New Patient Info - Dr. James Huang (www.holisticsportscare.com)
Please fill-in the following form and submit it when finished.  Completing this form before your visit will save you time, not to mention saves you from all the usual annoying paperwork that you have to endure in most offices.  The privacy of your information is important to us and we will never share any identifying information with any third parties without your direct consent.  Thanks and we look forward to seeing you soon!
Sign in to Google to save your progress. Learn more
Full Name (First and Last name) *
Contact Number *
Emergency Contact Number *
Address *
Email Address *
DOB *
Sex *
Married? Do you have Children? *
Do you Have a Primary Doctor? *
DC, MD, ND, etc
Required
If yes, who is it?
Do you have insurance?
If yes, what is it? Please put member ID if you would like us to check if you have benefits.
Is your visit due to an injury from a car accident?
Clear selection
If yes, please provide the following information: your current auto insurance provider, claim #, estimated damage to your vehicle, and medical coverage ($1000, $5k, $10k)
How did you hear about this office? *
Required
How can we help you today?  If you have multiple areas of pain please list them in order of importance. *
If you are experiencing pain please rate it on a scale of 1 to 10. (10 being the worse pain you have ever felt.) *
Have you been to a chiropractor before? If so, how was the experience?
Health History
This section will review your health history and provide Dr. Huang with the necessary information to give you a comprehensive picture of your health.  Please understand that this information will be used with the highest considerations for your privacy according to the regulations set out in HIPAA.  Your honesty is appreciated.
Family History *
List any known family illnesses (e.g. hypertension) and the side they originate, (e.g. maternal grandmother).
Have you ever been hospitalized or had a major illness?  Please explain. *
e.g. Hospitalized for mononucleosis at age 17
What do you do for work? *
Be specific about your workstation, and what you do for the majority of your day e.g. sitting, standing, typing, etc.
What do you do to stay active? *
List hobbies, sports, and activities outside of work.
Are you currently taking any medications? *
If so, what are you taking, and why are you taking it?
Do you have any gastrointestinal problems? *
e.g. indigestion, IBS, heartburn, etc
Do you ever have trouble breathing? *
e.g. shortness of breath, asthma, etc.
Do you have any known problems with your ears, eyes, nose or throat?  Please explain. *
e.g. chronic ear infections, nearsightedness, decreased sense of smell, swollen throat, etc.
Do you have any hormonal problems? *
e.g. thyroid issues, menopause, adrenal stress, etc
Do you have any known neurological disorders? *
e.g. headaches, Parkinson's, MS, depression, anxiety, etc.
If you mentioned Headaches, please explain further
e.g. location, frequency, intensity, triggers, treatments, etc.
Do you have any cardiovascular problems? *
e.g. hypertension, history of heart surgery, murmur, etc.
Do you have any reproductive problems? *
e.g. endometriosis, history of hysterectomy, severe menstrual cramping, frequent urination, prostate problems, etc.
Do you have any problems going to the bathroom? *
e.g. painful urination, incontinence, constipation, frequent urination
Do you have any musculoskeletal complaints other than those already mentioned? *
e.g. plantar fasciitis, old shoulder or knee injuries, etc.
Do you have any allergies that you're aware of at this time? *
e.g. seasonal, medicinal, food, etc
Do you have any skin conditions? *
e.g. eczema, rash, etc.
Do you have any other conditions you wish to share? *
e.g. diabetes, metabolic disorder (syndrome X), etc.
How are your stress levels on most days? *
I'm free as a bird
I'm ready to burst
What tools do you use to stay healthy? *
e.g. gym membership, fitbit, garmin, zeo sleep, smartphone apps, etc.
Have you had any imaging studies completed in the last 3 years (xray, MRI, CT) *
If yes, it is beneficial to have them with you at your visit (don't stress if you can't get them).
Informed Consent *
Doctors of Chiropractic who use manual therapy techniques are required to advise patients that  there are or may be some risks associated with such treatment. In particular you should note:  a) While rare, some patients may experience short term aggravation of symptoms, rib fractures  or muscle and ligament strains or sprains as a result of manual therapy techniques;  b) There are reported cases of stroke associated with many common neck movements  including adjustments of the upper cervical spine. Present medical and scientific evidence does  not establish a definite cause and effect relationship between upper cervical spine adjustment  and the occurrence of stroke. Furthermore, the apparent association is noted very infrequently.  However, you are being warned of this possible association because stroke sometimes causes  serious neurological impairment and may on rare occasion result in injuries including paralysis.  The possibly of such injuries resulting from upper cervical spinal adjustment is extremely  remote;  c) There is rare reported cases of disc injuries following cervical and lumbar spinal adjustments  or chiropractic treatment.  Chiropractic treatment, including spinal adjustments, has been the subject of government  reports and multi­disciplinary studies conducted over many years and has demonstrated to be  effective treatment for many neck and back conditions involving pain, numbness, muscle spam,  loss of mobility, headaches and other similar symptoms. Chiropractic care contributes to your  overall well being. The risk of injuries or complications from chiropractic treatment is  substantially lower than that associated with many medical or other treatments, medications,  and procedures given for the same treatments. I acknowledge I have discussed, or have had  the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment  in general and my treatment in particular (including spinal adjustment) as well as the contents of  this Consent.  I consent to the chiropractic treatments offered or recommended to me by my chiropractor,  including spinal adjustment. I intend this consent to apply to all my present and future  chiropractic care.
Required
End of Section
At this time, you have finished all the necessary paperwork.  If time permits, we will send you a brief online questionnaire that will help us gauge your current state of health.  The same privacy precautions apply to your personal information.  Thanks and we look forward to seeing you.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms