Initial Consult & Treatment
Confidential Intake Form and Consent
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Email *
Todays Date *
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Time
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Your Full Name *
Your Birth Date.  *
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Time
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Current Age & Gender.  *
Your Address *
Mobil number *
Single / Married / Divorce / Widowed       *
Your Occupation.   *
Who referred you? *
Emergency contact: Full name, relation to you and mobile number.  
HIPAA CLIENT CONFIDENTIALITY AND RELEASE FORM.  I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.  Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance.  HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation.  Clients should receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records (Please sign and date below to confirm you have read the above HIPAA CLIENT CONFIDENTIALITY AND RELEASE). *
Primary reason for visit:
When did your first notice it?
What brought it on?
Describe any stressors occurring at the time:
What activities provide relief?
What makes it worse?
Is this condition:
SECONDARY COMPLAINT:  Significant Illnesses:
Have you had any COVID vaccines? Please list type and date and location of the injection
Are you pregnant?
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Are you trying to conceive?
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STRESS SCALE ~ 1= no stress, 10= extreme stress
NO STRESS
EXTREME STRESS
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PAIN SCALE ~ 1= no PAIN, 10= extreme PAIN
NO PAIN
EXTREME PAIN
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ENERGY SCALE ~ 1= no energy, 10= best energy
NO ENERGY
BEST ENERGY
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List all Western Diagnosis:
List all Medicines (taken within the last 6 months including drugs, vitamins and herbs):biocidin,,,GI detox Carolina acid ,,apple cider vinegar
List all Major Operations (and dates):double hernia 11/2024
List all Accidents / Traumas (and dates):0
Do you have an Allergies?
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Please review and check the following: *
PAST cancer
PRESENT
N/A
Asthma
Cold Hands or feet
Swollen ankles
Sinus Conditions
Frequent Colds
Seizures
Low Back Pain
Skin Disorders
Sciatica
High Blood Pressure
Low Blood Pressure
Dentures/Partials
Headaches
Sore heels when walking
Anxiety
Depression
Sleep Disturbance
Fainting Spells
Muscular Tension
Varicose Veins
Hemorrhoids
Herniated/Bulging Discs
Artifical/Missing limbs
Contact Lenses
Cancer (past or current)
Numbness in feet or legs when standing
FAMILY HISTORY:  Short answers for the following immediate family members:  Please include Mother, Father, Siblings, Maternal Grandparents, Paternal Grandparents.... Any Major Health Issues?  Are the Still Living?  (If deceased, Cause and Age of Death) none
This space is to share more details from above answers if needed:
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