Revive Chiropractic Wellness Center
PATIENT APPLICATION FORM
WELCOME TO OUR CLINIC. We specialize in assisting our patients to
achieve their highest level of health through spinal correction and the 5
Essentials of Maximized Living. Our approach is very 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.
_________________________________________________
Patient Signature:
__________________________________
Today’s Date:
Date: _______________
PATIENT APPLICATION SURVEY
Name: _______________________________________________ Birth Date (m/d/y): ______ / ______ / ______ Gender: M
F
Home Address: ______________________________________________ Home Phone: (
) _________________________
City, Province, Postal Code: ____________________________________ Work Phone: (
) _________________________
Email Address: ______________________________________________ Cell Phone: (
Occupation: _____________________________________________
) __________________________
Employer Name: ________________________________
How were you referred to the office? _____________________________________
Your Revive PIN: _______________
Spouse’s Name: _______________________________
Marital Status: S M D W
Spouse’s Contact Information:
Work Phone: (
) _______________ Cell Phone: (
) _____________________
Spouse’s Occupation: ___________________________________ Employer: _______________________________________
Names and ages of Children: ________________________________________________________________________________
PURPOSE OF THIS VISIT
Reason for this visit – Main Complaint:________________________________________________________________________
________________________________________________________________________________________________________
Is this purpose related to an auto accident / work injury (WCB)?  Yes  No
If so, when: ___________________________
When did this condition begin? __________/_____/________
Did it begin:
Gradual
Sudden
Progressive over time
What activities aggravate your symptoms? ____________________________________________________________________
How often do you get your symptom?
Everyday 1x/wk
2x/wk
3x/wk
4x/wk
5x/wk
6x/wk
Bi-weekly Monthly
On a pain scale from 0-10 how would you rate your symptom? _____________
How long does the symptom last? _______________________
Is there anything, which has relieved your symptoms?  Yes  No
Type of Pain:
Sharp
Dull
Does the Pain Radiate into your:
Ache
Arms
Burn
Legs
Throb
Spasm
Describe: ______________________________________
Numb
Does not radiate
Tingling
Shooting
If so, where? ________________
Is this condition getting worse?  Yes  No
How often do you experience these symptoms throughout the day? :
Does complaint(s) interfere with (circle): Work
100%
75%
Sleep Hobbies Daily Routine
Have you experienced this condition before?  Yes  No
50%
25%
10%
Only with Activity
Explain: ___________________________
If so, please explain: _____________________________________
Who have you seen for this? ____________________________________________
What did they do? ____________________________________________________
How did you respond? ____________________________________________________________________________________
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EXPERIENCE WITH CHIROPRACTIC
Have you seen a Chiropractor before?  Yes  No
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?
 Yes  No
 Yes  No
 Yes  No
Explain: ________________________________________________________________________________________________
Are you aware of any poor posture habits in your spouse or children?  Yes  No
Explain: ________________________________________________________________________________________________
The most common postural weakness is Forward Head Syndrome (head and neck starting to bend forward and progressively
moving downward weakening your whole body). Abnormal postural habits or distortions are the result of trauma or stress to the
body that have misaligned the vertebrae in your spine. When these vertebrae are twisted from their normal position, they will
cause stress to the spinal cord and the delicate nerves that pass between the vertebrae. These misalignments are called
Subluxations (sub-lux-a-shuns). It has been extensively documented that subluxations, causing stress to your nerves, will weaken
and distort the overall structure of your spine. This results in a weakened and distorted POSTURE. Postural distortions have
many serious and adverse effects on your overall health. Have you ever been told or felt like you carry your head forward, noticed
a rounding of your shoulders or a developing “hump” at the base of your neck? Yes No
HEALTH CONDITIONS
Please list any medications or supplements (i.e. vitamins, minerals, herbs) you are currently taking and their purpose:
Please list any health conditions not mentioned:
Please list all past surgeries:
Please list all previous accidents and falls:
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Symptoms of Spinal Misalignment Questionnaire
`The nervous system controls and coordinates all organs and structures of the human body` (Gray`s
Anatomy, 29th Ed., p.4). Misalignments of spinal vertebrae and discs may cause irritation to the nerves,
which could affect the areas listed. Please help us help you by placing a check mark in the appropriate box to
indicate your symptoms.
