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Online Forms

Bearor Family Chiropractic offers our patient form(s) online so they can be completed in the convenience of your own home or office.

  • If you do not already have AdobeReader® installed on your computer, click here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Let us get started filling out this form.

Bearor Family Chiropractic Health Profile


About this Patient

Gender
Marital Status*
Please select one option
What type of complaint?*
Please select at least one option
How did this injury or condition occur?*
Please select one option
What is frequency of pain?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where does it travel to? Otherwise, choose non-radiating*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
What is the VAS? Rate your pain on a scale of 1-10 (10 being worst)*
Please select one option
What are symptoms relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has patient received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
What activity of daily living most affected?*
Please select at least one option
What does patient have difficulty performing due to this specific injury?*
Please select at least one option
What were the patient's specific therapeutic goals?*
Please select at least one option
Is there a 2nd complaint?*
Please select one option
What type of complaint?*
Please select at least one option
How did this injury or condition occur?*
Please select one option
What is frequency of pain?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where does it travel to? Otherwise, choose non-radiating*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
What is the VAS? Rate your pain on a scale of 1-10 (10 being worst)*
Please select one option
What are symptoms relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has patient received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
What activity of daily living most affected?*
Please select at least one option
What does patient have difficulty performing due to this specific injury?*
Please select at least one option
Is there a 3rd complaint?*
Please select one option
What type of complaint?*
Please select at least one option
How did this injury or condition occur?*
Please select one option
What is frequency of pain?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where does it travel to? Otherwise, choose non-radiating*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
What is the VAS? Rate your pain on a scale of 1-10 (10 being worst)*
Please select one option
What are symptoms relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has patient received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
What activity of daily living most affected?*
Please select at least one option
What does patient have difficulty performing due to this specific injury?*
Please select at least one option
Is there a 4th complaint?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where does it travel to? Otherwise, choose non-radiating*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
What is the VAS? Rate your pain on a scale of 1-10 (10 being worst)*
Please select one option
What are symptoms relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has patient received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
What activity of daily living most affected?*
Please select at least one option
What does patient have difficulty performing due to this specific injury?*
Please select at least one option
What type of complaint?*
Please select at least one option
How did this injury or condition occur?*
Please select one option
What is frequency of pain?*
Please select one option

LIST YOUR HEALTH CONCERNS BELOW

CIRCLE ALL CURRENT HEALTH PROBLEMS YOU HAVE
CIRCLE ANY CONDITION YOU HAVE NOW / HAVE HAD:
Have you ever been in an auto accident?
Have you had previous chiropractic care?

Social History

Smoking
How often?
Exercise, how often?
How does your present problem affect the following?
*PLEASE MARK the areas on the Diagram with the following LETTERS to describe your symptoms:

R= Radiating B= Burning D=Dull A=Aching N=Numbness S=Sharp/Stabbing T=Tingling

Mark your Pain Point
Instructions: On a scale of 1-10, please write the number that best describes the question being asked.

Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst.

Wellness Evaluation

In medicine today, leaky gut aka intestinal permeability, isn't typically diagnosed. However that doesn't mean it's not affecting your health. Many health issues related to LGS go undiagnosed, misdiagnosed, or are ignored by traditional medicine. Please take the quiz to help our doctors evaluate how we can help your condition and any underlying triggering limiting your health in process

Let's get started.

Please check any that apply to you prior to taking the quiz below:

Sub-Clinical symptoms including:
Autoimmune Conditions including:
Hormone imbalance including:
Thyroid conditions including:
Gastrointestinal issues including:
Developmental and social concerns including:
Respiratory Conditions including:
Skin conditions including:
Joint conditions including:

Write the number that most closely fits, then add up your results.

0 = None

1 = Mild

2 = Moderate

3 = Severe

Practice Member Information (Must be Completed Before Services Can be Rendered)

 Release of Authorized/ Assignment of Benefits 

I authorize and request payment of insurance benefits directly to R. Nathan Bearor, DC I agree that thisauthorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of thisform may be used in place of the original. All professional services rendered are charged to the patient. It iscustomary to pay for services when rendered unless other arrangements have been made in advance. Iunderstand that I am financially responsible for charges not covered by this assignment

Family Health History 

This form is to assist the doctor by providing past health history information for his review.

Condition
Who?

 X-RAY AUTHORIZATION

As your healthcare provider, we are legally responsible for your chiropractic records. We must maintain arecord of your X-rays in our files. 

PLEASE NOTE: X-Rays are utilized in this office to help locate and analyze vertebral subluxations. These x-raysare not used to investigate for medical pathology. The doctor of Bearor Family Chiropractic do not diagnose ortreat medical conditions; However, if any abnormalities are found, we will bring it to you attention so that youcan seek proper medical advice.

BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS.

FEMALE PATIENTS ONLY: To the best of my knowledge, I BELIEVE I AM NOT PREGNANT at the time X-rays are taken at Bearor Family Chiropractic

Terms of Acceptance

In order to provide the most effective healing environment, most effective application of chiropractic procedures, and the strongestpossible doctor-patient relationship, it is our wish to provide each patient with a set of parameters and declarations that willfacilitate the goal of optimum health through chiropractic. 

To that end, we ask that you acknowledge the following point regarding chiropractic care and the services that are offered throughour office: 

A. Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. Chiropractic is aseparate and distinct science, art and practice. It is not the practice of medicine. 

B. Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functions throughthe adjustment of spinal subluxation(s). Subluxations are deviations from normal spinal structures and configurations thatinterfere with normal nerve processes. 

C. The chiropractic adjustment process, as defined in the law and jurisdiction, involves the application of a specific directionalthrust to a region or regions of the spine with the specific intent of re-positioning misaligned spinal segments. This is a safeeffective procedure applied over one million times each day by doctors of chiropractic in the United states alone. 

D. A thorough chiropractic examination and evaluation is part of the standard chiropractic procedure. The goal of this processis to identify any spinal health problems and chiropractic needs. If during this process, any condition or question outside thescope of chiropractic is identified, you will receive prompt referral to an appropriate provider or specialist, according toinitial indications of the need. 

E. Chiropractic does not seek to replace or compete with your medical, dental or other type(s) of health professionals. Theyretain responsibility for care and management of medical conditions. We do not offer advice regarding treatmentprescribed by others. 

F. Your compliance with care plans, home and self-care, etc., is essential to maximum healing and optimal health throughchiropractic. 

G. We invite you to speak frankly to the doctor on any matter related to your care at this office, its nature, duration, or cost, iswhat we work to maintain as a supporting, open environment. 

By my signature below, I have read and fully understand the above statements. 

All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my satisfaction. Itherefore accept chiropractic care on this basis.

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my protected health information, under the Health InsurancePortability &Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in thattreatment directly or indirectly. 

2. Obtain payment from third-party payers.

3. Conduct normal healthcare operations, such as assessments and physician's certifications.

4. This office provides chiropractic care in a partially open adjusting environment.

5. It is also the practice of this office to display, on a bulletin board, patients celebrating birthdays for the month, as well asdisplaying each new patient and the person who referred them to our office, as well as paper sign in sheets.

I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses anddisclosures of my health information. I also understand that I may request, in writing, that you restrict how my privateinformation is used to disclose to carry out treatment, payment, or healthcare operation. I also understand you are not requiredto agree to my requested restrictions, but if you agree, then you are bound to abide by such restrictions.

INFORMED CONSENT FOR CHIROPRACTIC CARE 

Chiropractic care, like all forms of health care while offering considerable benefits may also provide somelevel of risk. This level of risk is most often very minimal, yet in rare cases, injury has been associated withchiropractic care. The types of complications that have been reported secondary to chiropractic careinclude: sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the rarestcomplications associated with chiropractic care occurring at a rate between one instances per one millionto one per two million cervical spine (neck) adjustments may be a vertebral injury that could lead to astroke.


Prior to receiving chiropractic care at Bearor Family Chiropractic, a health history and physical examinationwill be completed. These procedures are performed to assess your specific conditions, your overall healthand in particular your spinal health. These procedures will assist us in determining if chiropractic care isneeded, or if any further examinations or studies are needed. In addition, they will help us determine ifthere is any reason to modify your care or provide you with a referral to another health care provider. Allrelevant findings will be reported to you along with a care plan prior to beginning care.

I understand and accept that there are risks associated with chiropractic care and give consent to the examination thatthe doctor deems necessary and the chiropractic care, including spinal adjustments, as reported following myassessment

If practice member is a minor/child, parent or guardian must sign below.

I authorized Dr. R Nathan Bearor and any and all of Bearor Family Chiropractic Staff to perform diagnostic procedures,radiographic evaluations, render chiropractic care and perform chiropractic adjustments to my minor/child. 

As of this date, I have the legal right to select and authorize health care services for my minor/child. If my authority toselect and authorize care is revoked or altered, I will immediately notify Bearor Family Chiropractic.

Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING.  By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms").  Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein.  Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

  1. THE E-SIGNATURE SERVICE.
    • Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy.  The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
    • Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law.  The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18.  In order to use the Services, you must be identified by a unique email address.  Two or more natural persons may not use the Services using the same set of credentials.
    • Appropriate Conduct. You agree not to use the Services for any illegal or unauthorized purpose and agree to comply with all applicable domestic and international laws, statutes, ordinances, and regulations relating thereto.  You further warrant and agree that your use of the Services does not violate any relevant laws, regulations, legislation, or other applicable rules of any applicable authority.  You are solely responsible for determining the suitability of the Services for your particular purpose.

You agree not to (attempt to) modify, adapt, or hack the Services.  You agree not to engage in any activities that would create a false association with the Services.  You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

  • Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.
  1. WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
    • Warranty Disclaimer. The Services are provided to you without warranty of any kind, whether express or implied.  REVIEW WAVE SPECIFICALLY EXCLUDES AND DISCLAIMS WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUIET ENJOYMENT, NON-INRFINGEMENT, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE OF TRADE.

USE OF THE SERVICES IS DONE AT YOUR OWN RISK.  REVIEW WAVE ASSUMES NO RESPONSIBILITY FOR ANY LOSS OF YOUR DATA OR CONTENT OR ANY ERRORS OR OMISSIONS IN ANY CONTENT, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRECT AS A RESULT OF THE USE OF THE SERVICE.

  • Damages Limitation. REVIEW WAVE SHALL NOT BE LIABLE FOR ANY INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA, LOSS OF GOODWILL, THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS ARISING OUT OF OR IN CONNECTION WITH THESE TERMS, OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT REVIEW WAVE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, EVEN IF A LIMITED REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.
  • Limitation of Liability. IN NO EVENT WILL REVIEW WAVE'S AGGREGATE LIABILITY ARISING OUT OF OR IN CONNECTION WITH THESE TERMS AND YOUR USE OF THE SERVICES EXCEED THE AMOUNT RECEIVED BY REVIEW WAVE FROM YOU IN THE SIX (6) MONTH PERIOD PRECEDING THE ACTION GIVING RISE TO THE CLAIM.  THE LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BARGAIN BETWEEN REVIEW WAVE AND YOU.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
  • German Customers. Review Wave's liability to you if you are domiciled in Germany is limited as follows:
    • Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
    • If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.
  1. CUSTOMER OBLIGATIONS.
    • Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations.  You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
    • Customer Acknowledgements and Warranties. By using the Service you consent to do business electronically.  You hereby represent and warrant to Review Wave that: a.) you have all requisite rights and authority to use the Services under these Terms and to grant all applicable rights herein; b.) you are solely responsible for all use of the Services associated with your credentials; c.) you are solely responsible for maintaining the confidentiality of your account credentials; d.) your agrees to immediately notify Review Wave of any unauthorized use of your account of which it becomes aware; e.) you agrees that Review Wave will not be liable for any losses incurred as a result of a third party's use of your Account, regardless of whether such use is with or without its knowledge and consent; f.) you will use the Services for lawful purposes only and subject to these Terms; g.) any information you submits to Review Wave is true, accurate, and correct; and h.) you will not attempt to gain unauthorized access to the Services, other accounts, computer systems, or networks under the control or responsibility of Review Wave through hacking, cracking, password mining, or any other unauthorized means.

Review Wave is not a party to any Document executed via the Services.


Review Wave has no control over the contents of any Document.  Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.


Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.


Review Wave is not responsible for determining how long any contracts, documents, and other records are required to be retained or stored under any applicable laws, regulations, or legal or administrative agency processes. Further, Review Wave is not responsible for or liable to produce any of your Documents or other documents to any third parties.


With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements.  You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.


You agree that you are solely responsible for the accuracy and appropriateness of instructions given by you and your personnel in relation to the Services.


You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

  1. TERM AND TERMINATION.
    • Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased.  Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason.  Review Wave may notify you prior to any such termination or suspension at its discretion.
    • Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.
  1. INDEMNIFICATION.
    • Indemnity. You agree to release, defend, indemnify, and hold Review Wave, affiliates, and subsidiaries, and their officers, directors, employees, and agents, harmless from and against any claims, liabilities, damages, losses, and expenses, including, without limitation, reasonable legal and accounting fees, arising out of or in any way connected with your access to or use of the Service, or your violation of any term or warranty contained within these Terms.
  1. DOCUMENT RETENTION AND DATA PROTECTION.
    • Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so.  Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
    • Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

  • Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services.  Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.
  1. GENERAL.
    • Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
    • Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
    • Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion.  Your use of the Service signifies your agreement to these changes.  You will be notified of material changes by notice on the website or via e-mail.
    • Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave.  Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion.  These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
    • Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

 

  • Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email:  support (at) reviewwave.com

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