New Patient Forms & Intake Information

Welcome to our health center. At Total Health Solutions, we specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is unique and advanced from other rehabilitative programs. This allows our patients to achieve far superior results compared to most other systems.
Please fill out the following information thoroughly so the doctor can let you know if you are a case we can accept. Please feel free to ask any questions if you need assistance. We look forward to serving you.
 
 
 
Date:
 
 
 
PATIENT APPLICATION SURVEY
 
 
Name:
 
 
 
 
 
Age:
 
 
 
 
Gender:
 
 
 
 
 
 
Home Address:
 
 
 
 
 
Home Phone:
 
 
 
 
 
City, State, Zip:
 
 
 
 
 
Work Phone:
 
 
 
 
 
Email Address:
 
 
 
 
 
Cell Phone:
 
 
 
 
 
Birth Date:
 
 
 
 
 
 
Last 4 Social Security#:
 
 
 
 
Marital Status:
 
 
 
 
 
 
Names of Children:
 
 
 
 
 
Ages:
 
 
 
 
 
Occupation:
 
 
 
 
 
Employer Name:
 
 
 
 
 
Spouse’s Name:
 
 
 
 
 
 
Work Phone:
 
 
 
 
Cell Phone:
 
 
 
 
 
 
Spouse’s Employer:
 
 
 
 
 
Occupation:
 
 
 
 
How were you referred to this office?
 
 
PURPOSE OF THIS VISIT

 
Reason for this visit – Main Complaint:
 
 
 
 
Is this purpose related to an auto accident / work injury?
 
 
 
 
 
 
 
 
 
 
 
 
If so, When:
 
 
 
 
 
When did this condition begin?
 
 
 
 
 
Did it begin:
 
 
 
 
What activities aggravate your symptoms?
 
 
 
 
Is there anything, which has relieved your symptoms?
 
 
 
 
 
 
 
 
 
 
 
 
Describe:
 
 
 
 
Type of Pain:
 
 
 
 
Does the Pain Radiate into your:
 
 
 
 
 
Is this condition getting worse?
 
 
 
 
 
 
 
 
 
 
 
How often do you experience these symptoms throughout the day?
 
 
 
 
Does complaint(s) interfere with:
 
 
 
 
 
Explain:
 
 
 
 
 
Have you experienced this condition before?
 
 
 
 
 
 
 
 
 
 
 
 
If so, please explain:
 
 
 
 
How did you respond?
 
 
EXPERIENCE WITH CHIROPRACTIC

 
 
Have seen a chiropractor before?
 
 
 
 
 
 
 
 
 
 
 
 
Who?
 
 
 
 
When?
 
 
 
 
Reason for visits:
 
 
 
How did you respond?
 
 
 
Did your previous chiropractor take before and after x-rays?
 
 
 
 
 
 
 
 
 
 
Did you know posture determines your health?
 
 
 
 
 
 
 
 
 
 
Are you aware of any of your poor posture habits?
 
 
 
 
 
 
 
 
 
 
Explain:
 
 
 
Are you aware of any poor posture habits in your spouse or children?
 
 
 
 
 
 
 
 
 
 
Explain:
 
 
 
 
 
Date:
 
 
 
HEALTH LIFESTYLE

 
 
Do you exercise?
 
 
 
 
 
How often?
 
 
 
 
Other:
 
 
 
 
What activities?
 
 
 
 
Do you smoke?
 
 
 
 
 
How much?
 
 
 
 
 
Do you drink alcohol?
 
 
 
 
 
How much / week?
 
 
 
 
 
Do you drink coffee?
 
 
 
 
 
How many cups / day?
 
 
 
 
Do you take any supplements (i.e. vitamins, minerals, herbs)?
 
 
HEALTH CONDITIONS
Abnormal postural habits or distortions are the result of trauma or stress to the body that have misaligned the vertebrae in your spine. Whenthese vertebrae are twisted from their normal position, they will cause stress to the spinal cord and the delicate nerves that pass between thevertebrae. These misalignments are called Subluxations (sub-lux-a-shuns). It has been extensively documented that subluxations, causing stressto your nerves, will weaken and distort the overall structure of your spine. This results in a weakened and distorted POSTURE. Posturaldistortions have many serious and adverse affects on your overall health. The most common and detrimental postural distortion is called ForwardHead Syndrome (a “hunched forward” posture starting in the neck and progressively moving down your spine weakening the entire body).Please check any health condition you may be experiencing, now or in the past.
CERVICAL SPINE (NECK):
Postural distortions from subluxations, (causing Forward Head Syndrome), in your neck will weaken the nerves into your arms, hands and headaffecting these parts of your body. Do you experience…?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Explain:
 
 
THORACIC SPINE (UPPER BACK):
Postural distortions from subluxations (resulting from Forward Head Syndrome) in the upper back will weaken the nerves to the heart and lungsand affect these parts of your body. Do you experience…?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
THOPRACIC SPINE (MID BACK):
Postural distortions from subluxations (resulting from Forward Head Syndrome) in the mid back will weaken the nerves into your ribs/chest andupper digestive tract, and affect these parts of your body. Do you experience…?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LUMBAR SPINE (LOW BACK):
Postural distortions from subluxations in the low back (resulting from Forward Head Syndrome) will weaken the nerves into your legs/feet andpelvic organs and affect these parts of your body. Do you experience…?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please list any health conditions not mentioned:
 
 
 
Please list any medications currently taking and their purpose:
 
 
 
Please list all past surgeries:
 
 
 
Please list all previous accidents and falls:
 
 
Pregnancy Release
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his associates have my permission to perform an xrayevaluation. I have been advised that x-ray can be hazardous to an unborn child.
 
Date of last menstrual cycle:
 
 
 

Consent to Care

I do hereby authorize the doctors of Total Health Solutions to administer such care that is necessary for my particular case. This care may include consultation, examination, spinal adjustments, and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays or any other procedure that is advisable, and necessary for my health care.
Furthermore, I authorize and agree to allow the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working, or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological funciton. The doctor will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions treated at this clinic.
I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not.
I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor.
I have read or have had read to me, the above consent. I have also had the opportunity to ask questions about this consent, and by signing below I agree to the above-above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment.
 
 
Signature
 
 
 
 
 
Date
 
 
 
(If under age 18) Parent’s signature
 
 

Insurance Information

I clearly understand that all insurance coverage is an arrangement between my insurance carrier and me. If this office chooses to bill any services to my insurance carrier that they are performing these services strictly as a convenience for me. The Doctors office will provide any necessary report or required information to aid in insurance reimbursement of services, but I understand that insurance carriers may deny any claim and that I am ultimately held responsible for any unpaid balances. Any monies received will be credited to my account. I certify that this office visit is not related to any personal injury or worker's compensation case that is active or that has not been closed and finalized.
 
 
Signature
 
 
 
 
 
Date
 
 
 
(If under age 18) Parent’s signature