New Patient Intake (English)

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If any, please explain.","name":"textarea-1561991040056"},{"type":"textarea","label":"When did the condition start?","name":"textarea-1561991057537"},{"type":"textarea","label":"Have you received care for this problem? If yes, please explain:","name":"textarea-1561991059397"},{"type":"textarea","label":"How did the condition(s) first begin?","name":"textarea-1561991093743"},{"type":"checkbox-group","label":"How did the condition(s) first begin?","name":"checkbox-group-1561991125252","values":[{"label":"Gradually","value":"Gradually"},{"label":"Suddenly","value":"Suddenly"},{"label":"Post-Injury","value":"Post-Injury"}]},{"type":"checkbox-group","label":"Is the condition:","name":"checkbox-group-1561991191251","values":[{"label":"Getting worse","value":"Getting worse"},{"label":"Improving","value":"Improving"},{"label":"Intermittent","value":"Intermittent"},{"label":"Constant","value":"Constant"},{"label":"Unsure","value":"Unsure"}]},{"type":"textarea","label":"What makes the problem better?","name":"textarea-1561991255157"},{"type":"textarea","label":"What makes the problem worse?","name":"textarea-1561991308584"},{"type":"checkbox-group","label":"Describe the pain:","name":"checkbox-group-1561991559863","values":[{"label":"Aching","value":"Aching"},{"label":"Dull","value":"Dull"},{"label":"Deep","value":"Deep"},{"label":"Sharp","value":"Sharp"},{"label":"Burning","value":"Burning"},{"label":"Throbbing","value":"Throbbing"},{"label":"Numb","value":"Numb"},{"label":"Tingling","value":"Tingling"},{"label":"Other","value":"Other"}]},{"type":"drawableimage","label":"Where is the pain located?","name":"drawableimage-1629383765959","form_image_id":"assets\/male_default.jpg"}],[{"type":"header","label":"Chiropractic History"},{"type":"textarea","label":"Describe your top 3 health goals:","placeholder":"Long and Short Term","name":"textarea-1561991894369"},{"type":"checkbox-group","label":"What would you like to gain from chiropractic care?","name":"checkbox-group-1561991943814","values":[{"label":"Resolve existing condition(s)","value":"Resolve existing condition(s)"},{"label":"Overall Wellness","value":"Overall Wellness"},{"label":"Both","value":"Both"}]},{"type":"checkbox-group","label":"Have you ever visited a chiropractor before?","name":"checkbox-group-1561992000808","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"header","label":"TRAUMAS: Physical"},{"type":"textarea","label":"Have you ever had any significant falls, surgeries, accidents or injuries as an adult?","name":"textarea-1561992075298"},{"type":"textarea","label":"Describe any motor vehicle accidents you've been in:","name":"textarea-1561992099899"},{"type":"checkbox-group","label":"Exercise Frequency","name":"checkbox-group-1561992392088","values":[{"label":"1-2x\/week","value":"1-2x\/week"},{"label":"3-5x\/week","value":"3-5x\/week"},{"label":"Daily","value":"Daily"},{"label":"Never","value":"Never"}]},{"type":"textarea","label":"What types of exercise do you perform?","name":"textarea-1561992451410"},{"type":"checkbox-group","label":"Do you wake up:","name":"checkbox-group-1561992481098","values":[{"label":"Refreshed","value":"Refreshed"},{"label":"Stiff and Tired","value":"Stiff and Tired"}]},{"type":"number","label":"How many minutes per day do you commute to work?","name":"number-1561992514177"},{"type":"header","label":"TOXINS: Chemical & Environmental Exposure"},{"type":"paragraph","label":"Please rate your CONSUMPTION for each: (never=0; High=4)"},{"type":"checkbox-group","label":"Alcohol","name":"checkbox-group-1561992716132","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Water","name":"checkbox-group-1562098540151","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Sugar","name":"checkbox-group-1562098541676","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Dairy","name":"checkbox-group-1562098543981","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Gluten","name":"checkbox-group-1562098542481","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Caffeine","name":"checkbox-group-1562098595174","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Processed Foods","name":"checkbox-group-1562098595908","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Sugary Drinks","name":"checkbox-group-1562098596595","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Artificial Sweeteners","name":"checkbox-group-1562098669619","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Cigarettes\/Tobacco","name":"checkbox-group-1562098687352","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Recreational Drugs","name":"checkbox-group-1562098715660","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Fast foods","name":"checkbox-group-1562098717069","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"textarea","label":"Please list any drugs\/medications\/herbs\/vitamins\/supplements\/other that you are taking, and why:","name":"textarea-1562098751945"},{"type":"header","label":"THOUGHTS: Emotional Stress and Challenges"},{"type":"paragraph","label":"Please rate your STRESS for each: (Low, High)"},{"type":"checkbox-group","label":"Home","name":"checkbox-group-1562098831070","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Work","name":"checkbox-group-1562098846751","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Life","name":"checkbox-group-1562098868334","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Money","name":"checkbox-group-1562098883322","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Health","name":"checkbox-group-1562098884403","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]},{"type":"checkbox-group","label":"Family","name":"checkbox-group-1562098905204","values":[{"label":"Low","value":"Low"},{"label":"Medium","value":"Medium"},{"label":"High","value":"High"}]}],[{"type":"paragraph","label":"If the signer is a minor, this document must be completed and SIGNED by the parent\/legal guardian.\n\nNature of Chiropractic Care: The reason for a chiropractic adjustment is to reduce subluxations that interfere with a person's ability to enjoy optimal health. These are manifested by nerve interference from the spine. The chiropractor uses his hands and\/or a mechanical aid to adjust the spine. The techniques used are varied and the chiropractor will use the one that best suits your needs. Occasionally you may hear a \"click\" and can feel the joint move.\n\nPossible complications of chiropractic care: A minority of people experience increased discomfort, such as stiffness and muscle tension or increased symptoms, after the first few adjustment sessions. Other very rare complications of chiropractic care include sprains, bone fissures (rib fractures) and vascular injuries.\n\nLikelihood of complications following chiropractic care: The likelihood of complications following chiropractic care is extremely low. The risk of occurrence of a vascular injury following a cervical adjustment is estimated to be one in one million to one in twenty million, depending on the source taken as a reference. In any case, no increased risk of suffering a vascular accident after receiving chiropractic adjustments has been detected. There are low-quality articles that anecdotally relate chiropractic care to this type of injury. However, epidemiological studies of higher quality and statistical impact rule out this causal relationship. The risk of complications following chiropractic adjustments is substantially lower than in most health care procedures. Multiple scientific studies demonstrate that chiropractic care is safe and contributes to improved nervous system function and increased well-being.\n\nI declare that I have read and understood the contents of this document and therefore I expressly assume and accept the information described in its different sections. On this basis, I sign this informed consent voluntarily, expressing my desire to receive chiropractic care by the undersigned."},{"type":"signature","required":true,"label":"Signature","name":"signature-1687349841173"}]]

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