VITA NOVA SPINAL CARE, P.C. 5437 SOUTH PRINCE STREET, LITTLETON, CO 80120 

PH: 303.798.VNSC  .    www.VitaNovaSpinalCare.com 

Client Name: _____________________________________________ Chiropractic care focuses on the integrity of your nervous system, which controls and regulates every function in your body.

REVIEW OF SYSTEMS: (Mark applicable functional diseases with x) C = Constant F = Frequent (weekly) O = Occasional (monthly) C F O C F O C F O C F O C F O Neurological Allergies Anxiety Depression Dizziness Nervousnes Numbness Loss of sleep Pins & needles Other ____________________________________ ________________________________________________________________________________________________________________________ Muscle & Joint Arthritis Bursitis Foot/ankle pain Hip disorders Knee pain Low back pain Neck pain Poor posture Scoliosis TMJ disorder ________________________________________________________________________________________________________________________ Digestive Excessive gas Colon problems/IBS Constipation Diarrhea Hemorrhoids Gall bladder trouble Liver problems Parasite/fungus Anorexia/bulimia Ulcers ________________________________________________________________________________________________________________________ Cardiovascular and High blood pressure Low blood pressure Rapid heartbeats High cholesterol Pain over heart Poor circulation Excessive bruising Swelling of ankles Abnormal heartbeat Varicose veins ________________________________________________________________________________________________________________________ Eyes, Ears, Nose & Throat Ear infection Eye infection Sore throat Sinus infection Tonsillitis Ringing in ears Hearing loss Swelling of ankles Other____________________________________ ________________________________________________________________________________________________________________________ Respiratory Asthma Apnea Difficulty breathing Emphysema Chronic cough ________________________________________________________________________________________________________________________ Skin Acne Dryness Eczema Rash Yeast/fungus ________________________________________________________________________________________________________________________ Genitourinary Bedwetting Infertility Kidney infection Erectile dysfunction Prostate issues ________________________________________________________________________________________________________________________ Female Heavy flow Irregular cycle Painful cycle Discharge Menopausal No Yes ________________________________________________________________________________________________________________________ Constitutional Fainting Fatigue Low libido Poor appetite Weakness ________________________________________________________________________________________________________________________ PREVIOUSLY DIAGNOSED CONDITIONS: Acid reflux AIDS Alcoholism Anemia Arnold Chiari Autism/ADHD Cancer Diabetes Epilepsy Fibromyalgia Glaucoma Gout Heart disease Multiple sclerosis Herniated disc Hepatitis Migraines Spine degeneration Rheumatoid arthritis Other_____________________

Disease is caused when the body is unable to maintain homeostasis (balance). There are three forms of stress that cause imbalance in the body. Thoughts & Emotions: Reflect on the positive and negative patterns you choose and check the ones the relate more to you.

Pray/meditate Set goals Say affirmations Read stories Optimistic Praise others Visualize Constant noise Unorganized A.N.T."s Watch TV/news Pessimistic Gossip Job stress (Automatic Negative Thoughts)

Trauma: (Consider birth trauma, accidents, injuries, falls & Operations/year) Birth to infancy: __________________________________________________________________________________________________ Childhood to young adult: _________________________________________________________________________________________ Adult: __________________________________________________________________________________________________________

Toxins: (Consider chemicals from food, pollution, pharmaceuticals, OTC drugs, recreational drugs) Medications: (Include contraceptives) ________________________________________________________________________________ Nutrition: Poor (mostly processed and fast food some fruits and vegetables) Fair Medium Good Excellent (mostly fruits, vegetables & proteins. Limited processed foods Amount: Caffeine ______ Tobacco ______ Soda ______ Water ______ Vaccines Yes No Mercury fillings Yes No Family history: Age Health Illnesses Age at death Cause of death Good Poor Natural Illness

Mother _____ ______________________________________________________ __________ Father _____ ______________________________________________________ __________ Sister _____ ______________________________________________________ __________ Brother _____ ______________________________________________________ __________ ________ _____ ______________________________________________________ __________ ________ _____ ______________________________________________________ __________

The purpose of chiropractic is not to cure or treat disease , rather it is to prevent it from developing by the removal of neurological interference. The best gift we can give our children on their journey toward health is a proper functioning nervous system that is subluxation free.

VITA NOVA SPINAL CARE, P.C. 5437 SOUTH PRINCE STREET, LITTLETON, CO 80120 

PH: 303.798.VNSC  .    www.VitaNovaSpinalCare.com 

The vision of Vita Nova Spinal Care is to help our community become healthy, happy and inspired. The beginning of achieving this is to discover your priorities and goals as it relates to your health and wellness. Your answers will help us determine how we can best help you.

Rate on a scale of one (not willing) to five (very willing): In order to improve your health, how willing are you to: Importance to achieve the following: Significantly modify your diet..................................................... 1 2 3 4 5 Take several nutritional supplements each day.................... 1 2 3 4 5 Keep a record of everything you eat each day...................... 1 2 3 4 5 Modify your lifestyle (e.g., sleep habits, water intake)........ 1 2 3 4 5 Practice relaxation techniques .................................................... 1 2 3 4 5 Engage in regular exercise. .......................................................... 1 2 3 4 5

Reduce stress.............................. 1 2 3 4 5 Stop smoking.............................. 1 2 3 4 5 Reduce pain................................. 1 2 3 4 5 Increase my mobility................ 1 2 3 4 5 Improve my posture................. 1 2 3 4 5 Learn about wellness................ 1 2 3 4 5

How confident are you of your ability to organize and follow through on the above health related activities? Very Fairly Not at all If you are not confident of your ability, what aspects of yourself or your life lead you to question your capacity to fully engage in the above activities? __________________________________________________________________________________________________________ At the present time, how supportive do you think the people in your household will be to your implementing the above changes? ___________________________________________________________________________________________________________________ Acknowledgments: To set clear expectations, improve communications and help you get the best results in the shortest amount of time, please read each statement and initial your agreement. ________ I understand that the chiropractic care offered in this office is based on the best available evidence and is designed to reduce or correct the vertebral subluxation complex. I realize Chiropractic is separate from medicine and does not claim to cure any disease. With this knowledge, I permit the chiropractor to deliver care that, in his or her professional judgment, can best help me in the restoration of my health. ________ I may request a copy of your Privacy Policy at any time. In it, it is explained that my personal health information is protected and released only when seeking reimbursement from an involved third party. ________ I authorize the performance of x-ray examination of (CIRCLE: myself, my child) which Dr. Mario Chavez, D.C may consider necessary or advisable in the course of treatment. I acknowledge that these x-rays are the sole property of Vita Nova Spinal Care, P.C. and as such will be used exclusively for purposes unique to the care of Dr. Mario Chavez, D.C. ________ For women: I certify I am not pregnant and realize an x-ray examination may be hazardous to an unborn child. Date of last menstruation period. (MM/DD/YYYY) _______________ ________ I grant permission for this office to confirm or reschedule an appointment by phone, and to be sent occasional health related cards, letters, or emails. ________ I acknowledge I am responsible for payments of any insurance covered or non-covered services I receive, and any insurance coverage is an agreement between the carrier and me. I understand that Vita Nova Spinal Care is not a provider for insurance, but is considered an out of network provider. ________ To my best knowledge, the information supplied is complete and truthful without misrepresentation of the existence, origin or severity of my health concerns. If the client is a minor , print their full name and age:____________________________________________________________________________ CLIENT'S SIGNATURE:

X

Signing gives permission for care Date

(Parental Signature required for child under the age of 18)