Last Name __________________________ First Name ______________________ Date ____/____/_____
Address ________________________________________ City ______________________ Zip ________
Home Phone ________________________________ Cell Phone _________________________________
Email ____________________________________ Birthday ______/ _____ /_____ Age _____ Sex: M / F
Occupation __________________________________ Employer _________________________________
Marital Status: _______________ Spouse’s Name ________________________ Number of Children ____
Emergency Contact (name) ______________________ (phone) ____________ (relationship) __________
How did you hear about our clinic? _________________________________________________________
Please shade area(s) of complaint
Please rate each of your symptoms individually on a scale of 1-10,
0 being no pain at all and 10 being the most pain you’ve ever experienced.
Symptom #1: _________________________________ 0 1 2 3 4 5 6 7 8 9 10
Symptom #2: _________________________________ 0 1 2 3 4 5 6 7 8 9 10
Symptom #3: _________________________________ 0 1 2 3 4 5 6 7 8 9 10
Symptom #4: _________________________________ 0 1 2 3 4 5 6 7 8 9 10
Symptom #5: _________________________________ 0 1 2 3 4 5 6 7 8 9 10
Symptom #6: _________________________________ 0 1 2 3 4 5 6 7 8 9 10
Symptom #7: _________________________________ 0 1 2 3 4 5 6 7 8 9 10
1
Please check all that apply:
Current Condition(s) (continued)
Spinal: Neck Pain Upper Back Pain Mid Back Pain Low Back Pain
Neck Stiffness Upper Back Stiffness Mid Back Stiffness Low Back Stiffness
Upper Extremity: LEFT
Shoulder Pain
Arm Pain
Elbow Pain
Forearm Pain
Wrist Pain
Hand Pain
Lower Extremity: :LEFT
Hip Pain
Thigh Pain
Knee Pain
Calf Pain
Ankle Pain
Foot Pain
RIGHT
Shoulder Pain
Arm Pain
Elbow Pain
Forearm Pain
Wrist Pain
Hand Pain
RIGHT
Hip Pain
Thigh Pain
Knee Pain
Calf Pain
Ankle Pain
Foot Pain
Miscellaneous: Headache Jaw Pain Chest Pain Fatigue
Other: ________________________________________________________________
Does your pain travel or radiate to any of the following areas? (check all that apply)
LEFT
Shoulder
Arm
Elbow
Forearm
Hand
Fingers
RIGHT
Shoulder
Arm
Elbow
Forearm
Hand
Fingers
LEFT
Buttock
Thigh
Knee
Leg
Foot
Toes
RIGHT
Buttock
Thigh
Knee
Leg
Foot
Toes
Are you experiencing any numbness or tingling? (check all that apply)
LEFT
Shoulder
Arm
Elbow
Forearm
Hand
Fingers
RIGHT
Shoulder
Arm
Elbow
Forearm
Hand
Fingers
LEFT
Buttock
Thigh
Knee
Leg
Foot
Toes
RIGHT
Buttock
Thigh
Knee
Leg
Foot
Toes
2
Current Condition(s)
When did your symptoms begin? _____________________________________________________
What was the cause of your symptoms? Auto Accident Work Injury Lifting Slip/Fall Overexertion Strenuous Position Unknown
Other __________________________________
How soon did the symptoms start? Immediately Hours Later Next Day Days Later About a Week Later Other
_________________________________________________________________________
Have you experienced symptoms like these before? Yes / No (When?) __________________________
Have you missed any work due to this condition Yes / No If yes, give recent dates: _________________
___________________________________________________________________________________
What aggravates your condition? Coughing Sneezing Baring Down Lifting Bending Pushing
Pulling Sitting Standing Lying Down Walking Moving Your Head Other _______________
What alleviates your condition? Rest Movement Sitting Standing Lying Down Bracing Heat
Ice Massage Stretching ”Popping” Aspirin Ibuprofen Tylenol/Acetaminophen Prescribed
Medication
How would you characterize your pain? Dull Sharp Achy Shooting Burning Stabbing Throbbing Stiffness Other
____________________________________________________
What time of day are your symptoms worse? Morning Afternoon Evening While Sleeping
At Work Other _______________________________________________________________
What time of day are your symptoms better? Morning Afternoon Evening While Sleeping
At Work Other _______________________________________________________________
When your symptoms are at their worst, describe what happens.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_______________________________________
If these problems continue on without treatment, what do you think would happen?
