About You
Name:
Address:
City:
State:
Zip:
Chiropractic experience
Home Phone:
E-mail Address:
Date of Birth:
Marital Status:
Age:
S
M
Number of Children:
Employer :
Spouse’s Name:
Spouse’s Employer:
Reason for this visit
What is you primary reason for this visit:
Is this appointment related to one of the following:
_______Long term discomfort ______Injury at work
_______Auto accident _______Other
When did the problem(s) begin:
Has the problem?
How were you introduced to us?
Presentation________
Team sponsorship________
Community event ________
Family/friend _______
Internet ________
Other (Please explain)___________
____________________________________
Were you aware that…….
Chiropractic is the largest natural healing profession in
the world?
______Yes ______No
The nervous system controls all bodily systems and
functions?
______Yes ______No
If chiropractic care starts at birth, one can achieve a
highler level of health throughout life?
______Yes ______No
Have you been adjusted by a chiropractor in the past?
______Yes ______No
Is so, what was the reason for the adjustments?
Approximate date of last adjustment:
________Worsened
________Stayed the same
________Come and gone
If applicable, have you ever had your child/children
assessed for nervous system interferrence/damage?
______ Yes ______ No
If known, how did the problem happen?
Has this condition or anything similar ever occurred before?
______Yes ______No
If so, please explain:
Has this condition been treated by anyone in the past?
_______Yes _______No
Who was this condition treated by?
What were the results?
730 APOLLO DRIVE
SUITE 120
LINO LAKES, MN 55014
651-797-3756 (OFFICE)
Current condition(s)
Current medications
___Cholesterol
___Blood pressure
___Stimulants
___Blood thinners
___Tranquilizers
___Pain medication
___NSAIDS
___Muscle relaxants
___Insulin
__Other(Please list)
___Vitamins and supplements (please list):
Instructions: Please circle the health concerns
or conditions you may be experiencing now or
have had in the past. Each area of concern
relates to an area of the spine and nerve
functions.
SORE THROAT
STIFF NECK
RADIATING ARM PAIN
HAND/FINGER NUMBNESS
ASTHMA
ALLERGIES
HIGH BLOOD PRESSURE
HEART CONDITIONS
Mark areas of pain with an “X”
CONSTIPATION
COLITIS
DIARRHEA
GAS PAIN
IRRITABLE BOWEL
BLADDER PROBLEMS
MENSTRUAL PROBLEMS
LOW BACK PAIN
PAIN OR NUMBNESS IN LEGS
REPRODUCTIVE ISSUES
C1
C2
C3
C4
C5
C6
C7
T1
HEADACHES
MIGRAINES
DIZZINESS
SINUS PROBLEMS
ALLERGIES
FATIGUE
HEAD COLDS
VISION PROBLEMS
DIFFICULTY CONCENTRATING
HEARINGPROBLEMS
T2
T3
T4
T5
T6
T7
T8
T9
T1
0
L1
T1
L2
1
L3
T1
L4
2
L5
S
A
C
R
A
L
MIDDLE BACK PAIN
CONGESTION
DIFFICULTY BREATHING
BRONCHITIS
PNEUMONIA
GALLBLADDER CONDITONS
STOMACH PROBLEMS
ULCERS
GASTRITIS
KIDNEY PROBLEMS
Health status
Instructions: Please check each of the diseases or conditions that you have now or have had in the past. While they may seem
unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan, and possibility of being accepted for
care.
☐ SEVERE OR
☐ THYROID
PROBLEMS
☐ PAIN IN
ARMS/LEGS/HANDS
☐ NUMBNESS
☐ SINUS
PROBLEMS
☐ LOW BLOOD
PRESSURE
☐ ALLERGIES
☐ LOWER BACK
PROBLEMS
☐ HEPATITIS
☐ RHEUMATIC
FEVER
☐ DIABETES
☐ DIGESTIVE
PROBLEMS
☐ DIFFICULTY
BREATHING
☐ ULCERS/COLITIS
☐ SURGERIES:
☐ PAIN BETWEEN
SHOULDERS
☐ KIDNEY
PROBLEMS
☐ TUBERCULOSIS
☐ ASTHMA
☐ CONGENITAL
HEART DEFECT
☐ HIGH BLOOD
PRESSURE
☐ ARTHRITIS
☐ LOSS OF SLEEP
☐ FREQUENT NECK
PAIN
☐
CHEMOTHERAPY
☐ SHINGLES
☐ DIZZINESS
FREQUENT
HEADACHES
☐ HEART
SURGERY/PACEMAKER
For women:
Are you currently pregnant?
____Yes _____No
If yes, what is your due date?
__________________________
Are you nursing?
___Yes ___No
NOTICE OF PRIVACY POLICY
Protecting the privacy of your personal health information is important to us. Disclosure of your protected
health information without authorization is strictly limited to defined situations that include emergency
care, quality assurance activities, public health, research, and law enforcement activities. Any other
disclosure for the purposes of treatment, payment, or practice parathion will be made only after obtaining
your consent:
 You may request restrictions on your disclosures.
 You may inspect and receive copies of your records within 30 days with a request.
 You may request to view changes to your records
 In the future, we may contact you for appointment reminders, announcements, and to inform you
about our practice and its staff.
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have
certain rights to privacy regarding my protected health information. I understand that this information can
and will be used to:
 Conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be
involved in that treatment directly or indirectly.
 Obtain payment from third party payers.
 Conduct normal healthcare operations such as quality assessments and physician’s certifications.
I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I
also understand that I can request, in writing, that you restrict how my personal information is used or
disclosed.
PATIENT’S NAME (PLEASE PRINT):
SIGNATURE:
RELATIONSHIP TO PATIENT:
DATE:
Regarding: Chiropractic Adjustments, modalities, and therapeutic Procedures:
I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the
risks are most often very minimal, in rare cases, complications such as sprain/strain injuries,
irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at
a rate between one instance per two million adjustments.
Treatment objectives as well as the risks associated with chiropractic adjustments and, all other
procedures provided at Northern Chiropractic and Wellness have been explained to me to my
satisfaction and I have conveyed my understanding of both to the doctor(s). After careful
consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor
deems necessary to treat my condition at any time throughout the entire clinical course of my care.
Patient or authorized persons signature ________________________ Date _____________________
PAYMENT AGREEMENT/USE OF INSURANCE AUTHORIZATION
I hereby authorize the Doctors of Northern Chiropractic and Wellness to work with my condition through
the use of adjustments to my spine, as he/she deems appropriate. I clearly understand and agree that all
services rendered by me are charged directly to me and that I am personally responsible for payment. I
agree that I am responsible for all bills incurred at this office. Northern Chiropractic and Wellness will not
be held responsible for any preexisting medically diagnosed conditions nor for any medical diagnosis. I
also understand that if I suspend or terminate my care, any fees for professional services rendered by me
will become immediately due and payable.
I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to Northern
Chiropractic and Wellness, LLC for services rendered. I understand and agree that health and accident
insurance policies are an arrangement between an insurance carrier and myself. I understand that
Northern Chiropractic and Wellness will prepare any necessary reports and forms to assist me in collecting
from the insurance company and that any amount authorized to be paid directly to Northern Chiropractic
and Wellness, LLC will be credited to my account upon receipt.
Signature:
Date:
Guardian or Spouse Authorizing Care’s Signature:
Date: