Fortin Chiropractic & Athletic Health Care Center

Providers Dr. Daniel Fortin and Dr. Margaret Spencer

1003 E. Freeway Dr. SE Suite B

Conyers, GA 30094

770-760-0060

Patient Information

Legal First Name: __________________ MI:_____Last Name:______________________________

Street: _____________________________________________Apt:________________

City:______________________________State:_______________Zip:_________________

Social Security #___________________Marital Status: S M W D Spouse:_______________________

Language Spoken: _____English ____Spanish____French____Indian ____Japanese ____Chinese

____Korean ____German ____Russian ____Other:__________________

Race: ____White ____American India or Alaska Native ____Asian ____Native Hawaiin/Pacific Islander

____Black or African American ____Hispanic or Latino ____Decline to Answer

Ethnicity: ____Hispanic or Latino ____Not Hispanic or Latino ____Decline to Answer

DOB:____________________ Home Phone:_________________Cell:__________________

Work phone:___________________________ Email:____________________________________

Which method of communication is preferred? Call- Text- Email- Postal mail

Emergency Contact:__________________________Phone number:______________________

Emergency Contact Relation:_____________________

Who may we thank for referring you to our office?__________________________________________

Occupation:_________________________Employer:__________________________

Employer Address:_________________________________________________________

Have you ever been to a chiropractor before? Y N

If yes, who and when?______________________________________________________________

Primary reason for contacting us__________________________________________________

Patient Signature ____________________________________________Date__________________

Patient Signature_____________________________________________Date__________________

Patient Signature_____________________________________________Date __________________

Patient Signature_____________________________________________Date__________________

Patient Signature_____________________________________________Date__________________

Fortin Chiropractic and Athletic Health Care Center Patient Information Date:___________

Insurance Information

Company: ______________________________________ Policy Holder Name _____________________________________ DOB____________

Policy Holder Employer _____________________________

Number ____________________________ Group number_____________________________________

If not you, policy holder relationship: Self Spouse Parent Employer Other

Secondary Insurance Information

Company_______________________________________________________________

Policy Holder Name _____________________________________ DOB____________

Policy Holder Employer ________________________________________

Number___________________ Group number__________________________________

If not you, policy holder relationship: Self Spouse Parent Employer Other

Current Health Condition and Patient History- Fortin Chiropractic & AHCC

Name:________________________ Date_______________________________________________

Current Complaint: _____________________________________________________________________

When did the symptoms first appear? If years ago, when was the most recent aggravation?

______________________________________________________

How did the symptoms first appear? Fall, Yard Work, Housework, Heavy Lifting, Long Drive, Slept

Wrong, Other: ______________________________________________________

How often do you experience the symptoms?

__Constant 100% __Frequent 75% __Intermittent 50% __Occasional 25% __Rare 10%

What makes the symptoms worse? Circle: sitting, standing, walking, sneezing, working, sitting at desk,

lifting, bending, driving, other _____________________________________________________

What makes the symptoms better? Circle; sitting, standing, laying down, rest, movement, ice, heat,

massage, chiropractic, pain pills, other____________________________________________________

How would you describe the pain? __Ache __Dull __Sharp __Burn __Numb __ Throb __Shooting

__Other (write in )_______________

Rate the pain on a scale of 0-10, 0 no pain, 10 is the worst pain imaginable: Current_____At worst____

Have you seen other doctors for this condition? If yes, who?__________________________________

What activities are affected by the pain? Housework, driving, bathing, dressing, caring for children,

working, sports, working out, other ________________________________________________________