____________________________________________________________________________________________________________
______________________________________________________________
3
Previous/Current Conditions
Do you currently have or have you ever had any of the following:
Hearing
Changes
Aneurysm
Blood Press.
High / Low
Cancer /
Tumor
Dislocated
Joints
Easily
bruised
Stroke
Heart
Disease
Hypo / Hyper
Thyroidism
_________
_________
Allergies:
_______________
Tuberculosis
Arthritis
Change in
appetite
Emphysema
Insomnia
Bone Fracture
List / Date:
Anemia
Rheumatic
Fever
Diabetes
Osteoporosis
Epilepsy /
Seizures
Pacemaker
Heart
Palpitations
Frequent
Nose Bleeds
Polio
Kidney
Trouble
Liver
Trouble
Prostate Trouble
Mental /
Emotional
Difficulty:
_________
_________
Rash / Lesion
Scoliosis
Spinal Disc
Disease
STD
Multiple
Sclerosis
Ulcer
Other: _____
______________
Hernia
Tinnitus / Ears
Ringing
Medications/Supplements
Please list all medications that you are currently taking:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Please list vitamin, mineral, and herbal supplements you are currently taking:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Family History
Has any member of your family been diagnosed with any of the following:
Cancer
Diabetes
High Blood Pressure
Stroke
Heart Disease
If yes, what is their relation to you? _____________________________________________________
4
Vascular Screening Symptoms
Have you recently experienced any of the following? (mark all that apply):
Dizziness
Trouble Swallowing
Recent Unexplained
Weight Gain or Loss
Fainting/Loss of
Consciousness
Recent decrease in
coordination
Recent decrease in
coordination
Nausea / Vomiting
Slurred Speech
Change in Urination
Blurred Vision
Double Vision
Visual Disturbances
None of the above
If you are experiencing Headaches or Neck Pain, have you experienced pain like this before?
Yes, I have had headaches/neck pain like this before.
No, this pain is different than I have ever experienced in the past.
Is your headache worse in the ___ morning or ___ afternoon?
Do your headaches wake you from your sleep? Yes / No
Previous Testing
What testing have you had done and when?
X-Ray: Yes No Area: ______________ Date ________
MRI: Yes No Area ________________ Date _________
CAT Scan: Yes No Area ______________ Date _________
Electrodiagnostic (EMG/NCV) Yes No Area: ______________ Date ________
Was there a previous diagnosis for your condition? ____________________________________________
Previous Treatment
Have you ever seen anyone else for this condition? Yes No
If Yes, who and when? __________________________________________________________________
_____________________________________________________________________________________
Have you ever received: Physical Therapy Yes No Chiropractic Care? Yes No
Acupuncture Therapy Yes No Massage Therapy Yes No Other:___________________________
Have you considered any other treatment? If yes, what? _________________________________________
What were the results from each type of treatment? ____________________________________________
____________________________________________________________________________________________________________
______________________________________________________________
Is there any type of treatment that you would not consider at this time? _____________________________
_____________________________________________________________________________________
What is your most important treatment objective? (Reduce pain, increase function, correct cause, prevent progression…)
_________________________________________________________________________
_____________________________________________________________________________________
5
Previous Accidents/Injuries/Hospitalizations/Surgeries
Do you have a history of the following: Work Injury Auto Accident Slip and Fall Accident
If so, please list approximate dates and incident:
Date ____/_____/_____ Incident: _______________________________________________
Date ____/_____/_____ Incident: _______________________________________________
Have you ever been hospitalized? Yes No If so, when and for what condition?
