Contact Us - Dr. Todd M. Wulf

	Physical Therapy
	Chiropractic
	Spinal Decompression

	How It Works?
	Proof It Works?
	Thinking About Back Surgery?

	Whiplash & Auto Injury
	Treatment Offered

	Headache Relief Center
	Back Pain Relief Center
	Fibromyalgia Relief Center
	Neck Pain Relief Center
	Whiplash Relief Center
	Spinal Decompression Ctr.

	HIPAA Information & Consent Form
	Patient Application Form
	Records Release Consent Form

My husband (the skeptic) has noticed a change in me since I’ve begun my care here. He says I have more energy and have a more positive disposition. I have always known that the spine has so much to do with our overall well-being and this is proof to me that chiropractic care works.

Kendra B.

PATIENT APPLICATION FORM

Welcome to our clinic. We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. This allows our patients to achieve far superior results compared to most other systems.

Please fill out the following information thoroughly so the doctor can let you know if you are a case we can accept. Please feel free to ask any questions if you need assistance. We look forward to serving you.

Primary Care Physician/Family Doctor
Date
Name
Address
Phone
Fax

PATIENT APPLICATION SURVEY
Name
Age
M/F
Address
City
State
Zip
Home Phone
Cell Phone
Email
Social Security#
Drivers License#
Birthdate
Marital Status
# of Children
Names of Children
Ages
How were you referred to this office?
Employer
Type of Work
Work address
Work Phone
Spouse Name
Spouse ages
Spouse Employer
Spouse Type of Work
Spouse Work Phone
Spouse Cell Phone

PURPOSE OF THIS VISIT
Current complaints

Is the purpose related to an auto accident? Yes No
Work Injury Yes No
Describe

When did this condition begin/when did you first notice it?

What aggravates your symptoms?

Describe

Is there anything that relieves your symptoms? Yes No
Describe

Have you experienced this condition before? Yes No
Who have you seen for this?

What did they do?

How did you respond?

EXPERIENCE WITH CHIROPRACTIC OR PHYSICAL THERAPY
Have you seen a chiropractor or physical therapist before?
Yes No
Who?

When?

Reason for visits?

How did you respond?

Did you know your posture determines your health?
Yes No
Are you aware of any of your poor postural habits?
Yes No
Explain?
Are you aware of any poor postural habits in your spouse?
Yes No
Explain?
Do you notice poor posture in your children?
Yes No
Explain?
The most common postural weakness is Forward Head Syndrome (head and neck starting to bend forward and progressively moving downward weakening your entire body). Even less severe forms of this posture can cause many adverse affects on your overall health. Have you ever been told or feel like you carry your head forward?
Yes No

HEALTH LIFESTYLE
Do you exercise?
Yes No	How often?
What activities?
Do you smoke?
Yes No	How much?
Do you drink alcohol?
Yes No	How much/week?
Do you drink coffee?
Yes No	How much/cups/day?
Other caffeinated beverages?
Yes No	How much/cups/day?
Do you take supplements (i.e. vitamins, minerals, herbs)?

HEALTH CONDITIONS
Abnormal postural habits or distortions are the result of trauma or stress to the body that have misaligned the vertebrae in your spine. When these vertebrae are twisted from their normal position, they will cause stress to the spinal cord and other delicate nerves that pass between the vertebrae. These misalignments are called Subluxations (sub-lux-a-shuns). It has been extensively documented that subluxations, causing stress to your nerves, will weaken and distort the overall structure of your spine. This results in a weakened and distorted POSTURE. Postural distortions have many serious and adverse affects on your overall health. The most common and detrimental postural distortion is called Forward Head Syndrome (a “hunched forward” posture starting in the neck and progressively moving down your spine weakening the entire body). Please check any health conditions you may be experiencing, now or in the past.
CERVICAL SPINE (NECK):
	Neck Pain	Headaches	Sinusitis
	Pain in your shoulders/arms/hands	Dizziness	Allergies/Hay/Fever
	Numbness/tingling in arms/hands	Visual Disturbances	Recurrent colds/Flus
	Hearing disturbances	Coldness in hands	Low energy/Fatigue
	Weakness in grip	Tryroid conditions	TMJ/Pain/Clicking in jaws

THORACIC SPINE (UPPER BACK):
Postural distortions from subluxations, resulting from Forward Head Syndrome), in the upper back will weaken the nerves to your heart and lungs and affect these parts of your body. Do you experience…?
	Heart palpitations	Recurrent lung infections/bronchitis	Heart murmurs
	Asthma/wheezing	Tachycardia	Shortness of breath
	Heart attack/Angina	Pain on deep inspiration/expiration (breating)

THORACIC SPINE (MID BACK):
Postural distortions from subluxations, resulting from Forward Head Syndrome), in the mid back will weaken the nerves into your ribs/chest and upper digestive tract, and affect these parts of your body. Do you experience…?
	Mid back pain	Hypoglycemia	Reflux
	Pain in your ribs/chest	Tire/irritable after eating or when you haven't eaten for a while	Nausea
	Indigestion/Heart Burn	Ulcers/Gastritis

LUMBAR SPINE (LOW BACK):
Postural distortions from subluxations, resulting from Forward Head Syndrome), in the low back will weaken the nerves into legs, feet and pelvic organs and affect these parts of your body. Do you experience…?
	Low Back Pain	Muscle Cramps in your legs/feet	Constipation/Diarrhea
	Pain into your hips/legs/feet	Weakness/injuries in your hips/knees/ankles	Menstrual irregularities/cramping (females)
	Numbness/tingling in your legs/feet	Recurrent bladder infections	Sexual dysfunction
	Coldness in your legs/feet	Frequent/difficulty urination
Please list any health conditions not mentioned above

Please list any medications or surgeries

Please list any traumas (falls, car accidents, sports, etc.)

AUTHORIZATION OF CARE

I authorize and agree to allow the doctor to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration of normal biomechanical and neurological function.

I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges.

The Doctor will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions diagnosed at this clinic.

I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from these programs, and that if I terminate my care prematurely that all fees will be due and payable at that time.

I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered.

IN CASE OF EMERGENCY CALL:
Name
Relationship
Work Phone
Cell Phone
Home Phone

INSURANCE INFORMATION
I clearly understand that all insurance coverage, whether accident, work related, or general coverage is an arrangement between my insurance carrier and myself. If this office chooses to bill any insurance carrier that they are performing these services strictly as a convenience for me. The Doctors office will provide any necessary reports or required information to aid in the insurance re imbursement of services, but I understand that insurance carriers may deny my claims and that I am ultimately held responsible for any unpaid balances. Any monies received will be credited to my account.
Name of Insurance Co.
Policy#
Address
Phone#
Insured's Name
Insured's SS#
Relationship to Insured
Birthdate
Employer
Phone#
WHO SHOULD RECEIVE CHARGES ON YOUR ACCOUNT?
Patient Spouse Parent/Guardian Workers Comp Medicare Personal Insurance Attorney Auto Insurance

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