1522 State Street unit A, Santa Barbarba, CA

Past Health History

The majority of our patients have been involved in dozens of impacts that could cause
vertebral subluxations

1. When was your most recent Auto, Motorcycle, or Bicycle Accident, even as a passenger?

2. When was the accident before that?

Most people have a slip, strain, twist or fall playing sports, at home or at work, whether it was reported or not

1. When was your most recent injury?

2. When was your most recent injury before that?

3. When was your most recent injury before that?

Please list any surgeries, traumas, fractures, etc. that have not been mentioned above

Work Activity

Habits

Medications & Supplements

What percentage of your food is:

What percentage is

What percentage is:

Family History:

Current Health Condition

Terms of Acceptance & Informed Consent to Chiropractic Care

Please discuss any questions or concerns with the doctor before signing this consent

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment.

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

Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

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

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. Nor do we offer advice
regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. 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.

The Nature of the Chiropractic Adjustment

The doctor will use their hands or a mechanical device upon your body in such a way as to move your joints. That may cause an audible “pop” or “click”, much as you have experienced when you “pop” your knuckles. You may feel a sense of movement.

The Material Risks Inherent with the Chiropractic Adjustment

As with any health care procedure, there are certain complications which may arise during a chiropractic adjustment. Those complications include, but are not limited to: fractures, disc injuries, dislocations, muscle strains, and stroke. Some patients will feel some stiffness and soreness following the first few days of treatment.

The Probability of Those Risks Occurring

Fractures are very rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during the examination. Stroke has been the subject of disagreement within and without the profession with one prominent authority saying that there is at most a one-in-a-million chance of such an outcome. Since even that risk should be avoided, we look for risk factors and will perform tests to identify if you may be susceptible to that kind of injury if necessary. The other complications are also generally described as “rare”.

Ancillary Treatment

In addition to chiropractic adjustments, you may be given home instructions to use the following treatments, with the
associated risks:

• Heat ~ risk of 1st and 2nd degree burns, hemorrhage
• Cryotherapy (cold packs) ~ risk of skin reactions
• Trigger Point Therapy ~ risk of bruising, release of emboli
• Massage ~ risk of deep vein thrombosis

The Availability and Nature of Other Treatment Options

Other treatment options for your condition may include:

• Self-administered over-the-counter analgesics and rest
• Medical care with prescription drugs
• Hospitalization
• Surgery

The Material Risks Inherent In Such Options And The Probability Of Such Risks Occurring Include:

Overuse of over-the-counter medications produces undesirable side effects. If complete rest in impractical, premature return to work and household chores may the condition and extend the recovery time. The probability of such complications arising is dependent upon the patient’s general health, severity of the patient’s discomfort, his/her pain tolerance, and self-discipline is not abusing the medicine. Professional literature describes highly undesirable effects from long term use of over-the-counter medicines.

Prescription muscle relaxants and pain killers can produce undesirable effects and patient dependence. The risk of such
complications arising is dependent upon the patient’s general health, severity of the patient’s discomfort; his/her pain
tolerance, self-discipline in not abusing the medicine, and proper professional supervision.

Hospitalization in conjunction with other care bears the additional risks of exposure to communicable disease, iatrogenic(doctor induced) mishap, and expense. The probability of iatrogenic mishap is remote, expense is certain; exposure to communicable disease is likely with adverse result from such exposure dependent upon unknown variables.

The risks inherent in surgery include adverse reaction to anesthesia, iatrogenic mishap, all those of hospitalization, and an extended convalescent period. The probability of those risks occurring varies according to many factors.

The Risks and Dangers Attendant to Remaining Untreated

Remaining untreated allows the formation of adhesions and reduces mobility which sets up a pain reaction further reducing mobility. Over time this process may complicate treatment, making it more difficult and less effective the longer it is postponed. The probability that non-treatment will complicate a later rehabilitation is very high.

I have read the above explanation of the chiropractic adjustment and related treatment. I have discussed it with my doctor and have had all my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest (or said minor’s interest) to undergo the treatment recommended. I acknowledge that no guarantee or assurance as to the results that may be obtained from this treatment has been given.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physiotherapy and diagnostic x-rays, on me (or the below named minor in which I am legally responsible for) by Dr Jacob Martin, his staff, and/or associates.

Patient Acknowledgement of Privacy

I acknowledge that I have read and fully understand the Notice of Privacy Practices of Inner Strength Chiropractic. I
understand that I may request a copy of this notice at any time. I further understand that this Notice may be modified with no prior notification to me.

Office Fees and Financial Policy

We offer additional discounts for choosing health crisis care, correction & stabilization care, or lifestyle care, based on your individual health needs.

Financial Policy

We are committed to guiding you to heal your mind, body, spirit, & planet. You will be expected to pay for your chiropractic care at the time the service is rendered unless you make other arrangements in advance. These arrangements are designed to be the most cost effective way to keep you and your family as healthy as possible, and will be discussed with you on your second visit.

If a special situation arises, such as an auto accident or a worker’s compensation injury, a new examination will need to be performed and you will be charged our regular fees until the claim is settled. We will help you get reimbursed as quickly as possible on these claims.