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OUR CLINIC PURPOSE: EVERY HUMAN EXPERIENCE YOU HAVE OCCURS THROUGH YOUR NERVOUS SYSTEM. BY HELPING YOU ACHIEVE A HEALTHIER NERVOUS SYSTEM, WE HELP TO ENHANCE YOUR HUMAN EXPERIENCE! Personal Wellness History
PLEASE PRINT CLEARLY AND LEGIBLY
Todays Date: ______________________________

Patient Name (Last): _______________________________ (First):____________________________________ (M.I.): _______ Address: _______________________________________ City: _____________________ State: __________ Zip: ____________ Cell#:(____)_________________ Work#:(____)___________________Who can we thank for this referral?:__________________ Email Address: ___________________________________________ Preference for Appt Reminders? Call__ Text__ Email__ DOB: ____/_____/_____ Minor (Under 17)? Yes__ No__ Gender: M __ F __ Last 4 digits of Social Security # -___________ Occupation: ______________________________________ Employer: ______________________________________________ Marital Status: S __ M __ Other________________ _Significant Others Name: ________________________ # of Children: ___ If the Patient is a Minor, please fill out the Legal Guardians information below : Name: ________________________________________________ Relation to Patient: ________________________________ Address: ________________________________________ City: _____________________ State: __________ Zip: ___________ Home Phone: (____) _________________ Work Phone: (____) _________________ Cell Phone: (____) ___________________ DOB: _____/_____/______ Gender: M __ F __ Last 4 digits of Social Security # -___________

In Case Of Emergency (Name of relative or close friend not living in your home): Name: _________________________________ Home Phone: (____) __________________ Cell Phone: (____) _____________ Address: ________________________________________ City: _____________________ State: __________ Zip: ___________

WHY THIS FORM IS IMPORTANT:

On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health potential. Answering the following questions will help us determine some of the specific stressors you have faced in the past and those you are presently experiencing. The more information we have the better we may assess the challenges to your health potential. YOUR HEALTH CONCERNS OR SYMPTOMS AND HOW THEY MAY AFFECT YOUR LIFE Do you have any current symptoms or health concerns that brought you to our office?

___Yes ___No ___Wellness

If yes, please describe ( PAIN QUALITY-achy, sharp, dull; PAIN DURATION-constant, occasional; PAIN RADIATION -into legs or arms; ANYTHING that makes it BETTER or WORSE) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ When did this concern begin?______________________________________________________________________ When is it better and when is it worse?______________________________________________________________ Has this ever happened before? ___________________________________________________________________ Have you done anything about this situation or concern, or had any advice or treatment? ___Yes___No If yes, who did you go see and what was done to help you?______________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Did it seem to work? ___Yes ___No RehabShare>FORMS>IntakeForms>IntakeRevised 081213

www.facebook.com/rehabfxaustin p. 512.480.9999 f. 512.457.0894 Please grade the level this symptom or health concern affects these aspects of your functioning/quality of life.
0 It does not seem to affect me at all 1 It seems to slightly affect me 2 It seems to moderately affect me 3 It seems to drastically affect me

Work ___ Walking ___

Recreation/Play ___ Social Life ___

Rest/Sleep ___ Eating ___

Exercise ___ Sitting ___

Why do you think this happened or continues to happen? _______________________________________________ _____________________________________________________________________________________________ Do you think that there are other factors involved?__No__Yes, what?______________________________________ _____________________________________________________________________________________________ How is this complaint preventing you from doing the things you love?_______________________________________ _____________________________________________________________________________________________ Please tell us the 3 MOST important things in your life:__________________________________________________ _____________________________________________________________________________________________ When was the last time you felt REALLY good?_______________________________________________________ _____________________________________________________________________________________________
Have you had Diagnostics performed specific to todays complaints (ie. X-rays, MRI, CT, etc) on the area(s)? Yes____ No_____

If yes, What?_____________________________When? __________________ Where? _________________________________ Please list ALL X-rays/MRIs/Other imaging, accidents/injuries, and/or Surgeries you have had in the past, with dates:

Please list any medications, vitamins, or supplements you have taken in the past 30 days and why: Name Reason

Review of Systems
Check all that apply: Allergies / Sinus Problems Asthma / Difficulty Breathing Convulsions Dizziness Fever Headache / Migraines Loss of Sleep / Fatigue Sweats Loss of Weight / Increased Weight Nervousness / Depression Constipation / Loose Stools Indigestion / Stomach Problems ______________________________ High Blood Pressure (including if you take Medication) Skin Problems Vision Problems Ears Ringing / Hearing Problems Heart Problems (including Surgeries/Medications)