_____________________________________________________________________________________

CHECK ANY CONDITION YOU HAVE HAD IN THE PAST 6 MONTHS

Musculoskeletal

_General Stiffness

_General Weakness

_Swollen Joints

_Spinal Curvature

_Neck pain

_Arm Pain

_Pain Between Shoulders

_Low back Pain

_Foot Trouble

_Walking Problems

_Jaw Problems

Nervous System

_Nervous

_Numbness

_Dizziness

_Forgetfulness

_Depression

_Tingling Extremities

_Stress

_Twitching

_Diabetes

_Heat/Cold Intolerance

General

_Fatigue

_Allergies

_Headache

_Loss of Sleep

_Weight Change

_Fever/Chills

_Thyroid Problems

_Sweats

_Bleeding/Bruising

For Women

_Cramps

_Irregular Cycle

_Painful Periods

_Pregnant (now

Gastro-Intestinal

_Poor/Excessive appetite

_Excessive Thirst

_Vomiting

_Nausea

_Diarrhea

_Constipation

_Liver Problems

_Gall Bladder Problems

_Abdominal Cramps

_Gas/Bloating /Belching

_Heartburn

_Black/Bloody Stools

_Colitis

C-V-R

_Chest Pain

_Short Breath

_Asthma

_high/low Blood Pressure

_Irregular heartbeat

_Lung problems

_Varicose Veins

_Ankle Swelling

EENT

_Vision Problems

_Dental Problems

_Sore Throat

_Ear Aches

_Hearing Difficulty

_Frequent Colds

_Nose Bleeds

_Sinus Trouble

_Hoarseness

Genitourinary

_Bladder Trouble

_Painful/Excessive

Urination

_Discolored Urine

Family History

The following members

have same or similar

problem that I do:

_sibling

_mother

_father

_grandmother

_grandfather

_aunt

_uncle

_child

Current Health Condition and Patient History- Fortin Chiropractic & AHCC

Patient History

Are you seeing anyone else for other problems or health conditions? __ Y __N

Please list the problem/s, date problem/s began, and provider/s treating you for the conditions.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you smoke? __Never __Former smoker __Current/everyday smoker ___Current occasional smoker

Check any of the following conditions you have had:

__AIDS/HIV __Arthritis __Diabetes __ Gout __Osteoporosis __Anemia __Cancer __Epilepsy__Shunt

__Multiple Sclerosis __Rheumatic Fever __Back/Neck Surgery __Stroke __Breast Implant __Pacemaker

__Hypertension

Medications:

Please list all medications including vitamins, herbs, supplements, including date started, dosage, brand

name, strength, frequency, duration, quantity, refills, prescribed by

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you have any allergies? __Food __Environmental __Medication

Please list type of allergy and reaction

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Assignment and Release I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I

understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that

any amount authorized to be paid directly to this office will be credited to my account upon receipt. However, I clearly understand and agree

that all serviced rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend

or terminate my care and treatment, any fees or outstanding balances for services I have received will be immediately due and payable.

Patient’s/Parent’s/Guardian’s Signature____________________________________________________

Consent of Professional Services and Release of Information I hereby authorize and release the doctor and whomever he/she may designate as his/her assistants to administer treatment,

physical examination/x-ray studies, laboratory procedures, chiropractic care, or any clinic services that he/she deems necessary

in my case I furthermore authorized him/her to disclose all or any part of my patient record to any person or corporation which

is or may be liable under a contract to this office or to the patient or to a family member or employer of the patient for all or

part of the clinic’s charge, including but not limited to hospital or medical serves companies, insurance companies, worker’s

compensation carriers welfare funds, or the patient’s employer.

Patient’s/Parent’s/Guardian’s Signature____________________________________________________

Fortin Chiropractic & Athletic Health Care Center

Dr. Daniel Fortin

Dr. Margaret Spencer

INFORMED CONSENT

You have a right, as a patient, to be informed about the condition of your health and the

recommended care and treatment to be provided to you so that you can make the decision

whether or not to undergo such care with full knowledge of the known risks. This disclosure is

not meant to frighten or alarm you. This information is intended to make you better informed in

order that you can knowledgably give or withhold your consent.

INTRODUCTION

Chiropractic is predicated on the science which concerns itself with the relationship

between structures (Primarily the spine) and function (primarily of the nervous system) of the

body and the how this relationship can affect the restoration and preservation of health. The

following information is routinely furnished to all who consider Chiropractic care and treatment

in this clinic.

