To ensure we're fully prepared for your appointment, please take a few moments to fill out the information below. It should take 5-10 minutes. Thank you!

Full Name

Select Your Gender

Male

Female

Birthdate (DOB) *

Address *

City *

State *

Zip code *

Email *

Cell # *

SSN #

Employer

Work Duties

Occupation

# of Children

Ages of Children

Name of Spouse (Parent if patient Is under 18)

Birthdate (DOB) of Spouse (Parent if patient Is under 18)

Who may we thank for referring you to our office?

900 Geneva St. Shorewood, IL 60404 (815)436-1988

Health Profile

Current Health Conditions *

You can select multiple health conditions, if applicable.

Additional explanation about your Current Health Condition *

Past Health Conditions (3 months or longer) *

You can select multiple health conditions, if applicable. If No health issues in the past, select 'None of these'

Additional explanation about your Past Health Condition *

If No past health issues in the past, type 'None'

900 Geneva St. Shorewood, IL 60404 (815)436-1988

Daily Activities

Does your Condition/Problem Effect Any of the Following: Please select that apply.

Carrying Groceries *

Changing Positions *

Sit to Stand *

Climbing Stairs *

Pet Care *

Driving *

Extended Computer Use *

Household Chores *

Lifting Children *

Reading/Concentration *

Self Care- Bathing *

Self Care - Dressing *

Self Care - Shaving *

Sexual Activities *

Sleep *

Sitting Still *

Standing Still *

Yard Work *

Walking *

Please list any effects that this may have on any recreational activities: *

900 Geneva St. Shorewood, IL 60404 (815)436-1988

Are there any other conditions/past accidents or surgeries that the doctor should address? If so, list and describe: *

What medications are you currently taking and for what conditions? *

What are your goals from our care? *

Goal 1
Goal 2
Goal 3

How do you want us to handle your problem? *

Temporary Relief

Maximum Correction

Any known allergies? *

Yes

If yes, what are you allergic to?

Type 'None', if no allergies

900 Geneva St. Shorewood, IL 60404 (815)436-1988

History Check

Check if any of these applicable:

Smoker? *

Yes

If smoke, how many packs a day?

Alcohol? *

Yes

Alcohol, If yes, how much/frequency:

Illicit drugs? *

Yes

Illicit drugs, If yes, please explain:

Tobacco? *

Yes

Tobacco, If yes, how much/frequency:

900 Geneva St. Shorewood, IL 60404 (815)436-1988

Health History of Family Members and Self

The reason for this form is to assist the doctor by providing past health history information for their review

Note: You can select multiple if applies, or you can select 'None' if not applicable to anyone

Arthritis *

Asthma *

Back Trouble *

Cancer - Health History *

Constipation./ Diarrhoea /Gas *

Diabetes *

Difficulty Sleeping *

Disc Problems *

Ear Problems *

Emphysema *

Epilepsy / Seizures

Fatigue *

Thyroid Issues *

900 Geneva St. Shorewood, IL 60404 (815)436-1988

Heart Trouble *

High Blood Pressure *

Headaches / Migraines *

Kidney Trouble *

Nervousness / Anxiety *

Neck Pain *

Numbness *

Pinched Nerve *

Scoliosis *

Sinus & Allergies *

Stomach Trouble *

Stroke *

Fibromyalgia *

900 Geneva St. Shorewood, IL 60404 (815)436-1988

Informed Consent to Care

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.

Medical, medical weight loss, chiropractic, physical therapy, and massage therapy care, like all forms of health care, offering considerable benefit may also provide some level of risk. Prior to receiving medical, chiropractic, physical therapy, and massage therapy care in this integrated office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spine health. These procedures will assist us in determining if any further examinations or studies are required. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care. I understand and accept that there are risks associated with medical, chiropractic, physical therapy, and massage therapy care and give consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones),disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke.

The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events per one million persons per year and risk of death has been estimated as 104 per one million users.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

900 Geneva St. Shorewood, IL 60404 (815)436-1988

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

Patient Signature: *

Clear

Patient, draw Signature in the box above.

Patient Signature Date: *

Name of the Parent / Guardian

Parent / Guardian Signature

Clear

Parent / Guardian, draw the signature in the box above.

Parent / Guardian Signature Date

Name of the Witness

Witness Signature:

Clear

Witness, draw the Signature in the box above.

Witness Signature Date:

Terms & Conditions *

I agree to terms & conditions and by providing my phone number, I agree to receive text messages from the Shorewood Elite Integrated Healthcare.

900 Geneva St. Shorewood, IL 60404 (815) 436-1988