Please complete the paperwork below prior to your visit. This will decrease your wait time. Thank you. PersonalName(Required) Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required) Male Female Emergency ContactName(Required) Phone(Required)Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Relationship(Required) Spouse Parent Legal Guardian Other QuestionnaireTell us your main complaint / problem area?How Often?(Required) Constantly (100% of the time) Nearly Constantly (60-95% of the time) Intermittently (30-60% of the time) Occasionally (less than 30% of the time) When did it start? What activity bothers it most? Rate the Pain(Required)0123456789100 is no pain, 10 is unbearable painIs it getting better or getting worse? Better Worse In general, when is it the worst?(Required) Morning Afternoon Evening Night No Typical Pattern Other Chiropractors? Was your previous chiropractic experience positive? Yes No Not sure Other physicians/therapists? Was your previous physician/therapist experience positive? Yes No Not sure Do you smoke? Yes No Drinks per week? What kind of exercise do you do? List all medications/supplements you currently take:Health HistoryPlease select all that apply AIDS/HIV Allergy Shots Anemia Anorexia Arthritis Asthma Appendicitis Bronchitis Bullimia Cancer Cataracts Chicken Pox Chronic Fatigue Depression Diabetes Epilepsy Emphysema Fibromyalgia Fractures Glaucoma Goiter Gout Hepatitis Hernia Herniated Disc High Blood Pressure High Cholesterol Heart Diesease Implants Kidney Disease Liver Disease M. S. Migraines Measles Mumps Miscarriage Mono Prostate Prosthesis Parkinson’s Polio Pacemaker Pneumonia Osteoporosis Rheumatoid Arthritis Stroke Thyroid Tuberculosis Tonsillitis Tumors Ulcers Whooping Cough Authorization(Required)All above questions have been answered accurately and I understand that giving incorrect information can be dangerous. I authorize this office to release any information pertaining to my treatment to third party payers and/or other health care providers. I agree to the above statement.Photo/Video Consent(Required) Sure! You can use my picture/video on social media (I.e. Youtube, Facebook, etc.) pages. No thanks! I’ll pass for now. Informed Consent to Chiropractic TreatmentConsent to Chiropractic Treatment(Required) I herby request and consent to the performance of chiropractic treatments (also known as chiropractic adjustments or chiropractic manipulative treatments) and any other associated procedures. Examples of said procedures include but are not limited to; physical examinations, diagnostic x-rays, physio therapy, physical medicine, physical therapy, etc. I give Dr. Matthew Tuttle and/or Dr. John Richardson full consent to treat with any procedures as they see fit. I understand, as with any health care procedure, that there are risks for complications that may arise during chiropractic treatment. These complications include but are not limited to; fractures, disc injuries, dislocations, muscle strain, Homers’ Syndrome, diaphragmatic paralysis, cervical myelopathy, costovertebral strains and/or separations, etc. I do not expect the doctor to be able to anticipate all risks and/or complications. I will rely on the doctor to exercise judgment during the course of the procedure(s) that are in my best interest. I have had the opportunity to discuss with the doctor(s) and/or with office personnel the nature, purpose and risk of chiropractic treatment and other recommended procedures. I also understand that specific results are not guaranteed. I have read (or have had read to me) the above explanation of consent. By signing below, I state that I have been informed of the risks involved in chiropractic treatment at this facility. I believe it is in my best interest to receive chiropractic treatment. I give my consent for treatment and understand this consent covers the entire course for my present and future conditions for which I seek medical assistance. I agree to the above statement.Please Sign below when you arrive at our office. Printed Name of Patient: Signature of Patient: Signature of Minor: Date: 06/01/2023 44.200.82.149 CCBot/2.0 (https://commoncrawl.org/faq/)
