Adult Health Profile - Mobile


Introduction and History

Full Name

Date of birth (Month/Day/Year):

Gender

Occupation

Home Address and Phone Number

Employer and Work Phone Number

Family Medical Doctor

Have you had Chiropractic care before? If so, when and by whom?

Spouse’s Name and Occupation

Children’s Name and Ages

Hobbies

Referred by (please include person’s name)

*If this is a Worker’s Comp case please tell us immediately.

Why this form is important:

Our office focuses on your ability to be healthy. Our goals are to first address the issues that brought you to this office, and second, offer the opportunity to improve your health potential in the future. In order to give you the best possible Chiropractic care, we will need to discover any ‘stresses’ that are placed on your body. Please take the time to fill out this form completely, as each question gives us a clearer picture of your current health status.

Reason for consulting this office

Please describe your current problem, including the effect it has had on your life:

Please describe the character of your pain (check all that apply)

How often are the complaints present?

When is the pain or symptoms worse:

How bad is your pain or ache? (0= no pain, 10 = unbearable pain)

Since your problem began is the pain:

When did your problem begin: (specific date if possible)

Do you sleep on your:

Physical Activity at work:

General physical activity:

How would you rate your stress level:

Do you currently smoke?

If YES please indicate how many packs a day:     Number of years:

Who else have you seen for this condition:   

Please describe any falls, auto accidents or major injuries (include Month/Year, Type of accident):

Please describe any and all past surgery:

Please list ANY and ALL medication (prescription and over the counter): that you are currently taking:

Please Tick Any That Apply: PERSONAL HISTORY:

If Others, please specify:

Please Circle Any That Apply: FAMILY:

If Others, please specify:

Please check all symptoms or areas where you have problems, even if they do not seem related to your current problem.

Do you drink bottled or filtered water:

Do you belong to a health club or exercises regularly:

If you remember the details, what was your birth delivery like (eg – breach, c section, long):

Have you had any or all of your childhood vaccinations?

Any reactions to vaccinations?

Please list all supplements and vitamins you take:

How would your rate your health:   

How committed are you to improving your health:   

Do you want to live to be a healthy 85 years old?   

What is ‘being healthy’ to you (check all that apply)?

What is your goal or expectations with Chiropractic care:

What is your goal or expectations with Chiropractic care:

PHIPA AGREEMENT

For individuals enrolled in the Adult Health Profile form who receive Protected Health Information from their Doctors Informed Consent.

You acknowledge to Pike Chiropractic Healing Centre that you receive chiropractic care which enables your Doctor to transmit protected health information (“PHI”) and other data to your authorized email account on your computer device through the Pike Chiropractic Healing Centre website.

By signing below, you authorize your Doctor to utilize the Adult Health Profile form to transmit your PHI and Data to your authorized email account and agree to maintain such authorized email account on a secure basis, with a confidential User Name and Password. You further acknowledge and agree that any disclosure of your PHI and Data after transmission to you (“Transmitted PHI and Data”) through the website by the Doctor will be deemed to be under your custody and control thereafter, and the Doctor shall not have any responsibility under PHIPA for any further disclosure of such Transmitted PHI and Data to any party, whether authorized or unauthorized, which may occur.

Health is significant, but not necessarily serious – we will do what we can to make each visit stress-free.

I hereby authorize the Doctor to examine and treat my condition as he deems appropriate through the use of Chiropractic Care and Nutritional Care, and I give authority for these procedures to be performed. I have been informed of the Clinic’s financial policy and agree that I am responsible for all bills incurred at this office. I have had an opportunity to review the privacy policy and agree to its terms.

Please enter your legal full name, email address and signature below. Then click on “Agree & Sign” to complete this step.

Leave this empty:

Signed by Dr. Robert Stewart Pike
Signed On: April 20, 2018

Pike Chiropractic Healing Centre https://pikechiropractic.com
Signature Certificate
Document name: Adult Health Profile - Mobile
Unique Document ID: 295095c050e0b87068c3b3ab0a5f721067473a26
Timestamp Audit
April 20, 2018 3:47 am ESTAdult Health Profile - Mobile Uploaded by Dr. Robert Stewart Pike - [email protected] IP 175.158.225.57, 175.158.225.57