THE NATURE AND PURPOSE OF CHIROPRACTIC

Adjustments are made by chiropractors in order to correct spinal and extremity joint

subluxations. One of the most common disturbances to the nervous system is the vertebral

subluxation. This condition is one where one or more vertebra in the spine is misaligned

sufficiently to cause interference and/or irritation to the nervous system. The primary goal in

Chiropractic health care is the removal of nerve interference caused by subluxation. A

Chiropractic examination will be undergone which may include spinal and physical examination,

orthopedic and neurological testing, palpation, specialized instrumentation, radiological

examination (x-rays), and laboratory testing. The Chiropractic adjustment is the application of a

precise, high velocity movement of the spine over a very short distance. There are a number of

different methods or techniques by which the Chiropractic adjustment is delivered. Chiropractic

adjustments are typically delivered by hand, but some may require the use of an instrument or

other specialized equipment. In addition, physiotherapy or rehabilitative procedures may be

included in the management protocol. In addition to the benefits of chiropractic care and

treatment, one should also be aware of the existence of some risks and limitations of this care.

The risks are seldom high enough to contraindicate care, but they should be considered when

making the decision to receive Chiropractic care. All health care procedures have some risk

associated with them. Risks associated with some Chiropractic treatment may include

musculoskeletal sprain/strain, neurological injury, fracture, vertebral artery syndrome (VAS)

including stroke and perhaps death through complicating factors. Risks associated with

physiotherapy may include the preceding as well as allergic reaction and muscle and/or joint

pain.

CONSENT FOR CHIROPRACTIC CARE

Fortin Chiropractic & Athletic Health Care Center

Dr. Daniel Fortin

Dr. Margaret Spencer

I have been informed of the nature and purpose of chiropractic care, the possible

consequences of care, and the risks of care, including the risk that the care may not accomplish

the desired objective. Reasonable alternative treatments have been explained, including the risks,

consequences and probable effectiveness of each. I have been advised of the possible

consequences if no care is received. I acknowledge that no guarantees have been made to me

concerning the results of the care and treatment.

I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION

PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN

ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY

AUTHORIZE FORTIN CHIROPRACTIC AND ATHLETIC HEALTH CARE CENTER TO

PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.

DATED THIS ____ DAY OF _____________, 20___, CONYERS, GEORGIA

_______________________ __________________

Fortin Chiropractic & AHCC

1003 E. Freeway Dr. SE

Conyers, GA 30094

X-RAY WAIVER

PATIENT’S NAME_______________________________________

Due to the fact that I am currently pregnant and do not wish to have X-Rays taken while seeking

treatment, I release Fortin Chiropractic from all responsibility of knowledge of any disease

process, fracture, birth defect, or pathology that might be present and would be revealed if X-

Rays had been taken.

I further wish to attest the face that this waiver is given voluntarily and I understand that by

signing this form, I am waiving certain rights which I might have if my problem is no corrected.

Nevertheless, I choose to sign the waiver knowing that my health may be jeopardized due to

my decision.

Date:______________________________

Patient Signature:____________________________________________________

Fortin Chiropractic & Athletic Health Care Center

1003 E. Freeway Dr. SE

Conyers, GA 30094

CONSENT OF TREATMENT OF A MINOR CHILD

Patient:______________________________

I hereby authorize the doctors at Fortin Chiropractic & AHCC and whomever he/she ay

designate as his/her assistant(s) to administer chiropractic care as he/she deems necessary to

my child.

NAME OF PARENT/GUARDIAN:________________________________________________

ADDRESS:_________________________________________________________________

TELEHONE:__________________________________________

SIGNATURE:__________________________________________________

DATE___________________

Fortin Chiropractic & Athletic Health Care Center

1003 E. Freeway Dr. SE

Conyers, GA 30094

X-Rays and the Patient

I, the patient, ______________________________, have been told by the staff at Fortin

Chiropractic that any metal object that are on my person and not/cannot be removed will be

considered an artifact on my X-Rays.

Signed:___________________________________Date:_______________________________