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
The following may be used by anyone-used at your own risk.
- Gall Stone Cleanse
- Home Use of Ice
- OICV DietBrochure
- My Chiropractic Experience
- Blood Pressure Chart
- Ulcer Treatment Protocol-Natural