Correction of vertebral subluxation is designed to remove ...

ABOUT THE PATIENT REASON FOR SEEKING CARE PAST HISTORY
GENERAL HEALTH HISTORY
PAST HISTORY FAMILY HISTORY OFFICE POLICY SPINAL CHECK-UP:
. We recommend everyone have their spine checked early for spinal problems.
Prevention is the best medicine.
. Children especially to see if their spine is developing abnormally? A
spinal check-up is easy and fun for kids.
WE ALSO OFFER:
. Supplements, ice packs, nutritional/exercise counseling, custom
orthotics.
Please ask if you have any questions about these services!
AGREEMENTS FOR TOP RESULTS:
. Remember it takes time and effort to improve your health. No time + No
effort = No results
. Please keep your appointments and make-up any missed or rescheduled
visits within a day whenever possible.
. Please call if you are going to be late or need to reschedule.
. Feel welcome to refer your family and friends in for care. We are here
to help them too.
. If you're paid ahead, understand you will get any unused money back if
care ends early.
. I agree to allow my/family name, photo, video, or testimonial to be used
during the normal course of business.
. I understand that adjusting time is for adjustments and I can always talk
to the Doctor by special appointment or phone call. He is here to help
you any way he can. We want you to do great! (
OFFICE VISITS MAY INCLUDE: . Specific Chiropractic Adjustments to promote mobility, stimulate
tissue, enhance alignment. This is when the Doctor works directly on
your neck or back, sometimes making a popping sound. $45 to $75
. Extremity Adjustments to promote mobility, stimulate tissue, enhance
alignment of extremity joints. $35
. Intersegmental / Mechanical traction to tense / relax soft tissues,
aid healing and mobility. This is the black
table with the rollers that effectively extend, stretch, and traction
the spine. $30 . Heat for sub-acute or chronic conditions. The digital heat pack used
on the area of concern. $10 . Cold to reduce swelling, this is the ice pack used on the area of
concern. $10
. Electric Muscle Stim. To control swelling, modulate pain, tone
muscles. $25 . Manual Therapy / Manual Traction to modulate pain, increase
flexibility, reduce swelling, mobilize soft tissues. This is hands-
on work to your spine or other joints, performed by the Doctor. $45 . Therapeutic Exercises to improve spinal flexibility, strength and
motion. These are stretches or exercises that you perform or the
Doctor administers to you. Excellent for the neck, mid, and lower
back. $25 per unit . Neuro Muscular Re-Education to develop and improve coordination and
balance, as well as promote flexibility and strength. An example is
the Wobble chair the Doctor has you exercise with. $25 per unit . Myofascial release, muscle work to reduce muscular adhesions and aid
healing. This is commonly called 'Massage' or "Trigger point Therapy"
and can be performed in sessions of 15 to 90 minutes. $30 per unit
. Home and / or Work Activity of Daily Living Counseling $20 . Supports/Pillow/Braces if needed and as priced. Patient: _______________________________________________ Date
_____________________ Staff___________ -----------------------
Align Wellness Center
100 N 72nd Ave, Suite 108
Wausau, WI 54401 Name ______________________________________________ Today's
Date____________ Birthdate ____________ Age________
Address ____________________________________________ City
__________________________ State ______ Zip ___________
Home Phone ____________________ Cell Phone ____________________ Work Phone
____________________Gender ( M ( F
Significant Other's Name ______________________________ Kid's Names and
Ages _____________________________________
Your Employer ______________________________________ Type of Work
____________________________________________
e-Mail Address __________________________________________________ Have you
been to a chiropractor before? ¡% No ¡% Yes
Emergency Contact ______________________________________________ ph #
____________________________________________________ Have you been to a
chiropractor before? ? No ? Yes
Emergency Contact ______________________________________________ ph #
_______________________________________
Name of Medical
Doctor(s)___________________________________________________________________
___________________
. I authorize the doctor or his staff to render care as deemed
appropriate for me and / or my child.
. I authorize Align Wellness to release and / or request
records to or from other providers as may be necessary.
. I understand I am responsible for all bills incurred in this
office.
. I authorize assignment of my insurance benefits (if
applicable) directly to the provider.
. Person responsible for this account if other than the
patient?______________________________
. I understand that after any initial promotional services all
care is rendered at usual and customary fees.
. For my balance my preferred payment method is: ( Cash (
Check ( Credit Card ( Car/Work Ins. ________________________________________________________________________
_____________________________
Patient / Parent Signature (This represents a long term
authorization for all occasions of service) Date
PRESENT COMPLAINTS 1. ______________________________________________________ How long has
this been an issue? ______________________
Is it: ( Dull ( Sharp ( Ache ( Numb / Tingle ( Stabbing (
Constant ( Occasional ( Staying the same ( Getting worse
( Mild ( Moderate ( Severe ( Worse in the morning ( Worse in
evening ( Pain radiates to__________________________
2. ______________________________________________________ How long has
this been an issue? ______________________
Is it: ( Dull ( Sharp ( Ache ( Numb / Tingle ( Stabbing (
Constant ( Occasional ( Staying the same ( Getting worse
( Mild ( Moderate ( Severe ( Worse in the morning ( Worse in
evening ( Pain radiates to__________________________
3. ______________________________________________________ How long has
this been an issue? ______________________
Is it: ( Dull ( Sharp ( Ache ( Numb / Tingle ( Stabbing (
Constant ( Occasional ( Staying the same ( Getting worse
( Mild ( Moderate ( Severe ( Worse in the morning ( Worse in
evening ( Pain radiates to__________________________
4. ______________________________________________________ How long has
this been an issue? ______________________
Is it: ( Dull ( Sharp ( Ache ( Numb / Tingle ( Stabbing (
Constant ( Occasional ( Staying the same ( Getting worse
( Mild ( Moderate ( Severe ( Worse in the morning ( Worse in
evening ( Pain radiates to__________________________ 5. Does your condition affect: ( Sleep ( Work ( Daily Routine (
Sitting ( Driving
_______________________________________________________________________
6. What makes it
better?___________________________________________________
7. What makes it worse? __________________________________________________ 8. What Doctor's have you seen for
this?______________________________________
_______________________________________________________________________
9. Type of
treatment:______________________________________________________
10. Results: ____________________________________________________________
NOTES: _______________________________________________________________
_______________________________________________________________________
_________________________________________________
Please mark all areas of concern.
Are you pregnant?
( Yes ( No Page 1 of 2 [pic] Align Wellness Center
100 N 72nd Ave, Suite 108
Wausau, WI 54401
Patient Name__________________________________________ Mark the
conditions that apply to you. Past Present Past
Present
( ( Headaches ( ( Urinary
Problems
( ( Migraines ( ( Easy Bruising ( ( Shortness of Breath ( ( Tobacco
Use
( ( Allergies / Asthma ( ( Dental
Problems
( ( Medication Side Effects ( (
Fibromyalgia
( ( Diabetes ( ( Blood Thinner
use
( ( Hands or Feet cold ( ( HIV
Positive
( ( Muscle aches ( ( Cancer
( ( Trouble Walking ( ( Depression ( ( Leg / Foot Numbness ( ( Alcohol
Use
( ( Fainting ( ( ___High or
___Low Blood Pressure
( ( Gall Bladder Trouble ( ( Stroke
History
( ( Ringing in Ears ( ( High
Cholesterol
( ( Ear P