Date ____/_____/_____ Condition: _______________________________________________
Date ____/_____/_____ Condition: _______________________________________________
Have you had surgeries? Yes No If so, when and for what condition?
Date ____/_____/_____ Surgery: _______________________________________________
Date ____/_____/_____ Surgery: _______________________________________________
Sleep Habits
Healing occurs when you get restful sleep. Please answer the following questions about your sleep habits::
Do you have trouble falling asleep due to being uncomfortable Yes No
How long does it take you to fall asleep? __________________________
Is your sleep less restful? Yes No
Do you wake during the night? Yes No Approximately how many times? __________________
Do you wake earlier than you normally would? Yes No
Can you get back to sleep? Yes No
Activities of Daily Living
This next series of questions are about the affect your condition has had on your activities of daily life. We also will use this
information to measure your progress and the results of your treatment if we are able to accept you for care.
Work
How do your health problems make it harder to do your work? ___________________________________
_____________________________________________________________________________________
Are you less productive on your job because of your health problems? Yes No
Do you enjoy work less? Yes No
Do you have to take more breaks? Yes No
Are you concerned about your ability to do your job or the security of your job? Yes No
Please explain: _________________________________________________________________________
Social
How do your health problems affect your relationships with your family and friends? For example: Are you less fun to be with? Do
you help less around the house? Are there things you do less?__________________
____________________________________________________________________________________________________________
______________________________________________________________
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Recreational Activities
What hobbies or interests do you have outside of work?________________________________________
____________________________________________________________________________________________________________
______________________________________________________________
When your problems are at their worst, do they affect how you do or enjoy your hobby/interest? Yes / No
If you didn’t have this condition how would it affect how you do your hobbies/interests?
____________________________________________________________________________________________________________
______________________________________________________________
Is there anything else you would do more of or just enjoy more if it weren’t for these conditions?
____________________________________________________________________________________________________________
______________________________________________________________
Lifestyle Habits
Smoking (packs per day): Never 1 2 3 4+ Quit ___________ years ago
Caffeinated drinks (glasses per day) 0 1 2 3 4 5 6+
Drug/Substance use:: Yes No
Exercise (times per week) 0 1 2 3 4 5 6 7
Type of Exercise _______________________________________________________________________
Average amount of sleep per night (hours) 0 1 2 3 4 5 6 7 8 9 10 11 12
What do you feel your current level of stress is? (0 being no stress at all and 10 being maximal stress)
0 1 2 3 4 5 6 7 8 9 10
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Informed Consent for Chiropractic Care
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working
for the same objective. It is important that each patient understand both the objective and the method that will be used to
attain it. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed about the
condition of your health and the recommended care and treatment to be provided so that you may make the decision
whether or not to undergo chiropractic care after being advised of the known benefits, risks and alternatives.
Chiropractic is a science and art which concerns itself with the relationship between structure (primarily the spine) and
function (primarily the nervous system) as that relationship may effect the restoration and preservation of health. Health
is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.
One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24
vertebrae in the spinal column become misaligned and/or do not move properly. This causes alteration of nerve function
and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic.
Subluxations are corrected and/or reduced by an adjustment. An adjustment is the specific application of forces to correct
and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.
Adjustments are usually done by hand but may be performed by handheld instruments. In addition, ancillary procedures
such as physiotherapy and/or rehabilitative procedures may be included.
If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings and
recommend that you seek the services of another health care provider.
All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete
satisfaction. The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I have
read and fully understand the above statements and therefore accept chiropractic care on this basis.
__________________________ Print Name ________________________________ Signature _______________
Date
According to the state of Washington:
Chiropractic treatment or care includes the use of procedures involving spinal adjustments and extremity manipulation.
Chiropractic treatment also includes the use of heat, cold, water, exercise, massage, trigger point therapy, dietary advice
and recommendation of nutritional supplementation, the normal regimen and rehabilitation of the patient, first aid, and
counseling on hygiene, sanitation, and preventive measures. Chiropractic care also includes such physiological
therapeutic procedures as traction and light, but does not include procedures involving the application of sound,
diathermy, or electricity.
