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 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 While the completion of these forms is not mandatory, it is advisable that New Patients fill them out upon initiating care as an objective record against which to judge your progress. Ask the Doctor for copies based on your areas of complaint. Neck Pain Questionnaire
Low Back Pain Questionnaire
Revised Oswestry Questionnaire
FORM FOR TRAUMA, SURGERY OR MEDICATION CHANGES If you, as a current patient, have suffered any type of trauma to the body (not an automobile accident), including surgery or had changes in medications, remind the Doctor when you come in to have you complete a 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