Please Check Any Conditions That You Have
Previously or Are Currently Experiencing Below
Earache
Throat Conditions (Sore or Quinsy)
Hoarseness
Laryngitis
Eczema
Acne/Pimples
Blindness
Neuralgia
Deafness
Crossed Eyes
Adenoids
Runny Nose
Neuritis
Head Colds Dizziness
Headaches Nervousness Insomnia
Migraines
Nervous Breakdowns
High Blood Pressure
Chronic Tiredness
Sinus Trouble Allergies
Amnesia
Pain Around the Eyes
Stiff Neck
Croup
Upper Arm Pain
Colds
Bursitis
Asthma
Earache
Tonsilitis
Hay Fever
Chronic Cough
Boils
Thyroid Conditions
Pleurisy
Difficult Breathing or Shortness of Breath
Lower Arm and Hand Pain
Bronchitis
Pneumonia
Gall Bladder Conditions
Poor Circulation
Jaundice
Hardening of Arteries
Miscarriages
Ulcers
Kidney Conditions
Rheumatism
Dysentery
Varicose Veins
Impotency
Liver Conditions
Fevers
Indigestion
Stomach Conditions
Heartburn
Lowered Resistance
Constipation
Functional Heart Chest Conditions
Condition Influenza
Congestion
Shingles
Arthritis
Nervous Stomach
Cramps
Fainting Spells
Gastritis
Hives
Nephritis
Gas Pains
Pyelitis
Sterility
Diarrhea
Ruptures/Hernia
Bladder Conditions Sciatica
Menstrual Troubles (Painful or Irregular Periods)
Bed Wetting
Change of Life Symptoms
Knee Pain
Difficult, Painful, or Too Frequent Urination
Backaches
Swollen and Weak Ankles
Cold Feet
Weakness in Legs
Sacro-Iliac Conditions
Hemorrhoids (piles)
Weak Arches of Feet
Leg Cramps
Colitis
Spinal Curvatures
Pruritis (itching)
Pain at End of Spine on Sitting
Note: For further explanation of the conditions shown above, and
information about those not shown, ask your Chiropractor.
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TERMS OF ACCEPTANCE
When a person seeks chiropractic and rehabilitation health care and is accepted for such care, it is essential for both parties to be working towards
the same objective. Our goal as a Chiropractic Wellness Center is to detect and correct/reduce the vertebral subluxation complex. It is important
that each person understand both the objective and the method that will be used to attain this goal. This will prevent any confusion or
disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our
chiropractic method is by specific adjustments of the spine.
Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve
function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express it’s
maximum health potential.
Our overall goal is to eliminate the primary and secondary causes of disease process in the body, thus reducing the major interference to the
expression of the body’s innate wisdom and ability to heal. Our only method is specific adjusting to correct vertebral subluxations combined
with rehabilitation procedures and lifestyle coaching. NOTE: It is understood and agreed that the amount paid to Revive Chiropractic Wellness
Center for x-ray, is for examination only and the x-rays will remain the property of this office, being on file where they may be seen at any time
while a patient of this office.
CONSENT TO CARE
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 xray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
Please Circle if N/A.
Date of last menstrual cycle: _____________________
_______________________________________
Signature
____________________
Date
Consent to Evaluate and Adjust a Minor Child
I, ______________________________, being the parent of legal guardian of ______________________________ have read and fully
understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
_______________________________________
Signature
____________________
Date
Insurance Information
I clearly understand that all insurance coverage is an arrangement between my insurance carrier and me. If requested, this office can connect
with your insurance company regarding your assignment of benefits. The Doctor’s office will provide any necessary report or required
information to aid in insurance reimbursement of services at an additional cost. I certify that this office visit is not related to any personal injury
or worker’s compensation (WCB) case that is active or that has not been closed and finalized. If this office visit is due to a case that is currently
active, please provide your claim number below.
_______________________________________
Signature
(If under age 18 - Parent’s signature)
_____________________
Date
_______________________________________
Doctor Signature
_____________________
Date
Claim #:________________________________
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