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FAMILY CHIROPRACTIC &

NATURAL HEALING CENTER

PATHWAY TO HEALING AND HEALTH

Dr. Gregory A. Lind, D.C. Phone: (408) 263-8025

1778 Clear Lake Ave. Fax: (408) 263-8026

Milpitas, CA 95035 Email: glindchiro@att.net

Welcome

We look forward to your first visit with us. In order to provide a comprehensive holistic

approach and address the root cause of your condition, please take a few minutes to complete

a very detailed and comprehensive questionnaire. The quality of information you provide will

facilitate in your evaluation and assist us in providing you the best customized personal

program.

Appointment Policy

Welcome to Family Chiropractic & Natural Healing Center. I am delighted to have you as a

new patient and look forward to providing you with the highest quality care. In order to

optimize our relationship, please take a minute to carefully read the appointment policy below.

My time and expertise is what you essentially pay for. Occasionally there is a problem with

patients who are not used to keeping on schedule themselves. Patients who are late may not be

seen that day. If you expect to be more than 15 minutes late, please call to confirm availability.

A 24 hour notice for cancelled or rescheduled appointments (Sunday excluded) is required or

your standard treatment fee may be assessed. This allows me time to schedule another patient

and the time is not lost. I have found that most patients respect my time as much as I respect

theirs.

Financial Policy

This office collects fees for services at the time of service. Cash, Checks, or Credit Cards

(Visa, M/C, & AMEX) are all accepted. There is a $25.00 returned check fee for insufficient

funds.

Patients who qualify for insurance billing will pay their deductible, co-pay, and/or co-

insurance. All insurance information must be verified for their eligibility and benefits. Only

the primary insurance will be billed.

Any questions I have concerning my appointments and financial policy have been answered. I have read this statement and fully understand it.

Signature:__________________________________________Date:____________________

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Doctor’s Name: ___________________________ Referred By: ________________________

PATIENT HEALTH HISTORY

1. Name: First __________________________ M.I. ____ Last: ___________________________ Gender: □M, □F

Address: _____________________________, City: _____________________________ State:_ ____ Zip: ________

DOB: ____/_____/________ Height: _______ Weight: _______ E-mail: __________________________________

Cell Phone: ___________________ Home Phone: _____________________ Work Phone: ____________________

Primary Contact Method: (Check one) □Cell Ph □Home Ph □Work Ph □E-mail □Text (For Texting schedule alerts: Please provide Cell Phone service provider, ex. ATT, Verizon….)____________________

Marital Status (Check one) □Single, □Married □Widow □Divorced Children’s Ages_______________

Employer:__________________________________ Occupation:_______________________________

Spouse Name___________________ Emergency Contact:__________________ Referred by:__________________

2. What is the reason for your visit? What is your chief complaint? (Describe your condition at its worst)

______________________________________________________________________________________________

______________________________________________________________________________________________ Other Complaints: _______________________________________________________________________________

Diagnosed Medical Conditions: ____________________________________________________________________

3. Pain Symptoms: a.________________________ Began (Mo/Yr) ________ Previous Episodes (Mo/Yr)________

(In Order b.________________________ Began (Mo/Yr) ________ Previous Episodes (Mo/Yr)________

of Severity) c.________________________ Began (Mo/Yr) ________ Previous Episodes (Mo/Yr)________

4. Please Mark areas of pain or discomfort on drawing using the codes listed below:

N=Numbness, T=Tingling, B=Burning, P=Pain, S=Soreness, A=Ache, SB=Stabbing, SF=Stiffness, X=Scars

List the frequency and severity of your condition on a scale of 1 to 5: Frequency: Severity:

1=20% of the time 1=Annoying

2=40% of the time 2=Impairment to Activity 3=60% of the time 3=Need Medication

4=80% of the time 4=Impairment with Medication

5=100% of the time 5=Severe (Need Hospitalization)

Location Frequency Severity Initial Cause Getting Worse? a. ____________ ______ _____ _____________ Yes No

b. ____________ ______ _____ _____________ Yes No

c. ____________ ______ _____ _____________ Yes No d. ____________ ______ _____ _____________ Yes No

e. ____________ ______ _____ _____________ Yes No

f. ____________ ______ _____ _____________ Yes No g. ____________ ______ _____ _____________ Yes No

h. ____________ ______ _____ _____________ Yes No

5. Do you have, or have you ever had (check):

Osteoarthritis □ Bone Spurs □ Non-Union Fracture □ Cartilage injury □

Bulging Disc □ Tendonitis□ Avascular Necrosis □ (Meniscus Tear, Chondromalacia

Herniated Disc □ Joint Separations □ Post-herpetic neuralgia □ Patellar Syndrome)

