Michael C. O'Dell, DC
1140 Main StSuite 205
Suite 205
Ramona, CA 92065
760-315-6123

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Child Information


Personal Information
Contact Information
 

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)

   

Health Concerns


Concern #1 Rate of severity
1 = mild
10 = worst imaginable
When did it start?
For how long?
If you had this condition before, when? Did the problem begin with an injury? What % of the time pain is present?

Concern #2 Rate of severity
1 = mild
10 = worst imaginable
When did it start?
For how long?
If you had this condition before, when? Did the problem begin with an injury? What % of the time pain is present?

Concern #3 Rate of severity
1 = mild
10 = worst imaginable
When did it start?
For how long?
If you had this condition before, when? Did the problem begin with an injury? What % of the time pain is present?

Concern #4 Rate of severity
1 = mild
10 = worst imaginable
When did it start?
For how long?
If you had this condition before, when? Did the problem begin with an injury? What % of the time pain is present?

Pregnancy and Birth History


Trauma/Falls during pregnancy
Any ultrasounds or other radiation?
How many and for what reasons?
Invasive Procedures (Eg. Amniocentesis, CVS)?
During the pregnancy did the mother:
Smoke? How much?
Drink Alcohol? How much?
Prescription Medications? How much?
Recreational Drugs? How much?
Fall ill during pregnancy? Please explain










Childhood History



Type When? Doctor

Type When? Hospitalized?


Does your child play sports?
If yes, hours per week?





Coffee
Soft Drink
Fried Foods
Eggs
Fruit
Beef
Poultry
Organic Foods
Fasting
Diet Food
Refined Sugar
Fish
Seafood
Artificial Sweetener
Weight Control Diet
Raw Vegetables
Whole Grains
Dairy
Cooked vegetables
Canned/Frozen vegetables




Name Dosage For what?
Name Dosage For what?
Name Dosage For what?

Name For what?
Name For what?

Did mother have any difficulties with breast-feeding?
Did mother and baby have difficulty bonding?
Did mother experience any post-partum depression?

Number of hours

From what age?


Respond to sound? Sit alone?
Follow an object? Teethe?
Hold head up? Crawl?
Vocalize? Walk?



Authorization

Informed Consent to Chiropractic Care

When a person seeks chiropractic care, it is essential for both the individual and the chiropractor to be working towards the same objective.

Chiropractic care has one goal, to correct vertebral subluxations. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of the nerve function and interference to the transmission of mental impulses, resulting in a decrease in the body’s innate ability to express its maximum health potential.

Adjustment: An adjustment is a specific application of forces to facilitate the body’s correction of a vertebral subluxation. Our method of correction is by specific adjustments of the neurospinal system.

Health: A state of optimal physical, mental, and social wellbeing, not merely the absence of symptoms.

I understand that my care at this office will be focused on the detection and correction of vertebral subluxations. I hereby request and consent to the performance of chiropractic adjustments and assessments. Understanding that every body has a different potential for wellness thus, the maximal results I will receive in this office cannot be predicted or guaranteed.

Chiropractic care is considered to be one of the safest and most effective forms of care. I understand and am informed that, unlike many other health care professions, the risks associated in receiving chiropractic care are extremely minimal. In recent years there have been rare incidents of injury to the vertebral artery during the course of care by medical doctors, physiotherapists and chiropractors. To put this in perspective, the risk of stroke in the general population is 0.00057%. The risk of stroke after a chiropractic adjustment is 0.00025%. The risk of death from taking an aspirin and/or other anti-inflammatory drugs is 0.04%.

It is not our goal or intention to diagnose, treat or attempt to cure any physical, mental, emotional symptoms. Our expertise is in health, wellness, healing and human physiology. However, if during the course of chiropractic care, we encounter unusual findings, we will bring these to your attention. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Please discuss care alternatives with attending chiropractor.

Our primary goal is to release life in the body, through the detection and correction of vertebral subluxations.

At this office, the privacy of your personal information is an essential part of our office providing you with quality care. We are committed to collecting, using and disclosing your personal information responsibly. Our office has a privacy policy that complies with federal law, which you may view at any time by asking our staff.

I have also had an opportunity to ask questions about its content. I therefore accept chiropractic assessments and care on this basis. I intend this consent form to cover the entire course of my care in this office with my chiropractor.

Name of the Insured:
(Please Print)
_____________________________________________    
Patient's/Guardian's signature:
_____________________________________________
Date:
__________

Signature


Finalizing Form


  1. Submit Form!