TeamDC Patient History Form
Last Name:___________________ First:____________ Middle:____
Date of Birth:___/___/_____ Age:________ Occupation: ____________
Home Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________
Emergency Contact Name:____________________ Phone:____________
Relationship:__________________
Treatment Location: ________________________________
Treatment Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________
Who Referred You To TeamDC?________________________________
Have you ever been to a Chiropractic Physician before? _No _Yes
Clinic Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________ Date of last visit:_____________________
Primary Care Physician:____________________________________________________
Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________ Date of last visit:_____________________
Were you referred as a result of an accident? _No _Yes Date of Accident:___/___/_____
What primary condition will TeamDC be treating? Explain in detail:
____________________________________________________________________________________
____________________________________________________________
____________________________________________________________________________________
____________________________________________________________
When did the primary condition start? Explain in detail:
____________________________________________________________________________________
____________________________________________________________
____________________________________________________________________________________
____________________________________________________________
PAIN SCALE
Please circle the number that best describes your pain
0 1 2 3 4 5 6 7 8 9 10
NONE LITTLE MEDIUM SEVERE
When did the primary condition begin?_____________________
How did this condition develop?_____________________________________________
Ever had this problem before? _No _Yes Explain:__________________________________
Ever receive treatment for this condition? _No _Yes If yes, when, where and what were the results?
________________________________________________________________________
Has this problem been getting: _Better? _Worse? _Staying the same?
What makes your primary condition better?
______________________________________________________
What makes your primary condition worse?
______________________________________________________
Does anyone in your family suffer from your primary condition? _No _Yes If yes, who? ______________
Describe your past Health History
Prior Illness: ________________________________________________________________________
Past Hospitalizations:
________________________________________________________________________
Surgeries: ________________________________________________________________________
Medications: ________________________________________________________________________
Check any secondary symptoms you have been experiencing:
_Neck Pain _Upper Back Pain _Middle Back Pain _Lower Back Pain
_Headache _Nausea _Chest Pain _Dizziness_Loss of Balance _Ring in Ears _Numbness in Arm/Hand
_Numbness in Leg/Foot_Pain in Arm/Hand _Pain in Leg/Foot _Sensitivity to Light _Neck Stiffness_Cold
Sweats _Head Feels too Heavy _Memory Loss _Upset Stomach _Loss of Taste _Loss of Smell
_Shortness of Breath _Sleeping Problems __Weight Loss __Weight Gain __ Other __________________
When did the secondary symptoms begin?_____________________
How did this condition develop?____________________________________________
Ever had these symptoms before? _No _Yes If yes, explain:__________________________________
Ever receive treatment for this symptom? _No _Yes If yes, when, where and what were the results?
__________________________________________
Has this secondary symptom been getting: _Better? _Worse? _Staying the same?
What makes your secondary symptom better? __________________________________
What makes your secondary symptom worse? __________________________________
Does anyone in your family have similar secondary symptoms? _No _Yes If yes, who? ______________
Do you have or have you had:
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
Does or did any immediate family member have:
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
Do you use tobacco? _No _Yes If yes, type and amount per day ____________________________
Do you suffer from alcohol or drug abuse? _No _Yes If yes, explain _________________________
Do you suffer from allergies? _No _Yes If yes, to what? __________________________________
DISCLOSURE & CONSENT to CHIROPRACTIC CARE
You have a right as a patient to be informed about your condition and the recommended
chiropractic adjustments and other chiropractic procedures to be used so that you may make the decision whether or not to undergo the
procedure after knowing the potential risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to
make you better informed so you may give or withhold your consent to the procedure.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of
physical therapy and deep tissue massage, on me (or the patient named below, for whom I am legally responsible) by Dr. David Foster, DC,
CSCS, CCSP and/or other licensed TeamDC.
I have had the opportunity to discuss with the Doctor of Chiropractic named below, the diagnosis, the nature and purpose of chiropractic
adjustments and other procedures and alternatives.
I understand and I am informed that, in the practice of chiropractic there are some risks to exam and treatment including, but not limited to,
fractures, disc injuries, strokes, dislocations, sprains, localized bruising and increased symptoms including pain or no improvement of
symptoms including pain. I do not expect the TeamDC Doctor to be able to anticipate and explain all risks and complications, and I wish to
rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known,
and is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from
the treatment.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions, and all my questions have been
answered fully and satisfactorily. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of
treatment for my present condition and for any future condition(s) for which I seek treatment.
CONSENT TO TREATMENT OF MINOR
I, the undersigned, parent/person having legal custody/legal guardianship of the minor named below, do herby authorize David Foster, DC,
CSCS, CCSP and TeamDC as agent for the undersigned to consent to any examination and chiropractic treatment, which is deemed
advisable by a licensed chiropractor and to be rendered under the general or special supervision of a licensed chiropractor.
It is understood that this authorization is given in advance of any specific examination, diagnosis or treatment being required but is given to
provide authority to the above described agent to give specific consent to any and all such examinations and treatments which a
chiropractor, meeting the requirements of this authorization, may, in the exercise of his/her best judgment deem advisable. These
authorizations shall remain effective until revoked in writing, delivered to the agent noted above.