DDD □ Bursitis □ Intercostal Neuralgia □

Stenosis □ Sprains □ Morton’s Neuroma □

6. What seems to make the condition better? __________________________________________________________

What seems to make it worse? ___________________________________________________________________

What treatments have you tried? _________________________________________________________________

File #: ___________

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(Continued)

7. Please describe your family health history (Check what applies)

You Father Mother Spouse Brothers Sisters Children

Age

Arthritis

Acid Reflux or Stomach Problems

Allergy and Food Allergy

Asthma or Hay Fever

Back or Disc Problems

Bursitis

Cancer

Constipation

Emotion Problem

Epilepsy

Headaches or Migraines

Heart Problems

High Blood Pressure

Insomnia

Kidney Problems

Liver Problems

Lung Problems

Obesity

Scoliosis

Sinus Problems

Other:______________________

8. Please describe your lifestyle (please check):

Appetite: □ Low □ Moderate □ High Amount of Exercise

Thirst for Water: □ Yes □ No _____ Glasses/Day □ None

Coffee: □ Yes □ No _____ Cups/Day □ Light

Soda: □ Yes □ No _____ Oz’s/Day □ Moderate

Artificial Sweeteners: □ Yes □ No □ Active

Cravings for Sugar: □ Yes □ No □ Very Active

Cravings for Salty Foods: □ Yes □ No □ Elite Athlete

Stress Level: □ High □ Moderate □ Low Type of Exercise: __________________

Alcohol: □ Yes □ No _____ Glasses/Day _________________________________

Smoking: □ Yes □ No _____ Cigarettes/Day _________________________________

Marijuana: □ Yes □ No _____ Times/Day

Other Drugs : _________________________________ Frequency of Exercise:

Occupational Hazards: __________________________ (Days/Wk) ________________

Type of Job: □ Office/Sitting □ Labor/Lifting/Bending/Moving

Average Hours spent in front of Computer and/or TV per day: ___________

9. List vitamins or supplements taken in the last 3 months: _______________________________________________

10. List Over-The-Counter (OTC) and prescribed pharmaceutical medications taken in the last 3 months and reason:

____________________________________________________________________________________________

____________________________________________________________________________________________

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(Continued)

11. Please describe your health history (please check)

Now Past Now Past Now Past Now Past ___ ___ Acid Reflux/Heart Burn ___ ___ AIDS/HIV ___ ___ Alcoholism ___ ___ Allergies ___ ___ Anemia ___ ___ Appendicitis ___ ___ Arthritis ___ ___ Arteriosclerosis

___ ___ Asthma ___ ___ Atrial Fibrillation ___ ___ Birth Trauma ___ ___ Bronchiectasis ___ ___ Breast Lump ___ ___ Cancer ___ ___ Candida ___ ___ Chicken Pox

___ ___ Chronic Bronchitis ___ ___ Chronic Kidney disease ___ ___ Cirrhosis ___ ___ Congestive Heart Failure ___ ___ COPD

___ ___ Cystic Fibrosis ___ ___ Diabetes

___ ___ Diverticulitis ___ ___ Drug Withdrawal ___ ___ Emphysema ___ ___ Epilepsy ___ ___ Eczema ___ ___ Erectile Dysfunction

___ ___ Fatty Liver ___ ___ Fibromyalgia ___ ___ Fibroid ___ ___ Gall Bladder Stone ___ ___ Goiter ___ ___ Gout ___ ___ Hernia ___ ___ Heart disease

___ ___ Heart Murmur ___ ___ Hepatitis ___ ___ Herpes ___ ___ High Blood Pressure ___ ___ High Cholesterol

___ ___ Hyperlipidemia ___ ___ Influenza ___ ___ IBD ___ ___ IBS ___ ___ Kidney Stone ___ ___ Kidney Failure ___ ___ Lyme disease ___ ___ Meniere”s disease

