Complete Care Registration and Health History
(Please Print)
Name: ________________________________________________________________Social Security # __________________________
Address: ___________________________________________City, State, Zip: ______________________________________________
Age: _________ Date of Birth: ____________________Previous/Current Occupation: ________________________________________
Parent or Guardian: ______________________________________________________Social Security # __________________________
Home Phone: _________________________ Cell Phones: __________________________ Work Phone: _________________________
Spouse Name:_______________________________ Email:_____________________________________________________________
Are you here for:
Chiropractic
How did you hear about us?
Physical Therapy
Physician
Massage
Health Coaching
Friend/Family_________
Have you had previous chiropractic care?
Yes
No
Radio
Decompression
Event
Drive By
Unsure
Employee_________
If Yes, when?: __________________
Current Complaint: ____________________________________________How long have you had this condition? __________________
Is this condition due to:
A work injury?
Yes
No
An auto accident?
Yes
No
Other Injury?
Yes
No
How did this condition occur? _____________________________________________________________________________________
What aggravates this condition? ________________________________What helps your symptoms? _____________________________
Have you had similar conditions in the past?
Yes
No Other Complaints: ____________________________________________
Other physicians seen for this condition: _____________________________________________________________________________
Any recent illnesses or infections?
Yes
No If yes, please explain: ___________________________________________________
Have you been on antibiotics in the last two months?
Any fractures in last 6 months?
Yes
No
Have you had: any spinal surgeries?
Yes
No
Levaquin or Cipro?
Any joint replacements?
Yes
No
Yes
No
Yes
No
Any rib injuries?
Yes
No
If yes, please explain: ________________________________________________
What are the physical demands of your job?: __________________________________________________________________________
How many days per week do you exercise? _______ What type of exercise? ________________________________________________
Do you use:
Alcohol
Yes
No
_______ drinks/week
History of drug abuse?
Yes
No
Tobacco
Yes
No
____pack/day: # of years____
Coffee
Yes
No
_______ cups/day
Soda/Energy
Yes
No
______ cups/day
Sleep position (most common)? Side___ Back ___ Stomach ___
Recreational activities? ___________________________________________________________________________________________
Women Only: Are you pregnant?
Have you had a hysterectomy?
Yes
Yes
No Are you on birth control?
Yes
No
Do you have breast implants?
Yes
No
No Are you on replacement hormones? __________________________________________
What aspect of your health are you most unhappy with? _________________________________________________________________
INSURANCE INFORMATION
Do you have health insurance?
Yes
No
Medicare #: __________________________________________________________
Insurance Co.: _________________________________________________________________________________________________
ID/Policy/Subscriber #: ______________________________________________Group #:_____________________________________
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I
understand that Complete Care will prepare any necessary reports and forms to assist me in obtaining payment from the insurance company and that any
amount authorized will be paid directly to Complete Care and be credited to my account on receipt. However, I clearly understand and agree that all
services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminated
my care or treatment, any fee for professional services rendered to me will immediately due and payable.
Patient Name: __________________________________________________________________
Patient Signature: ______________________________________________________________ Date: ___________________________
Signature of Parent or Guardian: __________________________________________________ Date: ___________________________
Complete Care Registration and Health History
QUADRUPLE VISUAL ANALOGUE SCALE
Instructions: Please circle the number that best describes the question being asked.
1 – What is your pain RIGHT NOW?
No pain
0
1
2
3
4
Worst possible pain
5
6
7
8
9
10
6
7
8
9
Worst possible pain
10
0
2 – What is your TYPICAL or AVERAGE pain?
1
2
3
4
5
0
3 – What is your pain level AT ITS BEST (How close to “0” does your pain get)?
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0
4 – What is your pain level AT ITS WORST (How close to “10” does your pain get)?
1
2
3
4
5
6
7
8
9
Worst possible pain
10
No pain
No pain
No pain
5 – Please indicate the areas of your pain on the figures below.
___
6 – Please list current medications:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
7- Are you taking cholesterol lowering Statin Medications?
________________________________________________
________________________________________________
8- Allergies/Other? ________________________________
_________________________________________________
_________________________________________________
8 - Have you ever had the following? Circle “P” for past and “C” for current.
