Whom may we thank for referring you to this office  _______________________________________?
APPLICATION FOR CARE AT Carpenter Chiropractic, “Awaken to Wellness”
502 454 3500
161 St. Matthews Avenue Suite 13 Louisville, KY 40207
Today’s Date: __________________
PATIENT DEMOGRAPHICS
Name: ___________________________________________ Birth Date: _____-_____-_____ Age: _______
 Male  Female
Address: _________________________________________ City: _________________________________ State: _____ Zip: ____________
E-mail Address: ____________________________________ Home Phone: ________________________Mobile Phone:_______________
Marital Status:  Single
 Married
Do you have Insurance:  Yes
 No
Work Phone: ______________________________
Social Security #: ___________________________________ Driver’s License #: ______________________________________________
Employer: ________________________________________ Occupation: ____________________________________________________
Spouse’s Name _________________________________________Spouse’s Employer __________________________________________
Number of children and Ages: _________________________________
Name & Number of Emergency Contact: ______________________ ___________________Relationship: ___________________________
**Our goal is to serve you with exceptionally friendly and prompt service, and provide the best family well care available.
This office is a place of healing. In consideration of other patients all cell phones must be turned off during your time in our office.
APPOINTMENT SCHEDULING:
Doctors and wellness coaches will design a specific course of action to allow proper care for you. It is important for your wellness to
keep all scheduled appointments. If an appointment must be changed, 24 hours notice is requested. All missed appointments should
be made up within 7 days. Occasionally the office is closed while the staff is attending seminars. We will build your schedule around
those times.
NOTICE OF PRIVACY PRACTICES:
The below named patient acknowledges they have received a copy of Notice of Privacy Practices.
PATIENT NAME (please print)__________________________________________________________________________
PATIENT SIGNATURE__________________________________________________________________________________
(Parent or legal guardian if patient is under 18 years of age)
STANDARD AUTHORIZATION OF USE AND / OR DISCLOSURE OF PROTECTED HEALTH INFORMATION:
I hereby voluntarily authorize Awaken to Wellness / Carpenter Chiropractic Center to release any and all medical information, until
this authorization is further revoked, to:
_____________________________________________________________________Relationship:_________________________________
_____________________________________________________________________Relationship:_________________________________
_____________________________________________________________________Medical Doctor
I understand that if the person or organization authorized to receive the information is not a health plan or health care provider, the
released information may no longer be protected by federal privacy regulations.
Signature of Patient: _______________________________________ Signature of Patient Representative:
_____________________________
Signed and Dated: ______________________
You have the right to revoke this authorization at any time, provided that you do so in writing and except to the extent that we have already
used or disclosed the information in reliance on this authorization.
Awaken to Wellness/ Carpenter Chiropractic Center is not a participating provider with any insurance company including PPO’s,
HMO’s, or Medicare.
This office does not promise that insurance company will reimburse you for the usual and customary charges submitted by this office.
You are considered a cash practice member until our office “qualifies” your coverage to determine the extent of benefits under your policy.
Members and their guardians are responsible for the payment in full of all fees for service. Unless other arrangements are made, payment
is expected at the time of service regardless of insurance coverage.
In today’s healthcare system, insurance participation can be confusing. It will be our pleasure to verify your chiropractic benefits for you.
Most insurance companies provide some coverage for the services we offer in this office. Coverage varies and you may have limitations on
the number of paid visits, deductibles or exclusions and may or may not have coverage.
At Awaken to Wellness/ Carpenter Chiropractic Center, we never want a financial challenge to get in the way of a family receiving care in
our office. Therefore, we have established a fee schedule that creates affordable options for members. We are ready, willing, and able to
assist you!