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FOR WOMEN ONLY (Check all that apply);_________ Pregnant Fibrocystic/Congested Breasts Cramps or Backache Excessive Menstrual Flow Hot Flashes Irregular Cycle ___________ Menopausal Symptoms Painful Menstruation Vaginal Discharge

Other stressors throughout our life impact our bodys ability to adapt and function. Please take a moment to consider the impact of past or current stressors. PHYSICAL STRESS Have you experienced any of the following? ___Birth Trauma ___Falls ___Work Injuries ___Sports (either repetitive or specific incidences)

CHEMICAL STRESS Do you smoke or have you in the past? __Yes __No Please indicate if you consume any of the following using this scale:
D-Consume daily W Consume weekly M Consume monthly N Never consume

___ Coffee

___ Artificial Sweeteners

___ Soda Pop

___ Dairy

___ Refined Sugar

EMOTIONAL STRESS Do you have any of the following stressors? ____Childhood Stress_____School Stress____Stress due to Illness____Work Related Stress____Lifestyle Change How you feel is a poor indicator of your health. Most people are suffering with ill health long before symptoms appear. Nerve disturbance (ie. spinal subluxations) can occur in your spine for decades before symptoms appear, interfering with the proper functioning of the bodys most vital blood vessels, organs and glands causing your body to eventually dysfunction and breakdown. I would like to learn strategies to mentor my family to better health.___Yes ____No How can we best serve you? 1. ___Get rid of the symptoms, only. 2. ___Get rid of the symptoms, but then fix the problem so it doesnt come back. 3. ___Get rid of the symptoms, fix the problem, and also talk to me about exercise, supplements and nutrition so that I can be as healthy as possible and get the most out of life. Thank you for taking the time to complete this form. The more we understand your current health status the better we will be able to guide you toward your ideal health goals. Authorization to Use or Disclose Protected Health Information and Consent to Treatment Your authorization is requested for purposes of delivering your care in an open-door environment as described in the offices privacy notice. In the course of your care, in this environment, routine details of your condition and care may be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details of your care will be addressed and considered as confidential by other patients. We are requesting your authorization in this regard to assure that you are fully informed and in agreement with the method and circumstances in which we deliver treatment. Your care will not be conditioned on your agreement to this authorization. You have the right not to sign this authorization and you also have the right to revoke this authorization RehabShare>FORMS>IntakeForms>IntakeRevised 081213

www.facebook.com/rehabfxaustin p. 512.480.9999 f. 512.457.0894 at a later date if that is your wish. If you wish to revoke this authorization at some time in the future please advise us accordingly in writing. You always have the right to review our most updated PHI information. You can also contact our privacy officer at 512-480-9999. Additionally, you are consenting to treatment by the above named provider(s). You understand that results are not guaranteed and are partly based on my cooperation with receiving the recommended care. You also will hold harmless, any complications of treatment, regardless of how rare complications may occur. You also agree, you have discussed your care with our provider and understand the treatment that will be rendered to you. If you agree to this authorization and have received and reviewed our new HIPAA privacy notice effective September 23, 2013. A copy of this authorization will be maintained by this office. Name: Signature: Date:

If you are a minor or if you are being represented by another party please provide the appropriate persons: Name: Signature: Relationship to the patient:___________ Date: Regarding Major Medical Insurance: While our office firmly believes you should not entrust your health to an insurance carrier, as a courtesy to you we will bill services, which are deemed appropriate, to most major carriers on your behalf. I, the patient and/or Guardian am aware that if I have insurance available it will be billed for services rendered, unless I request otherwise. It is expected that payments be made at the time of service unless other arrangements have been made. I am also aware that my insurance company may send me payments for services rendered by Minors Chiropractic/rehabfx which includes consultation, examinations, rehabilitation services, chiropractic, and DME supplies. I agree that when I receive any payments for these services, I will: 1. 2. 3. Sign/Endorse the check and I WILL NOT DEPOSIT or CASH it. Under my signature, I will clearly and legibly print the following: Make Payable Only to Minors Chiropractic Inc I will enclose the check with accompanying letters or forms, such as the Explanation of Benefits (EOB), in an envelope and mail immediately to rehabfx, 2404 Lake Austin Blvd, Austin, TX 78703 or bring to the office within 5 business days from receipt of the checks. I understand that in the event that the check is not immediately sent to rehabfx, I will be responsible to pay the full and entire fee for all services rendered, plus any additional collection fees and legal costs related to collecting this debt. By signing below you are stating you understand the conditions of receiving treatment at rehabfx and will comply with all the terms above or will be liable for all bills. Print Name:____________________________ Signature:__________________________ Date: ________________ Witness: ______________________________ Date:________________

If you would like to see a copy of our HIPAA privacy policy, please ask Rehabfx staff for a copy. RehabShare>FORMS>IntakeForms>IntakeRevised 081213

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