___ ___ Measles ___ ___ Mental Disorder ___ ___ Migraines ___ ___ Multiple Sclerosis ___ ___ Mump ___ ___ Ovarian Cyst ___ ___ Pacemaker ___ ___ Pancreatitis

___ ___ Pleurisy ___ ___ Pneumonia ___ ___ Prostatitis ___ ___ Polio ___ ___ Psoriatic Arthritis

__ ___ ___ Psoriasis ___ ___ Pulmonary Fibrosis

___ ___ Rheumatic Fever ___ ___ Rheumatoid Arthritis ___ ___ Sarcoidosis ___ ___ Scarlet Fever ___ ___ Seizures ___ ___ Stroke

___ ___ Thyroid Disorders ___ ___ Tuberculosis ___ ___ Typhoid Fever ___ ___ Ulcers, Location: ______ ___ ___ Ulcerative Colitis ___ ___ Crohn’s Disease ___ ___ UTI ___ ___ Interstitial Cystitis

___ ___ Vitiligo ___ ___ Venereal Disease ___ ___ Whooping Cough

12. Please use the point scales to rate your symptoms over the past 3 months. 1 = Occasional, Not Severe 3 = Frequent, Not Severe

2 = Occasional, Severe 4 = Frequent, Severe

Digestive Tract ___Acid reflux/Heart Burn ___Poor Digestion

___Nausea & Vomiting ___Bloating ___Gas ___Hiccups ___Bad Breath ___Gluten Intolerance ___Food Allergies ___Chemical Sensitivities ___Malnutrition

___Diarrhea ___Constipation ___Laxative Use ___Blood in Stool ___Mucous in Stool ___Black Stool ___Stomach Pains/Cramps ___Abdominal Pain

___Abdominal Spasms ___Lack of Bowel Control ___Itchy Anus ___Rectal Pain ___Hemorrhoids ___Anal Fissures Bowel Movements: Frequency____________

Color________________ Texture/Form__________ Odor_________________

General ___Sweat Easily ___Night Sweats ___Gall Bladder Troubles

___Cold Hands or Feet _____Poor Circulation

_____Shortness of Breath _____ Spitting Blood _____ Fever

_____ Chills _____ Muscle Cramps

_____Feeling of Weakness/Tired __ ___Lower Extremity Edema

___Vertigo or Dizziness ___Bleed or Bruise Easily ___Frequent Illness ___Seasonal Allergy ___Addicted to Drugs

___Addicted to Smoking ___Peculiar Taste: Describe: ___________

Respiratory ___Tight Chest ___Shortness of Breath ___Difficulty Breathing

When Lying Down ___Itching Inside the Chest ___Wheezing ___Persistent Cough ___Coughing Blood ___Cough: Wet / Dry, Thick / Thin Color of Phlegm____________

Urinary ___Bedwetting ___Blood in Urine ___Lack of Bladder Control ___Pain During Urination ___Frequent or Urgent Urination ___Incomplete Urination

___Wake to Urination ___Prostate Problem

___Genital Itch or Discharge ___Kidney Stone ___Kidney Failure

___Recurrent Bladder Infections ___Impotence ___Increased Libido ___Decreased Libido ___Premature Ejaculation ___Nocturnal Emission

Weight & Eating ___Recent Weight Loss/Gain

___Binge Eating/Drinking ___Craving Certain Foods ___Excessive Weight ___Compulsive Eating ___Poor Appetite ___Heavy Appetite ___Strongly Like Cold Drinks ___Strongly Like Hot Drinks

___Water Retention

Musculoskeletal ___Muscle Pains ___Muscle Cramps ___Pains or Aches in Joints ___Stiffness/Limited Range of Motion ___Limited Use

___Pains or Aches in Muscles ___Swollen Tender Joints ___Growing Pains in Legs ___Hip Tightness/Coldness/Pain ___Rib Pain ___Neck/Shoulder Pain ___Upper Back Pain ___Back Pain

___Lower Back Pain ___Sciatic Pain

Cardiovascular ___Heart Murmur

___Heart Palpitations ___Irregular or Skipped Heartbeat ___Rapid or Pounding Heartbeat ___Chest Pain ___Difficulty Breathing ___High Blood Pressure ___Low Blood Pressure ___Blood Clots ___Anemia

