Welcome to Acton Family Chiropractic

Please fill out our health record as completely and accurately as possible. Our commitment to you is to promote the highest quality of health and well-being with chiropractic care. It is our pleasure to be of service to you.

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Name*

First Last

Preferred Nickname:

Email*

Phone*

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

Marital Status

Not Married

Married

Spouse's Name

Do you have children?

Yes

Number of Children

Height (inches)

Weight (pounds)

Employer

Type of Work

How did you hear about our office?

Emergency Contact

Emergency Contact Name

First Last

Emergency Contact Phone

Relation To You

Experience With Chiropractic

Have you been adjusted by a chiropractor before?

Yes, within the last year

Yes, more than a year ago

No, never.

What condition were they treating?

Reason For Visit

What is the MAIN reason for this visit?

Back Pain

Neck Pain

Headaches

Sciatica

Scoliosis

Disc Injury

Whiplash

Work Injury

Arm Pain

Leg Pain

Carpal Tunnel

Shoulder Pain

Pregnancy

Vertigo

Other

Please explain:

Approximate date this condition began

What caused this condition?

What term(s) describes your discomfort best?

Rate the severity of your discomfort at its worst, on a scale of 1-10 where 1 is the least severe and 10 is the most severe:

How often do you feel this discomfort?

How has this complaint changed since the onset?

What activity is most significantly affected by this discomfort?

When do you experience this discomfort the most?

What aggravates this condition?

What improves this condition or gives you relief?

What treatment, if any, have you received?

Have other health care provider(s) performed tests related to this condition?

Yes

What have they done?

Have you ever had any previous episodes of this condition:

Yes

Additional health concerns, if any:

Functional Rating Index

For use with Neck and/or Back Problems only. In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select the number which most closely describes your condition right now.

1) Pain Intensity

0 - No pain

1 - Mild pain

2 - Moderate pain

3 - Severe pain

4 - Worst possible pain

2) Sleeping

0 - Perfect sleep

1 - Mildly disturbed sleep

2 - Moderately disturbed sleep

3 - Greatly disturbed sleep

4 - Totally disturbed sleep

3) Personal Care (washing, dressing, etc)

0 - No pain; no restriction

1 - Mild pain; no restrictions

2 - Moderate pain; need to go slowly

3 - Moderate pain; need some assistance

4 - Severe pain; need 100% assistance

4) Travel (driving, etc)

0 - No pain on long trips

1 - Mild pain on long trips

2 - Moderate pain on long trips

3- Moderate pain on short trips

4 - Severe pain on short trips

5) Work

0 - Can do usual work plus unlimited extra work

1 - Can do usual work; no extra work

2 - Can do 50% of usual work

3 - Can do 25% of usual work

4 - Cannot work

6) Recreation

0 - Can do all activities

1 - Can do most activities

2 - Can do some activities

3 - Can do a few activities

4 - Cannot do any activities

7) Frequency of pain

0 - No pain

1 - Occasional pain; 25% of the day

2 - Intermittent pain; 50% of the day

3 - Frequent pain; 75% of the day

4 - Constant pain; 100% of the day

8) Lifting

0 - No pain with heavy weight

1 - Increased pain with heavy weight

2 - Increased pain with moderate weight

3 - Increased pain with light weight

4 - Increased pain with any weight

9) Walking

0 - No pain; any distance

1 - Increased pain after several hours

2 - Increased pain after 1 hour

3 - Increased pain after 1/2 hour

4 - Increased pain with any standing

Total Score:

Please enter a number from 0 to 36.

Personal & Family History

Have you had any surgical procedures? If so, what?

Are you on any medications? If so, what?

Are there any past illnesses or conditions we should be aware of?

What type of accidents and traumas have you experienced?

Insurance

We DO NOT accept any third-party payment for services rendered at our office. We try to make chiropractic care as affordable as possible, and by doing so we offer discounted rates with unique codes that are unable to be submitted to your insurance company for reimbursement purposes.

Authorization For Care

I hereby authorize the doctor to work with my condition using adjustments to my spine and/or extremities, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment.

I agree that I am responsible for all the bills incurred at this office.

The doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

My signature below signifies my agreement for payment in full on a cash basis.

Please check below:*

I have read and agree with the above statements.

Digital Signature

Date

MM slash DD slash YYYY