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...........

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Testimonials from Dr. Joe Kish

Testimonials on Chiropractic as experienced by Dr. Joe Kish

PERSONAL HEALTH TESTIMONIALS FROM DR. JOE

My life has been saved with prompt Chiropractic care, on at least three occasions.

 

 

STOMACH function

THE PROPER FUNCTIONING OF YOUR STOMACH.  

A PERSONAL TESTIMONIAL FROM DR. JOE

    I once had a T-5 SUBLUXATION and I didn’t know it. The 5th Thoracic spinal nerve goes through a nerve plexus and controls the proper function of your stomach.  It happened when I was a Police Officer in the Village of Fishkill, NY.  I was rear-ended while stopped at a traffic light. There was no damage to my vehicle, the “tap” was that slight, but I felt a pain in my mid-back between the shoulder blades. That night I took my parents out to dinner. It was their Anniversary.  I remember that I ate the broiled sea scallops. They were great! After dinner, while I was walking to the car, I threw up in the parking lot of the restaurant. I thought I had a “stomach bug”. 

     Fortunately, at this time I was going to a chiropractor regularly and my next appointment was in two days. The next morning I had sausage and eggs and had to run to the bathroom to throw up again. That afternoon I had a hotdog for lunch (this is before I cleaned up my diet!) and could barely keep it down. I was actually getting weak from lack of protein.

    The next morning I saw my chiropractor. I told him about the accident, what I had eaten, and the vomiting. "Hmmm” he said, “It sounds like achlor-hydria (lack of sufficient stomach acid) due to a subluxation.”

He knew just where to check, the fifth thoracic vertebra, and sure enough, it was subluxated. Spinal nerve interference is called “subluxation”. He gently adjusted this bone and said “There, I’ve gotten it, go home and enjoy some protein.” That night I had a steak (protein) for dinner and I had no digestion problems.

I have not had a stomach problem since.

 

HEART function

THE PROPER FUNCTIONING OF YOUR HEART,
A PERSONAL TESTIMONIAL FROM DR. JOE

      My life has been saved with prompt Chiropractic care, on at least three occasions.   The 1st Thoracic nerve goes through your Cardiac Nerve Plexus and controls the proper functioning of your heart.  

     I once had a T-1 SUBLUXATION and didn’t know it until I happened to get my blood pressure checked and my heart sounds listened-to. It turns out I incurred a T-1 Subluxation (“nerve interference” is called subluxation) from a tennis game 2 days earlier when I missed the ball  and "over swung".  Prior to this injury/subluxation I had normal blood pressure and normal heart sounds. Now I had a heart arrhythmia and high blood pressure. These findings were verified by 4 different doctors.

     With a stethescope I also listened to my heart sounds and heard the asymmetric heart beat. I quickly went to my brother (who was a Chiropractic Student-Doctor at the time) and he adjusted the 1st Thoracic bone. He immediately took my blood pressure: Now normal! He listened to my heart sounds: Now normal! I listened-to my heart sounds too, and sure enough, the normal heart beat (and blood pressure),  had returned. I have not had a heart problem since.

LIVER function

THE PROPER FUNCTION  OF YOUR LIVER,

A PERSONAL TESTIMONIAL FROM DR. JOE

     My life has been saved with prompt Chiropractic care, on at least three occasions.   I assure you, if the T-11 nerve is impinged (“nerve interference” called subluxation) it will affect your livers’ proper function.  It certainly affected mine. Many people believe that if they have no pain that they are healthy; sadly this is not true.

      I once had a SUBLUXATION of the T-11 nerve. It happened when I slipped on a staircase and fell onto the very edge of the step. I landed on my back, right at the location of the T-11 spinal bone. Wow, that did hurt – but the pain went away.

A few days later I went for a scheduled blood and urine test which was required in order to get a new life insurance policy. Two days later I received the results and was denied life insurance   (unless I wanted to go into some sort of “assigned risk” pool – at a much higher premium!) -because I had an "elevated Bilirubin level".

 Bilirubin shows up in the urine. It is an indicator of  LIVER FUNCTION.

      By now, I was a licensed Chiropractor, and I immediately understood the nerve-connection involved, and connected that to the fall on the steps. I insisted that my chiropractor check my 11th Thoracic bone. Sure enough, it was subluxated.

I  had it corrected (“adjusted”), and immediately called the insurance agent to demand another blood/urine test. A week later another test was made and two days after that a very confused insurance man called me back to report that the results were: a normal bilirubin level!  ("The first lab test must have been in error", he said!)

     I got the insurance policy from the same agent and the same company that originally denied me. I get a test done every couple of years and I haven’t had a bilirubin or liver problem since.

 

 

​​​

BLOOD pressure?

WHAT CAN CHIROPRACTIC DO ABOUT BLOOD PRESSURE?
Well, NOTHING…and maybe... EVERYTHING

     Recently a patient complained of her gradually increasing blood pressure, first in the moderately high range, and then up into the definitely high range: 160/100!  We did pre-and post-adjustment blood pressure testing, and after a week of intensive Chiropractic care, her blood pressure was 120/80… textbook normal.

HOW DID THE CHIROPRACTOR DO THIS?

 He didn’t. He simply adjusted her spine.

Chiropractors do not treat or cure disease, we only locate and adjust spinal subluxations.  Once subluxations are corrected, the body operates with optimum nerve function, and the internal organs can then function at optimum. It took a week for  her body to return to normal function. “ IT’S ALL ABOUT  YOUR  NERVES ! ”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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