CONSTITUTIONAL
P C Fatigue
P C Weight Gain / Loss
P C Fever
CARDIOVASCULAR
P C High or low blood pressure
P C Shortness of breath
P C Heart disease
P C Chest pain or angina pectoris
P C Palpitations
P C Feet or ankle swelling
GENITOURNIRAY
P C Burning or painful urination
P C Kidney stones
P C Male: Erectile Dysfunction
P C Male: Prostate problems
GASTROINTESTINAL
P C Abdominal Pain
P C Nausea or vomiting
P C Heartburn
P C Stomach pain
P C Constipation
P C Diarrhea
RESPIRATORY
P C Chronic or frequent cough
P C Shortness of breath
P C Asthma
P C COPD
NEUROLOGICAL
P C Vertigo/dizziness
P C Freq./recurring headaches
P C Convulsions or seizures
P C Tremors
P C Neurological Disorders
P C Peripheral neuropathy
P C Head injury/concussions
P C Stroke
P C Poor balance
P C TIA’s – Mini-strokes
P C Shingles
MUSCULOSKELETAL
P C Muscle pain or cramps
P C Difficulty walking
P C Fibromyalgia
P C Chronic Fatigue Syndrome
Patient Name: _____________________________________________________________________
Patient or Guardian Signature: ________________________________________________________ Date: _______________________
Complete Care Registration and Health History
Massage Benefits
Massage has been practiced for thousands of years. Complete Care is proud to offer many different medical
and therapeutic massage styles with a wide variety of pressures, movements, and techniques. Styles used
range from long, smooth strokes to short, percussive strokes. These all involve pressing, rubbing, or
manipulating muscles and other soft tissues with hands and fingers. Sometimes even forearms, elbows, or
feet are used.
Complete Care provides massage sessions that last anywhere from a half hour to 2 hours. Your massage
hour will consist of 53 minutes of hands on treatment. Many types of massage offer benefits beyond
simple relaxation. At Complete Care, qualified massage therapists work hand and hand with the other
physicians in our clinic to provide the most beneficial massage to meet your healthcare needs. Here is a list
of just a few of the massages styles that are offered at Complete Care.
Cancellation and No Show Policy
In order to better serve our patients we ask that you call if you are unable to make your appointment or if you may be late.
Your appointment time is reserved for you. If you fail to notify our office of a cancelation at least 24 hours before your
scheduled appointment it leaves a time slot open that could be used to help someone else. Please help us to help others.
Our office has a $30.00 cancellation fee if we are not notified at least 24 hours/1 business day prior to your massage,
physical therapy, health coach, or chiropractic appointment, of a cancellation.
Certain accident claims adjusters expect regular attendance to appointments as a requirement of an approved
treatment plan. If appointments are missed or cancelled on a regular basis it could affect the status of your claim.
Your treatment plan has been established by your medical practitioners to get you back to your regular activities
as quickly as possible. Missing appointments hinders that process and may end up prolonging recovery.
After missing two appointments without notice, you may be placed on a same day scheduling policy for your
treatments, which would not allow you to schedule any appointments in advance.
If you need to cancel or reschedule an appointment, please call Complete Care at 541-830-4325.
Thank you for providing our office and our patients with this courtesy
Signing below indicates you understand and agree to the terms of this policy.
Printed Name: _____________________________________
Signature: ________________________________________ Date: _______________
Complete Care Registration and Health History
Informed Consent
I hereby request and give my consent to the physicians and assistants of Complete Care Chiropractic and Massage to perform medical
procedures, including chiropractic adjustments, physical therapy, massage, and all other medical services deemed necessary and agreed
upon that I might need.
I am aware that, during the procedure, other procedures might be needed. I give my consent to do these procedures as needed.
I have had the opportunity to discuss with the doctor or physician the purpose, benefits, and risks of the recommended care, and
alternatives to the recommended treatments have been reviewed.
I further understand that health care providers cannot guarantee the results of treatment. I know that each person reacts in a different way
to treatments and procedures. Therefore, the results cannot be certain. I acknowledge that no guarantee of the outcome of the care I have
requested has been made. I have ample opportunity to ask questions, and my questions have been answered to my satisfaction.
Chiropractic Care, Physical Therapy, Osteopathy, Massage Therapy:
Though chiropractic, physical therapy, nutrition and massage therapy treatments are usually beneficial and rarely cause any problem, I
understand that, like many other forms of health care, there are some risks. These can include, but are not limited to, fractures, disc
injuries, cerebral-vascular accidents, dislocations, and sprains/strains. These complications are extremely rare occurrences.
______ Initial here to confirm that you have read and understand the Informed Consent
Medical Information Release Form
(HIPAA Release Form)
Name: _________________________________________________________
Date of Birth: ______/______/______
Release of Information
[]
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This
information may be released to:
[]
[]
Spouse_____________________________________
[]
Child(ren) __________________________________
[]
Other______________________________________
Information is not to be released to anyone.
This Release of information will remain in effect until terminated by me in writing.
Please call
[ ] my home
[ ] my work
If unable to reach me:
[ ] you may leave a detailed message
[ ] my cell number
[ ] please leave a message asking me to return your call
[ ]Other:_________________________
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
I have been provided with Complete Care Chiropractic and Massage’s Notice of Privacy Practices that informs me of uses, disclosures,
and rights pertaining to my protected health information.
I acknowledge that I was offered a Copy of Complete Care Chiropractic and Massage’s Notice of Privacy Practices.
___________________________________________________
Patient/Guardian/Guarantor Signature
________________________
Date
__________________________________________________
Please Print Name
*If you would like a copy of the Notice of Privacy Practices, please request a packet from the Front Desk.