1322 E. 15th Street Tulsa, OK 74120, Newark, DE, 19713
Phone: (918) 212.8688 • Fax: 1.866.352.5122Email: [email protected] • Website: 9l8chiropractic.com
Weilness Profile
Practice Member Information piie
Name:^Appointment Date D M 20 Birth Date D M YHome Address:City State ZipHome Phone; May we leavea message? LJYes LJNoCell Phone: May we leave amessage? OYes Q NoWork Phone: May we leave a message? LiYes L_:NoEmail:May we add you to ouremail newsletter and calendar ofevents? C Yes O No (Your email will not be shared)Spouse's name? _____Name(s) and age(s) of children:Occupation:
Doyou primarily: OSit U Stand O Perform repetitive tasksHow did you hear about us?
Healthcare HistoryHave you had previous chiropractic care? UNo UYesWho was your previous Chiropractor?
Where? When?Were X-rays taken in the last 6 months? [_}Yes O NoWhat was the primary reason for consultingthat office?Li Relief Care - Symptom reliefof pain or discomfortL.iCorrective Care - Correcting, relievingand stabilizing spinal, joint and postural issuesI )Weilness Care- Maximizing the body's ability for optimal healing and function
Do you feel your previous chiropractic care was effective? L.) No O YesPlease explain:
Are youwearing: C Heel Lifts [jCustom OrthoticsFamily Doctor:Date and reason of last visit:
May we contactyourfamily doctor regarding yourcare at our office ifnecessary? LJ No U YesNaturopathic Doctor:
Date and reason of last visit:
Other Specialists and healthcare professionals:Name:Professional Designation:Date and reason of last visit:Name:^Professional Designation:Date and reason of last visit: ^ .
When?
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Dr. J. Matthew Grisvvold 9l8chiropractic.com Wellness Profile
Wellness ProfileDo you have a specific concern that brings you in?n No, I'm interested inhaving my nervous system assessed to achieve optimal health and functioning.• Yes:
If yes, please answer the following questions:What isyour primaryarea of complaint today?How long have you been aware ofthis? days weeks months yearsWhere else does this paingo in your body?How often do you experience this? • daily • weekly Q monthly • comes and goes • constantlyOn a scale of I to 10(10 being the worst), how does it feel when it's at itsworst?How would you describe the pain/discomfort?_• Dull QAchy OThrobbing QStabbing (jTight/Stiff QBurning QSharp QOther
What makes it feel worse?What makes it feel better?
Do you notice any other problems in your body when you getthis pain/discomfort?Do you feel your condition getting progressively worse? U No G YesDo you feel your condition can be healed? Q No •Yes _What have you tried that hashelped? U Ice O Heat • Medication lj Massage • Physical Therapy • ChiropracticG Other ; ——;
What have you tried that hflsn't helped? Glee GHeat OMedication OMassage tJPhysical Therapy QChiropracticO Other —
See additional Spinal Nerve Function Form to provide further detail on your Wellness Profile (Pages)
Lifestyle InformationThe human body is designed tobe healthy.The primary system in the body which coordinates health and function is thenervous system.Yaur nervous system is surrounded and protected by the bones of the spine, called vertebrae. Physical,emotional, and chemical stresses, common toourcontemporary lifestyle, can result in misalignment to the spinal column aswell as damage the delicate nervous system.The result is acondition called a Vertebral Subluxation. The remainder of theintake form addresses the possible factors which may contribute tovertebral subluxation in your spine which may be impedingyour body'sability to heal.
PhysicalHeight WeightAre you happy with your current physical appearance and abilitl^? GYes GNoFrequency of exercise/weelc Cardio? G® Gl G2 G3 G^ • 6 07
Weight bearing?. GO Gl G2 G3 G^ G5 G6 07 ^Do you stretch after exercise or after other activities of poor posture? OYes G Sometimes O NoHours ofsleep/night? 0>6 G7-9 Ol0+Do you feel refreshed upon waking? O Always G Sometimes LD BarelyAge of mattress? Do you feel your mattress is appropriate for your sleeping style? GNo GYesWhich position do you sleep? GBack O Belly Side: GRight Gteft GBothNumber of hours spent commuting/week? GO-2 03-J 09-11 012+Number of hours spent at adesk or computer/week? GO 01-5 O6-I0 Gl l-20 O2I-40 IG4I+Number ofhours spent on smart device/tablet/week? GO Ql-S O6-I0 Gll-20 G2I-40 lj4I+Do you perform any repetitive tasks at home oratwork?GNo GYesHave you ever been hospitalized orhad surgery? GNoGYes If yes why and when? ^
Have you ever been in a motor vehicle accident (even if itwas minor)? Q No GYesIfyes,what kindand when?.
