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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 AdobeReaderĀ® 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!

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?

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.