___Fainting ___Vein Inflammation ___Rapid Heart Rate ___Post-stroke

Emotions ___Mood Swings ___Anxious, Fear, Nervous

___Angry Irritable, Aggressive ___Easily Stressed ___Argumentative ___Frustrated, Cries Easily ___Depression ___Abuse Survivor ___Considered/Attempted Suicide ___Seeing a Therapist

___ Obsessive Behavior ___ Compulsive Thoughts ___Uncontrollable Urges

Mind ___Poor Memory

___Difficulty Completing Projects ___Difficulty with Mathematics

___Underachiever ___Poor/Short Attention Span

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___Confusion ___Easily Distracted ___Difficulty Making Decisions ___Learning Disability

Neurological ___Seizures ___Numbness ___Tics ___Foot Neuropathy

Energy & Activity ___Apathy, Lethargy ___Attention Deficit

___Fatigue ___Lack of Strength ___Body Heaviness ___Hyperactivity ___Restlessness ___Stuttering or Stammering ___Slurred Speech

Ears ___Itchy Ears ___Ear Aches, Ear Infections ___Drainage from Ears ___Hearing Loss ___Reddening of the Ears ___Ringing in the Ears ___Headaches ___Concussions

Nose ___Stuffy Nose ___Dryness Inside the Nose ___Chronically Red, ___Inflamed Nose ___Sinus Problem ___Hay Fever ___Sneezing Attacks

___Excessive Mucous Formation

___Post Nasal Drip

___Nose Bleeding

Eyes ___Glasses/Contacts ___Watery or Itchy Eyes

___Red, Swollen or Sticky Eyelids ___Bags/Dark Circle Under Eyes ___Poor Vision ___Blurred or Tunnel Vision ___Sensitive to Sunlight ___Eye Strain ___Eye Pain ___Red Eye

___Itchy Eyes ___Easily Fatigued ___Spots in Eyes ___Night Blindness ___Glaucoma ___Cataract ___ Macular

Head ___Headaches ___Migraines ___Faintness ___Dizziness/Vertigo ___Facial Flushing ___Facial Pain ___TMJ

Sleep ___Insomnia ___Sleep Disorder ___Difficulty Falling Asleep ___Difficulty Staying Awake ___Wake up Frequently ___Morning Shakiness ___Cannot Wake Up in AM

Mouth & Throat

___Chronic Coughing ___Gagging, Often Clearing Throat ___Sore Throat, Hoarse, Voice Loss ___Swollen/Discolored Tongue/Lips ___Sores on Lips or Tongue

___Canker Sores ___Itching on Roof of Mouth ___Dry Mouth ___Excessive Saliva ___Recurrent Sore Throat ___Excessive Phlegm Color: _____________ ___Swollen Glands

___Lumps in Throat ___Enlarged Thyroid ___Teeth Problem ___Gum Problem ___Grinding Teeth

Skin & Hair ___Acne

___Itching ___Hives ___Rash ___Eczema ___Dry Skin ___Ulcerations ___Hair Loss ___Dandruff

___Flushing or Hot Flashes ___Change in Hair/Skin Texture ___Loss in Pigmentation ___Fungal Infections ___Scars

For Women Only Age Menstrual Cycle Began: ___________ Length of Cycle (Day 1 - Day 1): ___________

Duration of Flow: _________ ___Dark Color Flow ___Clots in Flow ___Excessive Flow ___Irregular Circle ___Painful Period ___Painful Intercourse ___Excessive Vaginal Discharge

___Menopause Symptoms ___Lump in Breast ___Vaginal Dryness ___Vaginal Sores ___Vaginal Odor Vaginal Discharge Color: _______________________ # of Pregnancies: _______

# of Live Births: ________ # of Premature Births: ____ Age at Menopause: ______ Date of Last PAP: _______ Date Last Period Began: ______________________

Any Other Symptoms:

___________________ ___________________

___________________

___________________ ___________________

___________________

______________________________________

___________________

13. List any past operations and/or procedures performed _________________________________________________________

________________________________________________________________________________________________________

14. List significant Traumas and or Injuries: __________________________________________________________

15. Have you ever lost consciousness? □ Yes □ No Why? _______________________________________

16. If you are currently under the care of a health care practitioner for any conditions or injuries, please provide their:

Name: _________________________ Phone: __________________ Email: _____________________________

