister
Brother
Grandparents
Husband
Wife
Are there any hereditary conditions that the doctor should be made aware of?
*
Yes
No
If yes, please list
Social History
Do you smoke (cigarettes, cigars, pipe)?
*
Daily
Weekends
Occasionally
Never
Do you consume alcoholic beverages?
*
Daily
Weekends
Occasionally
Never
Do you use marijuana?
*
Daily
Weekends
Occasionally
Never
Do you use drugs recreationally (Example: cocaine, methamphetamines)?
*
Daily
Weekends
Occasionally
Never
If yes, please list which drugs you use and how often.
Exercise level (number of times per week 0 - 7)
What position do you typically sleep in?
*
Back
Stomach
Side
Unsure
List all medications currently (in the space provided). And please give the reason for use (not all medications are prescribed for the symptom(s) or condition(s) they were approved for) and the length of time using:
Check the box if you are not currently taking any medications
I am not currently taking any medications
Life Goals
*
If you wish for our office to verify your insurance benefits, please provide us with the following information.
Do you wish to use health insurance for your visit(s)?
*
Yes
No
Primary Insurance
Identification Number
Secondary Insurance
Identification Number
Out of Network Health Insurance
If we are not in-network with your health insurance, understand that this decision was made after careful consideration. The demands from the insurance companies have became unrealistic. They were requiring PCP referrals, pre-authorizations and forms to be filled out at every visit which didn’t necessarily ensure that patients would have access to their full insurance benefits. Third party management groups were hired by the insurance companies to save the insurance company money by denying care. These management groups ended up dictating how many visits our patients could/could not utilize. Our office is focused on getting you well with the best results possible and we feel that we cannot provide you with the best results if a for-profit insurance company is dictating the care. Additionally, when we did an assessment of the insurance reimbursements we found that the average copayments, for our insurance patients, were within $5-$10 of our regular fees without insurance and in some cases our regular fees offered a savings to our patients. We understand that money can be an issue and a road block to receiving care. We encourage you to reach out to your insurance company and ask them for your chiropractic benefits (for an in-network provider). Compare the rates with our cash plans (which our staff will provide) and then make a decision that is right for you. Don’t just blindly go to another office because they are in your network without knowing the facts. Thank you.
*
I have read and fully understand the above statements.
Standard Waiver of Liability
I understand that I am financially responsible for any charges incurred at this office. For those patients using insurance, this would include co-pays, deductibles, and charges denied or not covered by the insurance company. The insurance company will review any and all documentation submitted by New Beginnings Chiropractic and I understand that final determination is based upon the insurance company’s medical guidelines. Insurance policy limitations are per individual insurance policy plans, as are co-payments, co-insurance, deductibles, referrals, etc. I understand this office agrees to notify me as soon as possible whether my care is approved or denied by the insurance company. I understand my initial visits may be denied and this may be beyond the office’s ability to notify me prior to rendering acute care, while waiting for insurance coverage approval. These charges will be my responsibility if denied by the insurance company.
*
I hereby authorize my insurance benefits to be paid directly to New Beginnings Chiropractic. I have read this document and understand my obligations for payment in the absence of insurance coverage.
Informed Consent
Chiropractic is a art, science, and philosophy which concerns itself with the relationship between the spinal structure and the health of the central nervous system. Any disturbance to the CNS will create sickness and disease. One such disturbance to the nervous system is known as a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properlycreating nerve interference which may result in pain and dysfunction or may be entirely asymptomatic. In order to reduced or correct the vertebral subluxation the doctor will be using his/her hands to gently move the vertebra back in to a healthier position. At which time, you may feel a sense of movement of the vertebra and hear an audible “pop” or “click”. The sound created is completely natural and is merely a release of gas within the joints of the spine. Chiropractic care has been proven to be extremely safe and effective; however, it is not unusual to be sore after your first few specific chiropractic adjustments. Other commonly reported side effects include muscle spasm(s), stiffness, headaches, and dizziness. Although extremely rare, rib fracture has been reported but is (typically) due to an underlying condition being present. Imaging helps us rule in/out the presence of such conditions. If at the beginning or during the course of care we encounter a non-chiropractic issue we will refer you out to the appropriate health care provider. I have the right, as a patient, to be informed about the condition and the recommended care to be provided so that I can make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives.
*
I have read and fully understand the above statements and therefore accept chiropractic care on this basis. By checking the box, I am consenting to care.
Thank you! We will contact you ASAP.
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