New Patient forms

If you wish to become a new patient, please print out these forms.

It will save you a few minutes' time on your first visit to our office.

                 

                         FOR BEST RESULTS, COPY AND PASTE THESE 2 PAGES ONE PAGE AT A TIME!

BY SETTING YOUR PRINTER MARGINS TO 1/2" LEFT AND 1/2" RIGHT,

YOU SHOULD NEED ONLY 2 PIECES OF PAPER.

  PLEASE

  NOTE:

CHIROPRACTIC CASE HISTORY FORM OF DR. JOSEF J. KISH, CHIROPRACTOR SINCE 1986

None of the following information will be released without your written permission.

Name....................................................................................Street...................................................... Town/City....................................................................................State........................ZIPCODE........

Date of Birth:______ /______ /______......email address:...............................................................

Age:___   Home tel.#..................................... Work #............................................ Cell #.........................................

# children living with you:...... ages......................Do your children have any health conditions?......

Name/phone of nearest relative..........................................................................................................

Who referred you to our office (We'd like to thank them!)...................................................................

 

Chiropractors correct subluxations to your spine.

This nerve and spinal cord pressure (subluxation) can cause internal organ dysfunction-even without any pain symptoms.

Have you had previous Chiropractic care?......[.. ]NO.......     [..]] YES, I last saw Dr......... in (year)...........

CONDITION: I am here for:....[ ..]Health care....   [. .]Personal injury or accident....   [..]auto accident.   

[ ..]work related.....Other ........................................................................................................................

Date condition began:  ....... / ........ / .............How did it occur?.........................................................

List all areas of the body that are involved:........................................................................................

My condition is:.....[ ..]Constant....[ ..]Comes and goes......[. .]Is worse in a.m.......[. .]Is worse in p.m.

Other............................................................................................................................................... 

What makes it better?........................................... ..........................................................................

What makes it worse?......................................................................................................................

​(There is a danger in using HEAT on the spine. Ask the Dr. to explain this to you.)

PAST TRAUMAS. Past traumas could be an underlying cause of chronic subluxations, which may have resulted in your current condition. Do you know of any trauma associated:

With your birth? . . . . . . . . . . . No.......Yes: ...................................................

With childhood injuries?.........No.......Yes: ..........................................

With sports Injuries? . . . . .  . .No.......Yes: ................................................

With home injuries?................No.......Yes: .........................................

With work injuries? . . . . . . . . No.......Yes: ................................. .............

With any auto accidents?.......No.......Yes: .......................................................................................

ANY PAST SURGERY: (Hospital surgery):.No........Yes: .......................................................................

 

Relax, you are almost finished with this form. Please finish page 2 now.

If you set your RT and Left margins to 1/2 inch, this page should fit on ONE piece of paper.

END OF PAGE 1

EXERCISE: How often do you exercise per week?...............Type of exercise?...................................

Chiropractors correct subluxations (=Nerve interference or spinal cord pressure). After subluxations are corrected,

many people notice an improvement in digestion, heart function, respiration, liver, gall bladder, hearing, vision, etc.,

DO YOU HAVE ANY PROBLEMS OR SYMPTOMS INVOLVING:.....[.. ]Stomach....[.. ]Intestines.....[...]Heart....[...]Lungs

[...]Gall bladder......[...]Kidneys.....[...]Liver......[...]Sinus....[...]Eyes...[...]Ears....[...]Physical Strength....[...]Balance/Coordination Other:............................................................................................................................................................................................................

EMOTIONAL STRESS-can easily cause subluxations. What is your level of stress :

At your home:..........HIGH..........Moderate..........Low

At your work:............HIGH..........Moderate..........Low

In your past: ............HIGH..........Moderate..........Low

Memories, old angers, fears, worries, grudges, refusal to forgive, ARE causes of stress.

​​CHEMICAL STRESS-can also cause subluxations.  How would you rate your:

Coffee /tea intake: .................HIGH..........Moderate..........Low

Tobacco use: .........................HIGH..........Moderate..........Low

Alcohol; intake: ......................HIGH..........Moderate..........Low

Drug or medications: .............HIGH..........Moderate..........Low

Medications taking:........................................................  For:.....................................................

Medications taking:........................................................  For:.....................................................

Medications taking:........................................................  For:.....................................................

Medications taking:........................................................  For:.....................................................

Medications taking:........................................................  For:.....................................................

Do you know what a subluxation is?....  [_]NO......[_]YES........................................

​EVALUATION OF FUNCTION: What activities, movements, work, hobbies, etc., CAN YOU NOT DO NOW THAT YOU COULD DO BEFORE THE INJURY/INCIDENT?.... (for example: "I cannot climb stairs now, but I could before..."

Functionality Test #1 ...................................................................................................................................................

Functionality Test #2 ...................................................................................................................................................

Functionality Test #3 ...................................................................................................................................................

 This office does not accept insurance assignment, insurance cases, or Medicare cases. But there is an affordable "Wellness Plan".  (This plan does not apply to those eligible for Medicare UNLESS you are on "maintenance care"--which Medicare does not pay for anyway.)  A separate contract is required. and requires Dr. approval to begin. Please ask for an application. A pre-requisite for beginning this program is to attend a "Doctors Report" in its' entirety. This report will help you to understand what you can do to attain maximum recovery in the shortest period of time. Patients who attend this report always recuperate faster than those who do not.

OFFICE POLICY:

1. I AGREE that I AM SOLELY responsible for all bills incurred at this office.

2. My payment is to be made before I leave the office-unless other arrangements or payment plans have already been arranged.

3. I UNDERSTAND that Dr.Joe Kish does not accept Medicare assignment, Medicare cases, Medicare Program, Insurance cases, Insurance reimbursement plans, or any 3rd party payments.

4. I UNDERSTAND that Dr. Joe Kish will not submit  insurance forms to insurance companies,  lawyers, etc.,  and that the only receipt I will receive is an end-of-year-receipt for income tax purposes.

Your signature........................................................................  Dr. signature...........................  Date...........

 

  • 1 hr 30 min

    300 US dollars
  • 1 hr 20 min

    250 US dollars
  • 1 hr 20 min

    250 US dollars
  • 1 hr 20 min

    250 US dollars
  • 30 min

    150 US dollars