CURRENT HEALTH CONDITIONS

Please indicate where you are experiencing pain or discomfort.

YOUR HEALTH GOALS

CHIROPRACTIC HISTORY

TRAUMAS: PHYSICAL INJURY HISTORY

TOXINS: CHEMICAL & ENVIRONMENTAL EXPOSURE

THOUGHTS: EMOTIONAL STRESSES & CHALLENGES

PATIENT REVIEW OF SYSTEMS

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THE NERVOUS SYSTEM CONTROLS AND COORDINATES ALL ORGANS AND STRUCTURES OF THE HUMAN BODY.

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Please check the corresponding boxes for each symptom or condition you have experienced – including both past and present.

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CERVICAL

FUNCTIONS

• Autonomic Nervous System

• ENT System

• Vision, Balance & Coordination

• Speech

• Immune System

• Digestive System

• Nerve Supply to Shoulders, Arms & Hands

• Sympathetic Nucleus

• Metabolism

SYMPTOMS

UPPER THORACIC

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FUNCTIONS

• Upper G.I.

• Respiratory System

• Cardiac Function

SYMPTOMS

MID THORACIC

FUNCTIONS

• Major Digestive Center

• Detox & Immunity

SYMPTOMS

LOWER THORACIC

FUNCTIONS

• Stress Response

• Filtration & Elimination

• Gut & Digestion

• Hormonal Control

SYMPTOMS

LUMBAR, SACRUM & PELVIS

FUNCTIONS

• Lower G.I. (Absorption & Motility)

• Gut-Immune System

• Major Hormonal Control

SYMPTOMS

ANPTH Informed Consent for Chiropractic Care

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We encourage and support a shared decision making process regarding your health needs. As a part of that process, you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the informed decision whether or not to undergo such care with full knowledge of the known risks.

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Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily the nervous system) and how this relationship can affect the restoration and preservation of health.

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Adjustments are made by chiropractors to correct or reduce spinal and extremity subluxations. Vertebral subluxation (VSC) is a condition where one or more vertebrae in the spine is misaligned and does not move properly causing interference and irritation to the nervous system. The main goal in chiropractic care is to reduce nerve interference caused by VSC.

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A chiropractic examination will be performed which may include: spinal and physical examination, orthopedic, neurological and orthosis testing, palpation and specialized instrumentation.

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The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life.

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In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them.

Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, disc aggravation/injury and fracture. In addition, there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment.

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Alternatives - There are no equivalent care approaches as Chiropractic focuses on optimizing central spinal-neural function so your body can better regain function and health. For symptom care you may include consulting other health professionals, over-the-counter pain relievers, rest and exercise. Each may have their own benefits and risks.

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Questions or concerns - Please ask questions at any time about your assessment and treatment. Bring any concerns you have to the chiropractor’s attention. If you are uncomfortable, you may stop care at any time. You are encouraged to be involved in and responsible for your care. Inform the chiropractor immediately of changes in your health or condition.

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I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and the risks of care, including the risk that care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment.

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I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AND VOLUNTARILY REQUEST AND CONSENT TO THE CARE AND TREATMENT DESCRIBED ABOVE.

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Fee Schedule:

• Initial Assessment : $199.00

• Regular Adjustment : $65.00

• Reassessment & Scan : $99.00 + Adjustment

• Missed Appointment/Change without one full business day’s notice : Price of appointment

• Maintenance/Wellness Adjustments : $50.00