Zen Wellness New Patient Intake
Please fill out this form and upload it to the "Document" section of your Mindbody Profile, no later than 24 hours before your appointment. Please fill out form thoroughly and include past medical diagnoses even if they seem irrelevant. If you have imaging like MRI or Xrays previously done; please send reports to zenwellnessLA@gmail.com. Thank you!
Full Name *
Your answer
Address *
Your answer
City *
Your answer
Zip *
Your answer
Mobile/Home Phone *
Your answer
Birthdate *
MM
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DD
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YYYY
If you are a new patient, how did you hear about us- insurance list, current patient, google, etc.? (please share a name if a current patient referred you) *
Your answer
Height in feet/inches *
Your answer
Weight in lbs *
Your answer
Concern: What ONE area of pain/discomfort is the worst for you today? *
Your answer
Do you have any other areas of concern or issues you'd like to address? *
Your answer
Have any of the following occurred during this episode? check all that apply *
Required
Onset: Is this the first time you’ve felt this primary pain? *
When did this pain FIRST start (days, weeks, months, years- please be as specific as possible)? *
Your answer
How long has this current episode been noticeable? *
Your answer
Was there a specific activity that you feel caused it?
Your answer
Pain Level: 1-10 *
Barely noticeable
Worst pain imaginable (like broken bone)
Pain Type: check all that apply
Sharp
Dull
Achy
Deep
Shallow
Pain types
Pain Types: check all the apply
Grinding
Numb
Tingling
Intense
Throbbing/pounding
Pain Types
How much of the day are you feeling pain? *
Is there a time of the day that the pain is worst? *
Your answer
What activities or actions make the pain worse, or make it return? *
Your answer
Have you done anything to reduce the pain (medication, ice, stretching etc.) If so, what did you do, and did anything help? *
Your answer
Does the pain start from one main point, and then shoots out to another area, feeling as if they are directly connected? check all that apply *
Required
Does the pain interfere with sleep? *
What is Your Dominant hand? *
What is Your Occupation? *
Your answer
How long have you done this work?
Your answer
Occupation Activities: check all that apply
How much time a day do you spend in the car?
Your answer
Possibly Pregnant? *
Yes
No
Maybe
Answer:
If pregnant, please list current week of pregnancy and due date:
Your answer
Do you have any gynecological/reproductive health Issues? If not, put NA. If female, please include last menstrual cycle date. *
Your answer
Health Conditions: Check any that apply *
Required
Do any of the above Medical conditions run in your family that you may be at risk for? *
Your answer
Psychiatric/Mental Health History. If not, put NA. *
Your answer
Do any Psychiatric/Mental Health conditions run in your family? *
Your answer
Medications/Supplements, Dosage & Reason Taking. If none, put NA. *
Your answer
Allergies (Medication & Other) & Reaction. If none, put NA. *
Your answer
Surgeries/Hospitalizations & Dates. If none, put NA. *
Your answer
Car accidents, major falls, traumas (like bone breaks or sprains) & Dates. If none, put NA. *
Your answer
In the past 4 weeks, have you consistently gotten moderate exercise at least 30 minutes for 5 days each week? (Moderate exercise means you can carry a conversation but speaking would take more effort than usual) *
Your answer
If you have exercised in the last 4 weeks, how often was it, and what type of exercise? *
Your answer
Nutrition: Please check all the apply:
Substance Use: Alcohol *
Required
Substance Use: Nicotine: check all that apply
Have you recently had an unusual amount of stress, major life change (like moving or relationship ending), or any emotional trauma? *
Your answer
Even if it doesn’t seem related, have you had any other Physical or Mental symptoms that have occurred with the onset of this episode of pain/discomfort/concern? *
Your answer
New patients: Have you had Chiropractic before? *
How was your experience?
Your answer
Chiropractic sometimes requires clinical touching NEAR sensitive areas, such as the top of the buttocks, or at the ribs near the chest, or the feet. There is always a reason for this, and the Dr. is happy to explain what she is doing if you are ever uncomfortable. Is there anywhere near these or other regions you are uncomfortable with due to previous trauma or sensitivities? *
Your answer
Treatment Plan: Chiropractic care is dose dependent, meaning staying on recommended schedule is vital for appropriate progress. Is there anything that would keep you from scheduled treatments for 2-6 weeks (financials, work schedule)? *
Your answer
INFORMED CONSENT TO EXAM & TREAT: I have read the above information and certify it to be true and correct to the best of my knowledge. I am aware that certain risks can be associated with Chiropractic manipulation including soreness, sprains, strains, and in very rare cases, strokes, which have been linked to certain birth defects in the blood vessels. I understand that the Doctors will fully examine me and screen for any conditions that put me at risk for receiving Chiropractic manipulation. I hereby authorize the office of Zen Wellness, and its Doctors of Chiropractic , to examine me and provide me with Chiropractic care, that may include Conventional and Non-Conventional Complementary therapies, such us, but not limited to Nutritional and Herbal Guidance, Mindfulness/Mind-Body Medicine, in accordance with California state's statutes and licensing laws. I represent that I am seeking treatment in order to further my own health and for no other reason. I agree to take a responsible role in improving my own health. I acknowledge that if I do not follow the treatment plan as provided, I may not receive the full benefit of the treatments proposed by the Doctor and I accept responsibility for less than satisfactory results. I am aware that I may withdraw this consent and discontinue following the recommendations at any time. TYPE YOUR NAME HERE: *
Your answer
NON-COVERED SERVICES (HMOs): Certain insurances cover the Chiropractic Adjustment ONLY and occasionally electric muscle therapy. Our Doctors provide some combination of Physical Therapy, Muscle Techniques, Stretches, and Home Care Instructions during every visit. These therapies enhance the adjustment and aim to decrease recovery time. These non-covered services are available for a fee of $25, in addition to your agreed upon co-payment/co-insurance. This fee is included in your quoted pricing. If you choose to opt out of these services, please contact our office for a waiver and special scheduling. Otherwise; TYPE YOUR NAME HERE: *
Your answer
APPOINTMENT POLICIES: I understand I will be charged full CASH price for each missed appointment without a 24-hour cancellation notice via email, direct conversation with employee, or leaving voicemail. Please keep a screenshot of your call to our number or email for cancellations in the case of dispute. To avoid this fee, I understand that I must call to cancel my appointment no later than 24 hours from my appointment. I understand Zen attempts to allow 5-10-minute grace period for lateness to my scheduled appointment, but this is not guaranteed. If I am late, the Doctor will do everything to be able to honor my appointment, but if the schedule is full, then my appointment will be rescheduled for another day/time. I understand that we require a debit or credit card to be held on file with privacy encryption that will only be charged in the above cases. TYPE YOUR NAME HERE: *
Your answer
Please remember to read your confirmation email for important details; and to update us with your insurance information if not already done. Thank you and we look forward to seeing you!
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