THEOBALD FAMILY CHIROPRACTIC -- Patient Information

DATE: _______________

Patient Name: _______________________________________________   Case No. ______________

Address: ___________________________________________________   City: __________________

State: _______  Zip Code: ______________   Date of Birth: ___________________      Male/Female

Home Phone: _________________________             Business Phone: __________________________

E-mail address: ______________________________________ (optional)

Marital Status: _______________         Spouse Name: ______________________________________

Children's Names and Ages: ___________________________________________________________

Occupation: __________________________     Employer: ____________________________________

In case of emergency notify: ____________________________     Phone: ________________________

SS No. ___________________________         Referred by: ____________________________________

Past Chiropractic Care (where & when): ___________________________________________________

Reason for office visit: _________________________________________________________________

List prior surgeries, falls, accidents and/or injuries and their dates:

____________________________________________________________________________________
____________________________________________________________________________________

List all:
MEDICATIONS                                             DOSAGE                                     PURPOSE

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Allergies: _____________________________________________________________________________

Vitamins/Minerals/Herbs: ________________________________________________________________

YOUR BIRTH RECORD

Type of birth -- cesarean, natural, etc. ______________________________________________________
Any complications during your birth: _______________________________________________________
Any complications after your birth: ________________________________________________________

CURRENT HEALTH

How would you describe your current health? _________________________________________________
_____________________________________________________________________________________

How would you describe your family's health? _________________________________________________
______________________________________________________________________________________

Do you or any of your family suffer from the following? (circle all that apply)

    Headaches                 Dizziness             Nausea                 Malaise

TERMS OF ACCEPTANCE

When a patient seeks Straight Chiropractic healthcare, and we accept a patient for such care, it is essential for both to be working towards the same goal.

Straight Chiropractic has only one goal.  It is important for the patient to understand this goal and the method that will be used to attain it.   This will prevent confusion and disappointment.

"Vertebral Subluxations" are mechanical interferences by the spinal bones, to the normal flow of mental impulses traveling over the nerve pathways.  The goal of Straight Chiropractic is to locate, analyze and remove these vertebral subluxations.

The Straight Chiropractic method is by specific adjustments of the spine. These adjustments are intended to remove vertebral subluxations, thereby allowing the innate healing abilities of the body to work at maximum efficiency.

With a proper nerve supply restored through Straight Chiropractic adjustments, the body can begin the process of repair, leading to health.   In some patients, this happens quickly, in others more slowly.  In some patients the repair and maintenance is complete, in others only partial.

Regardless of what the disease is called, we do not offer to treat it, nor do we offer advice regarding treatment prescribed by other healthcare providers.  We do not diagnose conditions or diseases other than vertebral subluxations.  OUR ONLY GOAL IS TO ALLOW THE BODY TO DO ITS JOB.

I, _______________________________________, have read and fully understand the above statements and accept chiropractic care on that basis beginning on the following date: _____________________.