Were you evaluated and treated after each accident? O No GYesHave you had any non-vehicle accidents orfalls? Q No G Yes
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91 Schiropractic.com Wellness Profile
Early YearsTo your knowledge, was your delivery difficult? O No OVesU If yes: O Forceps O Vacuum LiCaesarean l_J Breech OOther_
Were you breast fed? CjNo CjYes For how long?Did you experienceemotional trauma as a child? i, jNo;,.jYesWere you ever given antibiotics as a child? L JNo LJYesDid you ever have ear infections as a child? L.!No CjYesAny major childhood illness? L No Yes
Emotional
Rate your current level ofpersono/stress in your life: LjNone CjLow CRate your current level of re/ationsh»p stress in your life: CjNone GLow fRate your current level of financial stress in your life: U None U Low CRate your current level ofhea/th stress in your life: QNone LjLow [Rate your current level offamZ/y stress in your life: UNone [jLow LRate your current level of coreerstress in your life: ONone LJLow '•Do you feel you have a supportive network of friends and family? . . . QYes ljNoDo you fee! you have healthy coping strategies for life stress? O Yes U No
JModerate LJHighjModerate OHighjModerate LJHighjModerate L.)HighJModerate OHighJModerate OHigh
Chemical
Were you vaccinated as achild? ONo OYesAny adverse reactions to vaccines? lJNo i jYesDo you choose to have annual flu shots? ONo OYesDo you take antibiotics? OYes. How often?^
nio+
n 10+nio+
OYes 0 Trying to eliminate from diet[ jYes f 1 Trying to eliminate from dietOYes Q] Trying to eliminate from dietOYes Oi "Frying to eliminate from diet
How many glasses ofwater/day: QO OI-3 i J 4-6 L;'0+How many glasses of caffeinated beverages/day: OO 0^*3 L.) 4-6 LjHow many glasses ofcow's milk, juice and pop/day: OO 0'*3 O 4-6 O 7-9 i_,IO+Do you eat gluten? QNo QYes O Trying toeliminate from dietDo you eatdairy? QNo OYes fj Trying to eliminate from dietDo you eatrefined sugars? (white sugar, white bread and pasta) lJ^® jYes O Trying to eliminate from dietDo you eat boxed/frozen foods? OY®s i j Trying to eliminate from dietDo you choose organic foods? GiNo QYes, which: OVeggies i—;Fruits LJMeats OGrainsDoyou eat any artificial sweeteners? (Splenda, Aspartame, Diet Soda, etc). LJNo i lYesAny food/drink allergies, sensitivities, intolerances? UNo ;_.'Yes_Doyousmoke? (JNo OYes (j Iused tofor years [llwishlAre you or have you been exposed to second hand smoke? . . . . QNo LJYes _ _ _Do you drink alcohol? ONo QYes rjO-6/week G6-l2/week U' +ADo you take a probiotic daily? LjNo jYes, CFU s/dayDo you take vitamin D3 daily? LJNo QYes, lU s/dayDo you take Omega 3 Fish Oils daily? QNo QYes, mg/day fjCapsule QLiqtOther supplements or homeopathics?Any other daily medication and their purpose?
Do you have aplan in place with your medical doctor to wean yourself off of any long term medications? CjNo QYes
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GlYesJjYes CJ Iused to for years CJ1 wish Ididn't(JYesQYes GO-6/week fG6-l2/week Gl2+/we€riYes. CFU's/day•Yes. lU's/day•Yes, mg/day fjCapsule QLiquid
l2+/week
Ci^ropractlcJ. Matt'icvv onv-vc4U
Family Health
9 i 8chiropractic.com
<f\<mWeliness Profile
At our clinic we are not only interested inyour health and weliness, but also the health and weliness of the important peoplein your life. Please mention below any health conditions or concerns you may have about your:Children:
Spouse;
Mother;
Father:
Brothers/Sisters;Are you seeking chiropractic care today for:
ij Relief Care - Symptom relief of pain or discomfort
M Corrective Care - Correcting, relieving and stabilizing spinal, joint and postural issuesi_lWeliness Care - Maximizing the body's ability for optimal healing and function
Do you have other concerns we should know about?
