Date Format: MM slash DD slash YYYY
History of Complaint
- Please identify the complaints that have brought you to our office (Please describe in detail):
- On the scale of 0 to 10, with 10 being the worst pain, rate your above complaints:
- If you have ever been diagnosed with any of the following conditions, please indicate if it was in the Past, Currently, or Never have had:
- PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem (including auto or related accidents):
- OPT-IN CONSENT FOR E-MAIL
- I would like to communicate by email with Vida Chiropractic.
- I will be responsible for maintaining any information regarding my care that I have saved onto my personal computer
- I understand that my email authorization and a copy of the email guidelines I have received will become part of my permanent medical record.
- I agree to follow the guideline for email communication with Vida Chiropractic and will use email for non-emergency purposes only.
- Emails containing transitory information (routine or short term transactions, and contain little or no information of ongoing value, i.e. confirmation of appointments) will be securely deleted by the Clinic.
- Email correspondence containing clinical or significant information will be entered into my permanent medical record by Vida Chiropractic.
- I agree to inform Vida Chiropractic if my email address changes.
- I understand that the Clinic will normally respond to email communications within 1 business day. If I have not heard from the Clinic by this time, I will phone the Clinic.
- The email I would like to have on file is a personal, non-shared, confidential email. I assure Vida Chiropractic that information sent to this email is secure and does not place Vida Chiropractic at risk of breaching confidentiality or privacy regulations.
The Statements made on this form are true to the best of my knowledge and I consent to allow Vida Chiropractic to further evaluate my condition with an exam and other tests as deemed necessary by the doctors.
Parent or guardian if under 18
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