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Welcome to TLC Holistic Wellness
Dr. Carol Ann Fischer, D.C., N.D.
Phone: 734-664-0339
The purpose of this office is to provide alternative holistic wellness care to help people reduce their stress so that they can achieve optimal health and wellness for themselves and their family. We provide gentle, non-force chiropractic care, nutrition/diet and homeopathic counseling, detoxification, allergy elimination and natural hormone balancing. Your experience with this office will include improved health and healing of
your body, as well as learning the truth about optimal health and wellness.
New Patient Information
Please complete all questions and bring this with you on your first visit.
Today’s Date:
Name:
Address:
City/State/Zip:
Home Phone:
Work Phone:
Cell Phone:
Birth
Date:
Age:
Social Security #:
Marital Status: Married
Windowed
Divorced Single
Number of Children:
Children’s Names & Ages:
Your E-Mail Address:
(For the purpose of providing you with our Health Tips!)
Your Employer:
Occupation:
Spouse’s Name:
Spouse’s Employer:
Emergency Contact:
Cell Phone:
Home
Phone:
Your Favorite Hobbies:
Who may we thank for referring you?
When did you last see a Chiropractor?
Name of Medical or Chiropractor
Other Doctors you’ve seen recently:
OTC/Prescription Medicines you take:
Vitamins you take:
Are you here because of a recent auto or work injury?
Yes No
Date of Accident:
Surgeries you’ve had: (circle all that
apply; write in others)
Hysterectomy
Appendectomy
Gall bladder
Tonsils
C-section
Cataracts
Knee
Hip
Back
Other
Ever diagnosed with cancer?
Yes No
What kind?
The vast majority of our patients have experienced dozens of impacts
that could cause physical stress and health problems.
Help us discover a few of yours.
How many total auto accidents/fender benders have you been involved
in?
(please circle)
5+
3-4
1-2
0
Motorcycle accidents?
Yes
No
Four
Which of the following sports have you been involved in?
(please circle)
Football
Basketball
Soccer
Field hockey
Gymnastics
Horseback Riding
Martial arts Rollerblading
Ice hockey
Skating
Skiing
Sledding
Snowmobiling
Ski diving
Water Skiing
Dance
Ballet
Softball
Volleyball
Other:
Have you ever... (please check)
[
] fallen down the stairs
[
] slipped on ice or snow
[ ] had a stress
or strain while working
[
] had a sports injury
[
] had a work or personal injury
Do you... (please check)
[
] sit more than four hours per day
[ ] drive more than
two hours per day
Are you a... (please check)
[
] computer operator [
] assembly line worker [ ] construction worker [ ] truck driver
[ ] single or working mother
[ ] night shift worker
[
] stressed worker
Chiropractic treats the physical condition known as a subluxation. This occurs when a bone moves from its normal position causing pain, abnormal motion and interference in the nerve communication between
the brain and the body.
Subluxations can cause malfunction in any part of the body.
Please check the health complaints you are currently experiencing:
[ ] Stress
[
] Low Back Pain
[
] Arm/Hand Problem
[
] Carpal Tunnel Syndrome
[
] Neck Pain
[
] Leg/Foot Problem
[
] Ear Infections
[
] Headaches
[
] Asthma
[
] Allergies, Food or Pollen
[
] Frequent Colds/Infections [
] Upper/Mid Back Pain
[
] Moodiness/Irritability
[ ] Spinal
Curvature
[
] Shoulder Pain
[ ] Sinus Problems
[
] Digestive Problems [ ] Fatigue
[
] Sleep Trouble
[ ] Unwanted Weight
[
] Hormone Issues
[
] Hair Loss
Do your health complaints effect your life by causing you...
(please check)
[
] additional stress
[
] difficulty in performing normal daily activities
[
] difficulty sitting
[
] difficulty standing
[
] difficulty sleeping
[
] difficulty walking
[
] difficulty moving/exercising
[
] fatigue
[
] lack of motivation
[
] inability to do what you want to do in life
What activities would you like to do that your health is impairing you from doing?
How would your life change if you had optimal health?
What needs to happen in order for you to have optimal health, healing
and wellness?
Who is financially responsible for this bill?
Method of Payment: [
] Cash
[ ] Check
[ ] Credit
Card [
] Insurance
Please note: All first visit charges are payable when services are
rendered.
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that TLC Holistic Wellness will prepare any necessary reports and forms to assist me in making collections from the insurance company, and that any amount authorized to be paid directly to TLC Holistic Wellness will be credited to my account upon receipt. However, I clearly understand and agree that I am personally responsible for payment of all charges for
all services received.
Patient's Signature
Date
Guardian's Signature Authorizing Care for Minor
Date
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you in the reception room before signing this consent. If there is anyone you do not want to receive your medical records, please inform our office.
Patient's Signature
Date
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