Goals <S Consent
What is your primary goal for consulting our clinic?Our goals are to providea detailedassessmentof your current healthstatus and provide to you the resources for ahighly engagedand healthy body which is functioning at its absolute peak potential. Essential is a healthy nervous systemfunctioning free from interference called subluxations. You've taken an important step for your health througha chiropractic evaluation!
Consent to Evaluation
I herebygrant permission to receive a chiropractic evaluationincluding history, spinal scan and examination.Anyfindings will be communicated before consenting to commencementof treatment, if appropriate.
Consenting Adult's Signature
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SPINAL NERVE
918chiropractic.com
ORGANS & GLANDS
The organs and glands listedbelow are linked to thecorresponding sections of thespine and it's spinal nerves.
Parotid Gland • ScalpBase of Skull • EyesLacrimal Gland • Sinuses
Inner, Middle & Outer Ear
Nose • Mouth
Intracranial Blood Vessels
Sympathetic Nervous SystemNeck Muscles • DiaphragmShoulders • Elbows • Arms
Wrists • Hands & FingersTonsils •Vocal Cords
Esophagus • HeartLungs• Chest • Thyroid
Arms • Wrists
Esophagus * Chest • HeartLungs • Trachea • LarynxDiaphragm • StomachGallbladder • Liver
Pancreas • Small Intestine
Spleen • Kidneys 'AppendixAdrenals • Colon • Buttocks
Uterus • Ovaries • Testes
Large Intestine • ColonThighs • Buttocks • Groin
Knees • Legs • FeetReproduccive Organs
Buttocks • Groin • LegsAnkles • Feet • Toes
Prostate Gland • Bladder
Reproductive Organs
SystemsFunction ofSpinal Nerves
ASSOCIATED SYMPTOMS
Please indicate below any symptoms you are currentlyrixperiencingas well as any you have previously experienced.
( ' Sinus & Ear Pain/Infection
i3 Runny Nose &Allergies( j Frequent Head Coldsi_i Sore Throat &Tonsilitis
0 Strep Throat[ 1 Chronic Cough & Croup
10 Difficulty Breathing0; Poor Immunityr j DizzinessScVertigoC : Tinnitus & Ear Fullness
r " Vision Problems
( ; Watery/Dry Eyes0 Chronic Fatigue01 Poor Concentration
01 Depression
Asthma
Bronchitis & Pneumonia
Congestion
Reflux & GERD
Indigestion & Heartburn
Stomach Pains
Ulcers
Gas & Bloating
Jaundice
Liver Conditions
Blood Sugar Dysregulation
irritable Bowel,Colitis, Crohn's
Gas Pain & Constipation
Diarrhea
Hemorrhoids
Bladder infections
Bladder Incontinence
& BedwettingPainful/Excessive Urination
Varicose Veins
Leg Cramping
Resdess Legs
Poor Circulation
& Cold Feet
Anxiety & Stress
Seizures
ADD/ADHD
Thyroid DysfunctionMetabolic Dysfunction
insomnia
High/Low Blood Pressure
Enlarged Lymph Glands
Migraines & Headache
TMJPain
Stiff Neck
Arm Pain
Hand/Finger NumbnessLoss of Grip Stren^h
' ; KidneyStones; ; Gall Bladder Attacks
Skin Conditions & Rashes
' J Menstrual Cramps/PMS. J Infertility
; . Menstrual Dysfunction
0' Rashes & Eczema
0; Hyperactivity
01 Shoulder Pain
0. Midback Pain
1 Rib Pain
Prostate Dysfunction& Impotence
Ovarian Cysts &Endomethosis
Fertility Problems/Loss of Menstruation
Low Back Pain
Hip Pain
Thigh PainNumbness &Tinglesin Legs
Sciatica
i' 1 Pelvic Pain
1_; Knee Pain
0: AnklePain &Sprains10 Foot Pain &Weak Arches
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