Forms

NEW PATIENTS: ALL NEW PATIENTS MUST THOROUGHLY COMPLETE THE INTAKE & HISTORY FORMS AND THE INFORMED CONSENT FORM (WHICH DR WILL REVIEW WITH YOU) (no blanks on any forms, if something doesn’t apply, note: N/A). Print them out, fill them out and bring them to the first appointment. Failure to have these forms completed will result in the Doctor rescheduling the appointment for another time, since the appointment has been scheduled based on the forms being completed. If you have difficulty downloading these forms, send a text to 865-584-8444.
INTAKE AND HISTORY – Required of All New Patients                                           INFORMED CONSENT – Required of All New Patients

NEW PATIENTS – MEDICARE If you are a new patient and wish to receive services from Dr. Fair, you will need to read, comprehend and sign this form PRIOR to receiving any services.                                                                                                                                 NOTICE TO MEDICARE ELIBIBLE PATIENTS

FORMER PATIENTS/TRANSIENT PATIENTS If you consider yourself a patient but haven’t been in to see the doctor in over a year, please complete the Case History Update. If you are a regular patient at another Chiropractor’s office, from whom we can verify your status, please also complete the Case History Update.
CASE HISTORY UPDATE                                                                                            TRANSCIENT CARE

FORMS FOR MONITORING PROGRESS It is advisable that New Patients fill out the following three questionnaires. These forms will provide us with a record of your progress as you continue through a treatment plan; however, it is not mandatory.
Neck Pain Questionnaire
Low Back Pain Questionnaire
Revised Oswestry Questionnaire

FORM FOR TRAUMA, SURGERY OR MEDICATION CHANGES If you’ve suffered any type of trauma to the body (not an automobile accident), including surgery or had changes in medications, please fill out this form to bring us up to date and bring it with you on your next visit.

NEW INCIDENT REPORT

CAR ACCIDENT (MVA) if the trauma you suffered was an automobile accident or workman’s compensation injury, then fill out the initial Intake and History forms noted above. Then, in addition, complete the MVA Questionnaire noted below.                           MVA QUESTIONNAIRE

STRESSFUL LIFE EVENTS If you believe your health may have suffered as a result of extremely stressful circumstances associated with traumatic events and/or relationships, please fill out the following three section questionnaire. Read the directions carefully.
SOCIAL READJUSTMENT RATING SCALE

ANTI-BIOTIC USAGE If your health challenges have resulted in numerous rounds of anti-biotics, please complete the following.
YEAST EXPOSURE QUESTIONNAIRE-Page1 and Page2

The following may be used by anyone-used at your own risk.

 

2 Responses to Forms

  1. Kathy says:

    It was nice talking to you today. Will try and get the forms done quickly – Kathy

    • admin says:

      Hi Kathy, I too enjoyed our conversation. It is my hope I will be able to find some resolution for your issues. I look forward to the search. Be thorough with your Case History forms…they really are a great help. Be sure to read some of the testimonials.

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