Description of Treatment: _______________________________________________________________________

I authorize Dr. Lind to Examine and Treat my condition as deemed appropriate through the use of Chiropractic Care, Homeopathic remedies, Traditional Chinese Medicine, and other natural healing methods. In the course of Treatment

it may be necessary to share your personal health information with WEI Laboratories for the purpose of examination

and analysis to assist with treatment recommendations. WEI Laboratories is HIPPA compliant to protect your personal information. Yes No

Patient’s / Guardian’s Signature: ___________________________________ Date: __________________________________

Dtd: 2018/05

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Family Chiropractic & Natural Healing Center _______________________________________________________________________

1778 Clear Lake Ave Phone: (408) 408-263-8025 Fax: (408)-263-8026

I. HIPAA NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you and maybe used and disclosed and how you can access this

information. Please review carefully.

Under the Health Insurance Portability & Accountability Act of 1996 “HIPAA” it is our legal duty to safeguard your

Protected Health Information (PHI). Please note that we reserve the right to change the terms of the Notice and our privacy policies at any time as permitted by law. Any changes will apply to PHI already on file with us. Before we make any

important changes to our policies, we will immediately change this Notice and post a new copy of it in our office. This

Notice will remain in effect until it is replaced or amended.

During the course of our relationship with you, we will use and disclose PHI about you for treatment, payment, and

healthcare operations. We gather personal information and health information from you, other healthcare providers, and

third party payers. Use of PHI means when we share, apply, utilize, examine, or analyze information within our practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside our practice. You may

specifically authorize us to use PHI for any purpose or to disclose our health information by submitting the authorization in

writing. Such disclosures will be made to any personal representative you choose to have your PHI.

Marketing

This office will not use or disclose your PHI for marketing communications without your written authorization. This

office may send birthday cards, thank you cards, notice of clinic events, newsletters, and/or appointment reminders.

Disclosure

This office may use or disclose your PHI without your consent or authorization when required by law.

Patient Rights

1. Upon written request, you have the right to review and receive copies of your PHI

2. Upon written request, you have the right to receive a list of disclosures about your PHI. 3. You have the right to request additional restrictions on the use and disclosure of your PHI, permitted by law.

4. Upon written request, and as permitted by law, you have the right to request that we amend your PHI.

5. You have the right to receive all notices in writing.

If you have questions about this Notice or any complaints about our privacy, please contact our office. Please send written

complaints to the Secretary of the Department of Health & Human Services, 200 Independence Ave. S.W. Washington, D.C. 20201.

This Notice went into effect April 14, 2003.

I acknowledge consent for use and disclosure of PHI and receipt of this Notice of Privacy Practices.

__________________________ __________________________________________ Date Print Name

__________________________________________ Signature

Dtd: 2018-05

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Family Chiropractic & Natural Healing Center ________________________________________________________________________

1778 Clear Lake Ave Phone: (408) 408-263-8025 Fax: (408)-263-8026

INFORMED CONSENT Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. The nature of the chiropractic adjustment

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hand or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis / Examination / Treatment

As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

Spinal manipulative therapy, various manual hands on techniques, neuro-motor re-patterning, stress release techniques, range of motion testing, muscle strength testing, ultrasound, radiographic studies, palpation, orthopedic testing, postural analysis, hot/cold therapy, vital signs, basic neurological testing.

The material risks inherent in chiropractic adjustment

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications and their probabilities include but are not limited to: facture, disc injuries, dislocations, muscle strain, cervical muscle pain, rib/vertebra strains and separations, and burns. These are rare occurrences. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. The scientific literature puts this risk at 1 in 1 million to 5 million which is extremely rare. Some patients will feel stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to identify any reason not to undergo this type of care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The availability and nature of other treatment options Other treatment options for your condition may include:

Self-administered, over-the-counter analgesics and rest

Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers

Hospitalization

Surgery If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of those options and you may wish to discuss these with your primary medical physician.

The risks and danger attendant to remaining untreated Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

I have read ( ) or have had read to me ( ) the above explanation of the chiropractic adjustment and related treatment. I have discussed it with Dr. Lind and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. Dated: _________________________ Dated: _____________________________

____________________________________________ __________________________________________________Print Patient’s Name Doctor’s Signature

_________________________________

Signature of patient or Guardian (if a minor) Dtd: 2018-05