Anything done in my office outside these guidelines is not chiropractic care.
We keep a record of the health care services we provide you. You may ask us to see and copy that record. You may also
ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law
authorizes or compels us to do so. You may see your record or get more information about it by contacting our office.
Communication to the doctor regarding subjective symptoms, if any, is the responsibility of the patient. Be sure to note
any changes including any new accidents, injuries or changes to your health status.
__________________________ Print Name ________________________________ Signature 8
_______________
Date
MISSED VISIT POLICY
All scheduled visits must be cancelled with 24 hours advanced notice.
Any missed cash visits are charged the cash price for the session.
Any missed insurance, auto accident or LNI visits will be charged at the cash price for the session,
not the copay or co-insurance.
I , ______________________________________________, understand I will be responsible
financially for any care given that my insurance does not cover. This includes charges for noncovered services and/or the cash price for missed visits or visits cancelled/rescheduled within 24
hours of the appointment time.
Patient’s Signature: __________________________________ Date: ___________
Witness Signature: __________________________________ Date: ___________
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PAYMENT PLANS
To All New Patients;
Please Initial Next to Your Method of Payment.
__________ Cash Patient: Payment is expected at the time services are rendered. We accept Cash,
Check, Visa, MasterCard, and Discover.
__________ Insurance Patient: You need to provide our office with your insurance information. We
will bill your insurance as a courtesy to you; with the understanding that you are ultimately
responsible for your account in our office. All co-pays are expected at the time of service.
__________ Personal Injury Patient: It is your responsibility to provide our office with any and all
insurance information; including PIP, third party, health insurance, etc. We need all claim numbers
and insured person’s name, address, and phone numbers. You are responsible for payment to our
office for any services rendered.
__________ Labor & Industries Patient: You are responsible for filling out Labor & Industries long
form or the form for self insured L&I. You are also to have an accident report filed with your employer.
If your claim is not accepted, you will be responsible for your account balance.
Patient’s Signature: __________________________________ Date: ___________
Witness Signature: __________________________________ Date: ___________
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An Evolution in Chiropractic Notice of Privacy Practices
THIS NOTICE, EFFECTIVE 1/1/2014, DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
An Evolution in Chiropractic is required by law to maintain the privacy and confidentiality of your Protected Health Information
(PHI) and to provide our patients with notice of our legal duties and privacy practices with respect to your Protected Health
Information (PHI).
Disclosure of your Health Care Information:
Treatment: We may disclose your healthcare information to other healthcare professionals within our practice for the purpose of
treatment, payment, or healthcare operations. A few examples are listed below:
• It may be necessary to seek consultation regarding your treatment from other healthcare providers associated with An
Evolution in Chiropractic.
• It is our policy to provide a substitute healthcare provider, authorized by An Evolution in Chiropractic to provide assessment
and/or treatment to our patients, without advance notice, in the event of your primary healthcare provider’s absence due to
vacation, sickness, or emergency situation.
• Due to the nature of An Evolution in Chiropractic’s adjusting areas; others may overhear conversations between the doctor
and patient although every effort will be made to avoid loss of confidentiality. At any time, you may request a private
consultation with the doctor.
Payment: We may disclose your PHI to your insurance provider for the purpose of payment or healthcare operations. As a courtesy to
our patients, we will submit an itemized statement to your insurance carrier for the purpose of payment to An Evolution in
Chiropractic for healthcare services rendered. If you pay for your healthcare services personally, we will, as a courtesy to you, provide
an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical
information including diagnosis, date of injury or condition, and codes which may describe the healthcare services received.
Workers Compensation: We may disclose your PHI as necessary to comply with State Workers Compensation Laws.
Emergencies: We may disclose your health information to notify or assist in notifying a family member or another person responsible
for your care about your medical condition in the event of an emergency.