Printed Name: _________________________________________________ Date_____________________
Signature: _______________________________________________________________________________
HISTORY of COMPLAINT (if this is a wellness visit please skip to Past History)
Please identify the condition(s) that brought you to this office: Primarily: _____________________________________________________
Secondarily: __________________________ Third: _____________________________ Fourth: ___________________________________
On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling the number:
Primary or chief complaint is : 0 - 1 - 2 - 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
Second complaints is
: 0 - 1 - 2 - 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
Third complaint:
: 0 - 1 - 2 - 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
Fourth complaint:
: 0 - 1 - 2 - 3 – 4 – 5 – 6 – 7 – 8 – 9 – 10
When did the problem(s) begin? ____________________ When is the problem at its worst?  AM  PM  mid-day  late PM
How long does it last?  It is constant OR  I experience it on and off during the day OR  It comes and goes throughout the week
How did the injury happen?____________
Condition(s) ever been treated by anyone in the past? No  Yes If yes, when: ______ by whom? ________________________________
How long were you under care: ____________
What were the results? ______________________________________________________
Name of Previous Chiropractor: _______________________________
 N/A
*PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms:
R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling
What relieves your symptoms? ____________________________
What makes them feel worse? _________________________________
LIST RESTRICTED ACTIVITY:
CURRENT ACTIVITY LEVEL
USUAL ACTIVITY LEVEL
___________________________________:
______________________________________________________________________
___________________________________:
______________________________________________________________________
___________________________________:
______________________________________________________________________
___________________________________:
______________________________________________________________________
Is your problem the result of ANY type of accident?  Yes,  No
Identify any other injury(s) to your spine, minor or major, that the doctor should know about:
___________________________________________________________________________________________________________
QUADRUPLE VISUAL ANALOGUE SCALE
Please read carefully:
Instructions: Please circle the number that best describes the question being asked.
Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each
complaint. Please indicate your pain level right now, average pain, and pain at its best and worst.
1 – What is your pain RIGHT NOW?
No pain ________________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
2 – What is your TYPICAL or AVERAGE pain?
No pain ________________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
3 – What is your pain level AT ITS BEST (How close to “0” does your pain get at its best)?
No pain ________________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
4 – What is your pain level AT ITS WORST (How close to “10” does your pain get at its worst)?
No pain ________________________________________________________________________________ worst possible pain
0
1
2
3
4
5
6
7
8
9
10
OTHER COMMENTS:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
ACTIVITIES OF DAILY LIVING
ACTIVITIES:
EFFECT:
Carrying Groceries
Sit to Stand
Climbing Stairs
Perform
Pet Care
Driving
Extended Computer Use
Household Chores
Lifting Children
Reading/Concentration
Bathing
Dressing
Shaving
Sexual Activities
Sleep
Static Sitting
Static Standing
orm
Yard work
Walking
Swee
Laundry
Please mark P for in the Past, C for Currently have and N for Never
___ Headache ___ Pregnant (Now)
___ Dizziness
___ Prostate Problems ___ Ulcers
___ Neck Pain ___ Frequent Colds/Flu ___ Loss of Balance
___ Heartburn ___ Jaw Pain, TMJ
___ Impotence/Sexual Dysfun.
___ Convulsions/Epilepsy
___ Fainting
___ Digestive Problems
___ Heart Problem
___ Shoulder Pain
___ Tremors
___ Double Vision
___ Colon Trouble
___ High Blood Pressure
___ Upper Back Pain
___ Chest Pain
___ Blurred Vision
___ Diarrhea/Constipation
___ Low Blood Pressure
___ Mid Back Pain
___ Pain w/Cough/Sneeze
___ Ringing in Ears
___ Menopausal Problems
___ Low Back Pain
___ Foot or Knee Problems
___ Hearing Loss
___ Menstrual Problem
___ Asthma
___ Difficulty Breathing
___ Hip Pain
___ Sinus/Drainage Problem
___ Back Curvature
___ Scoliosis
___ Depression ___ PMS
___ Swollen/Painful Joints
___ Skin Problems
___ Irritable
___ Mood Changes
___ Lung Problems
___ Bed Wetting
___ Kidney Trouble
___ Learning Disabilty ___ Gall Bladder Trouble
___ Numb/Tingling arms, hands, fingers ___ ADD/ADHD ___ Eating Disorder
___ Liver Trouble
___ Numb/Tingling legs, feet, toes
___ Hepatitis (A,B,C)
___ Allergies
___ Trouble Sleeping
PAST HISTORYHave you suffered with any of this or a similar problem in the past?  No  Yes If yes how many times? ________ _
When was the last episode? _____________________ How did the injury happen?____________
Other forms of treatment tried:  No  Yes If yes, please state what type of treatment: _________________________________, and
who provided it: _________________________ How long ago? _______What were the results.  Favorable  Unfavorable please
explain. ____________________________________________________________________ ____________________________________
Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:
______________________________________________________________________________________________________________
If you have ever been diagnosed with any of the following conditions, please indicate with a P for in the Past, C for Currently have and N
for Never have had:
___ Broken Bone ___Dislocations
___ Tumors ___Rheumatoid Arthritis ___ Fracture ___Disability ___Cancer
___ Heart Attack ___Osteo Arthritis ___ Diabetes ___Cerebral Vascular
___ Other serious conditions:
PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:
HOW LONG AGO
TYPE OF CARE RECEIVED
BY WHOM
INJURIES

SURGERIES

CHILDHOOD DISEASES
ADULT DISEASES

WELLNESS GOALS
Welcome to our wellness center,
Today we are here to discover your goals and priorities as it relates to your health and wellness. Your answers
will help us determine how we can best help you.
Let’s get started…
On a scale of 1 – 10, rate the importance for you to achieve the following:
1 = not important 10 = necessary
Get fit 1 2 3 4 5 6 7 8 9 10
Eat better 1 2 3 4 5 6 7 8 9 10
Reduce stress 1 2 3 4 5 6 7 8 9 10
Stop smoking 1 2 3 4 5 6 7 8 9 10
Reduce pain 1 2 3 4 5 6 7 8 9 10
Increase my mobility 1 2 3 4 5 6 7 8 9 10
Improve my posture 1 2 3 4 5 6 7 8 9 10
Improve my sleep 1 2 3 4 5 6 7 8 9 10
Learn about wellness 1 2 3 4 5 6 7 8 9 10
Learn about wellness products that are right for me 1 2 3 4 5 6 7 8 9 10
Other ________________________________________ 1 2 3 4 5 6 7 8 9 10
Which of the above would you say is the most important goal for you to achieve and why?
________________________________________________________________________________
Have you ever attempted to accomplish this goal in the past? Yes No
If yes, what happened and what prevented you from maintaining your results? _________________
________________________________________________________________________________
Do you have any questions or comments? ______________________________________________
Remember: your health is your greatest asset, the more of it you have the healthier you are.
We look forward to helping you Awaken to Wellness!
SOCIAL HISTORY
1. Smoking: cigars  pipe  cigarettes  How often?  Daily  Weekends  Occasionally  Never
2. Alcoholic Beverage: consumption occurs 
 Daily  Weekends  Occasionally  Never
3. Recreational Drug use:
 Daily  Weekends  Occasionally  Never
4. Hobbies -Recreational Activities- Exercise Regime: How does your present problem affect the following:
FAMILY HISTORY:
1. Does anyone in your family suffer with the same condition(s)?  No  Yes
If yes whom:  grandmother  grandfather  mother  father  sister’s  brother’s  son(s) 
daughter(s)
Have they ever been treated for their condition?  No
 Yes
 I don’t know
2. Any other hereditary conditions the doctor should be aware of.  No Yes: __________________________
List Prescription & Non-Prescription drugs you
take:________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
___________________________________
Patient or Authorized Person’s Signature
________________________________________
Doctor’s Signature
_____ - _____ - _____
Date Completed
______ - ______
Date Form Reviewed