Questions or concerns may be directed to Dr. David Foster, DC, CSCS, CCSP at 949 752 7752, DrFoster@TeamDC.info or P.O. BOX 50321
Irvine, CA 92619-0321
Patient Signature:_____________________________________________Date:_____________
Parent Signature: _________________________________ Date: ________
Doctor Signature:____________________________________________ Date: _________
Last Name:___________________ First:____________ Middle:____
Date of Birth:___/___/_____ Age:________ Occupation: ____________
Home Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________
Emergency Contact Name:____________________ Phone:____________
Relationship:__________________
Treatment Location: ________________________________
Treatment Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________
Who Referred You To TeamDC?________________________________
Have you ever been to a Chiropractic Physician before? _No _Yes
Clinic Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________ Date of last visit:_____________________
Primary Care Physician:____________________________________________________
Address:_________________________________
City:______________________ State:_______ Zip:_____-_____
Phone:______________________________ Date of last visit:_____________________
Were you referred as a result of an accident? _No _Yes Date of Accident:___/___/_____
What primary condition will TeamDC be treating? Explain in detail:
____________________________________________________________________________________
____________________________________________________________
____________________________________________________________________________________
____________________________________________________________
When did the primary condition start? Explain in detail:
____________________________________________________________________________________
____________________________________________________________
____________________________________________________________________________________
____________________________________________________________
PAIN SCALE
Please circle the number that best describes your pain
0 1 2 3 4 5 6 7 8 9 10
NONE LITTLE MEDIUM SEVERE
When did the primary condition begin?_____________________
How did this condition develop?_____________________________________________
Ever had this problem before? _No _Yes Explain:__________________________________
Ever receive treatment for this condition? _No _Yes If yes, when, where and what were the results?
________________________________________________________________________
Has this problem been getting: _Better? _Worse? _Staying the same?
What makes your primary condition better?
______________________________________________________
What makes your primary condition worse?
______________________________________________________
Does anyone in your family suffer from your primary condition? _No _Yes If yes, who? ______________
Describe your past Health History
Prior Illness: ________________________________________________________________________
Past Hospitalizations:
________________________________________________________________________
Surgeries: ________________________________________________________________________
Medications: ________________________________________________________________________
Check any secondary symptoms you have been experiencing:
_Neck Pain _Upper Back Pain _Middle Back Pain _Lower Back Pain
_Headache _Nausea _Chest Pain _Dizziness_Loss of Balance _Ring in Ears _Numbness in Arm/Hand
_Numbness in Leg/Foot_Pain in Arm/Hand _Pain in Leg/Foot _Sensitivity to Light _Neck Stiffness_Cold
Sweats _Head Feels too Heavy _Memory Loss _Upset Stomach _Loss of Taste _Loss of Smell
_Shortness of Breath _Sleeping Problems __Weight Loss __Weight Gain __ Other __________________
When did the secondary symptoms begin?_____________________
How did this condition develop?____________________________________________
Ever had these symptoms before? _No _Yes If yes, explain:__________________________________
Ever receive treatment for this symptom? _No _Yes If yes, when, where and what were the results?
__________________________________________
Has this secondary symptom been getting: _Better? _Worse? _Staying the same?
What makes your secondary symptom better? __________________________________
What makes your secondary symptom worse? __________________________________
Does anyone in your family have similar secondary symptoms? _No _Yes If yes, who? ______________
Do you have or have you had:
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
Does or did any immediate family member have:
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
_High Blood Pressure _Cancer _Diabetes
_Kidney Problems _Heart Problems _Other:____________
Do you use tobacco? _No _Yes If yes, type and amount per day ____________________________
Do you suffer from alcohol or drug abuse? _No _Yes If yes, explain _________________________
Do you suffer from allergies? _No _Yes If yes, to what? __________________________________
DISCLOSURE & CONSENT to CHIROPRACTIC CARE
You have a right as a patient to be informed about your condition and the recommended
chiropractic adjustments and other chiropractic procedures to be used so that you may make the decision whether or not to undergo the
procedure after knowing the potential risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to
make you better informed so you may give or withhold your consent to the procedure.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of
physical therapy and deep tissue massage, on me (or the patient named below, for whom I am legally responsible) by Dr. David Foster, DC,
CSCS, CCSP and/or other licensed TeamDC.
I have had the opportunity to discuss with the Doctor of Chiropractic named below, the diagnosis, the nature and purpose of chiropractic
adjustments and other procedures and alternatives.
I understand and I am informed that, in the practice of chiropractic there are some risks to exam and treatment including, but not limited to,
fractures, disc injuries, strokes, dislocations, sprains, localized bruising and increased symptoms including pain or no improvement of
symptoms including pain. I do not expect the TeamDC Doctor to be able to anticipate and explain all risks and complications, and I wish to
rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known,
and is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from
the treatment.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions, and all my questions have been
answered fully and satisfactorily. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of
treatment for my present condition and for any future condition(s) for which I seek treatment.
CONSENT TO TREATMENT OF MINOR
I, the undersigned, parent/person having legal custody/legal guardianship of the minor named below, do herby authorize David Foster, DC,
CSCS, CCSP and TeamDC as agent for the undersigned to consent to any examination and chiropractic treatment, which is deemed
advisable by a licensed chiropractor and to be rendered under the general or special supervision of a licensed chiropractor.
It is understood that this authorization is given in advance of any specific examination, diagnosis or treatment being required but is given to
provide authority to the above described agent to give specific consent to any and all such examinations and treatments which a
chiropractor, meeting the requirements of this authorization, may, in the exercise of his/her best judgment deem advisable. These
authorizations shall remain effective until revoked in writing, delivered to the agent noted above.
Questions or concerns may be directed to Dr. David Foster, DC, CSCS, CCSP at 949 752 7752, DrFoster@TeamDC.info or P.O. BOX 50321
Irvine, CA 92619-0321
Patient Signature:_____________________________________________Date:_____________
Parent Signature: _________________________________ Date: ________
Doctor Signature:____________________________________________ Date: _________
 |  |  |  |  |  |  |  |
| Team Chiropractor |
Performance & Sport Specific Therapy