Public Health: As required by law, we may disclose your PHI to public health authorities for the purpose related to, but not limited to
preventing or controlling disease, injury disability, reporting child abuse or neglect, reporting domestic violence, report to the Food &
Drug Administration problems with products and reactions to medications, and reporting disease or infectious exposure.
Law Enforcement: We may disclose your PHI to law enforcement officials for the purposes such as, but not limited to identifying or
locating a suspect, fugitive, material witness, missing persons, complying with a court order or subpoena, and other law enforcement
purposes.
Deceased Persons: We may disclose your PHI to coroners or medical examiners.
Organ Donation: We may disclose your PHI to researchers conducting research that has been approved by the Institutional Review
Board.
Public Safety: It may be necessary to disclose your PHI to appropriate persons in order to prevent or lessen a serious and imminent
threat to the health and/or safety of a particular person or to the general public.
Specialized Government Agencies: We may disclose your PHI for military, national security, prisoner, and government benefits
purposes.
Marketing: We may contact you for marketing purposes or fundraising purposes. It is our practice to participate in charitable events
to raise awareness, food donations, etc. During these times, we may send you a letter, postcard, email, or call you to invite you to
participate in the event/activity. We will provide you with information about the type of activity, dates and times, and may request your
participation. It is not our policy to disclose your PHI for the purpose of An Evolution in Chiropractic sponsored fundraising or
marketing events to outside parties.
Change of Ownership: In the event An Evolution in Chiropractic is sold or merged with another organization, your PHI will become
property of the new owner(s).
Continued on next page...
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Your health information rights:
• You have the right to request restrictions on certain uses and disclosures of your PHI. Please be advised, An Evolution in
Chiropractic is not required to agree to the restrictions you request.
• The right to receive confidential communications of protected health information from An Evolution in Chiropractic by
alternate means or at alternate locations as provided by the Privacy Rule.
• An Evolution in Chiropractic is required by law to maintain the privacy of protected health information and to provide
individuals with notice of its legal duties and privacy practices with respect to protected health information.
• You have the right to receive a copy of your PHI after a written request has been signed per our Office Policy. A fee may be
charged for necessary copies.
• You have the right to request that An Evolution in Chiropractic amend your PHI. Please be advised that An Evolution in
Chiropractic is not required to amend your PHI. If your request to amend has been denied, you will be provided with an
explanation of our denial reason(s) and information how to dispute the denial.
• You have the right to receive an accounting of disclosures of your PHI by An Evolution in Chiropractic.
• You have the right to a paper copy of this Notice of Privacy Practices at any time upon request.
• It is our policy that a Records Release Form is signed by you before your PHI is disclosed to a requesting physician, aside
from provisions stated in this notice.
Changes to the Notice of Privacy Practices: An Evolution in Chiropractic reserves the right to amend this Notice of Privacy
Practices at any time in the future and will make the new provisions effective for all the information that it maintains. Until such
amendment is made, An Evolution in Chiropractic is required by law to comply with this Notice. Any questions about this Notice or if
you would like more information about your privacy rights, please contact the Office Manager at (425) 444-4815. If he/she is not
available, you may make an appointment for a personal conference. A revised copy will be available for you in our office at all times.
Complaints: Complaints about your privacy rights should be directed to the Office Manager by calling (425) 444-4815. If he/she is
not available, you may make an appointment for a personal conference. If you are not satisfied with the manner your PHI has been
handled, it is your right to contact DHHS at 200 Independence Ave SW, Washington, DC 20201.Thank you!
It is our goal at An Evolution In Chiropractic to protect your PHI!
Acknowledgment of receipt of Notice of Privacy Practices
I acknowledge that I have read and understand the Notice of Privacy Practices at An Evolution in Chiropractic and that I may receive
a copy of this Notice immediately upon request.
_____________________________________________
Print Patient Name
_____________________________________________
Patient/Parent Signature
Date _____________________
760 N 34th St. Seattle, WA 98103 P: (425) 444-4815 F: (425) 406-6200
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