Welcome to Pinnacle Health Services

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Welcome to Pinnacle Health Services Powered By Docstoc
					                                   Welcome to Pinnacle Health Services
We are excited to get to know you today and our hope is that you will find your experience with us a pleasant one. We
all know that completing paperwork is a necessity that is time consuming. However, we have done our best to condense
the information we need on this form, please ask and we will be glad to help you.

Patient Name _________________________________________________________                           Date _____________
Address _________________________________________________________________________________________
City ___________________________________________ St _______ Zip _______________
Sex: Male Female         Date of Birth ________________ Age______ Marital Status ______________
Social Security # ________________________ Email Address: _____________________________________________
Occupation _____________________________________ Employer __________________________________________
Phone Numbers: Home ________________________ Cell ______________________ Work ___________________
Which number would you prefer we use to contact you? ___________________________________________________
In case of emergency who should we call? _______________________________________________________________
Relationship ___________________________ Contact Number _____________________________________________
                                             Your Current Health Information
Please provide us with a brief description of your current situation and why you are here today.
ALLERGIES: Please check and list all allergies you currently may be suffering from.
MEDICATIONS: Please check and list all medications that you are currently taking with the date you began taking them.
                                                                Medication Name                            Start Date
      Blood Pressure Lowering Meds
      Cholesterol Lowering Meds
      Hormone Replacement (HRT)
      Oral Contraceptives
SCARS/SURGICAL PROCEDURES: List all scars and surgical procedures you have had.
SUPPLEMENTS: Do you take Vitamins/Supplements or Herbs? Yes No
If yes, who prescribed them? _________________________________________________________________________
List Supplements: __________________________________________________________________________________
HABITS:                          Heavy                   Moderate                   Light                 None
Soda/Diet Soda
Recreational Drugs
Stress Level
              5-7x/wk             3-5x/wk          1-3x/wk            None                      Type of Exercise
                  8+ hours        7-8 hours       6-7 hours        5-6 hours         < 5 hours
                     5+                4               3                2
Meals / day
                   64+ oz         32-64 oz         16-32 oz           <8 oz
Water / day

Work Activity      Heavy Labor   Light Labor      Mostly Sitting   Mostly Standing   Walking/Moving   Driving

FAMILY HISTORY: Identify any conditions that you, or any of your family members have now or have had in the past:
                          (G = Grandparents, M = Mother, F = Father, S = Siblings, X = Self)
__ Alcoholism                __ Eczema                       __ Miscarriage(s)              __ Ulcer(s)
__ Anemia                    __ Emphysema                    __ Mumps                       __ Other: _____________
__ Cancer                    __ Epilepsy                     __ Pleurisy                       ___________________
__ Cold Sores                __ Goiter                       __ Pneumonia                      ___________________
__ Deep Vein Thrombosis __ Gout                              __ Polio
__ Detached Retina           __ Heart Disease                __ Rheumatic Fever
__ Diabetes                  __ Stroke                       __ Tumor(s)

                                             Turner Release Method™
                                                 John M. Turner, DC
                                             Therapeutic Practitioner
Informed Consent, Private License & Release
       The undersigned hereby grants a Private License to the Practitioner to provide Turner Release Method
education services to undersigned as expressive association activities. I acknowledge that I am not receiving these
services as a patient of Dr. Turner’s chiropractic practice.
        The undersigned acknowledges that the Method does not diagnose or prescribe for chiropractic, medical or
psychological conditions nor claim to prevent, treat, mitigate or cure such conditions. The Practitioner does not
provide diagnosis, care, treatment or rehabilitation of individuals, nor apply medical, mental health or human
development principles, but rather provides a traditional Release Method that may offer therapeutic benefit by
supporting normal structure and function. The undersigned gives Informed Consent to the services that will be
provided. The undersigned hereby releases the Practitioner from all claims and liabilities arising from the use or misuse
of the Turner Release Method, indemnifying and holding the Practitioner harmless from all claims and liabilities there
from whatsoever. The Practitioner reserves all rights.
Date: ______________                               Signature_____________________________________________
                                                   Print Name:___________________________________________

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Description: Welcome to Pinnacle Health Services