Life storyYour first visit Step 1 of 4 - General information 25% Name* First Last What do you prefer to be called?Gender*- select -MaleFemaleMailing address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employer*Type of work*Marital status*- Select -MarriedDomestic PartnerSingleWidowedDivorcedNumber of children*Name of spouse or partner* First Last Save and Continue Later How did you hear about us?*Reason for seeking services with us today*What is your level of commitment to your health and wellbeing?*HighMediumLowAny previous trauma to your body or spine? Any previous surgeries? Any health related concerns/challenges?*List any recreational drugs, over the counter drugs, or prescription medication?*List any supplements or vitamins*How does your condition interfere with work? Sleep? Your daily routine or activities?*Have you experienced Chiropractic before?*NoYesWhen was your last Chiropractic adjustment?*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Save and Continue Later Please describe your diet / nutrition / eating habits*What are your exercise habits? (What kind and how often)?*What is your daily water intake?*Family relationships (i.e. good, stressful, none...)*What's your satisfaction with work?*12345678910What are your rest/relaxation activities?*List the stresses in your life*Grade your physical health*Getting worseGetting betterFairGoodExcellentGrade your mental / emotional health*Getting worseGetting betterFairGoodExcellentDo you feel connected to your spiritual self?*NoYesIf so, what does that mean for you?*What brings you Joy? Inspires You? Makes you feel better about yourself?*Any unhealthy habits?*Do you feel it is necessary to make changes to your current lifestyle?*For women:*YesNoAre you pregnant?Are you nursing?Are you taking birth control?Do you experience painful periods?Do you have irregular cycles?Do you have breast implants?Health conditionsPlease check each of the diseases or conditions your body is expressing or has expressed in the past. While they may seem unrelated to the purpose of this visit, they can affect the overall assessment and care plan Severe or Frequent Headaches Sinus Problems Dizziness Loss of Sleep Pain Between the Shoulders Frequent Neck Pain Numbness/Pain in Arms/Hands Numbness/Pain in Legs/Feet Lower Back Problems Digestive Problems Ulcers/Colitis Heart Attack/Stroke Congenital Heart Defect Heart Surgery/Pacemaker Heart Murmur High/Low Blood Pressure Difficulty Breathing Asthma Arthritis Alcohol/Drug Abuse Venereal Disease HIV/AIDS Diabetes Tuberculosis Shingles Kidney Problems Hepatitis Cancer Chemotherapy Anemia Rheumatic Fever Psychiatric Issues Thyroid Issues Save and Continue Later Authorization For Care* I hereby authorize the Chiropractor and/or Massage Therapist to work with me. I clearly understand and agree that all services rendered are charged directly to me and that I am responsible for payment. The Chiropractor and/or Massage Therapist will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. For Chiropractic Urban Hippie Chiropractic exists to make a positive contribution in the lives of people by assisting them in expressing and experiencing more light in their lives. This light is the essence of what sustains us from the moment of conception until our last breath. The same light creates, recreates, adapts, and allows for wellbeing and healing within us all. The nerve system is the medium used for the transfer of vital information essential for all human works – from body functions to emotions, creativity, performance, and spiritual expression. The nerve system consists of the brain, the spinal cord, the nerves, and the infinite array of neurotransmitters. The extensiveness of the nerve system is such that it is impossible to determine where the brain ends and where the body begins. It is our link between the inner and outer world. By far, it is the most efficient, specialized, sophisticated, complex, and delicate biological information highway known to humanity. A free flow in communication enhances our ability to express, develop, and experience life fully. Wellbeing, increased performance, and greater personal expression are the natural byproducts. Chiropractic adjustments free up life force in the body, allowing every individual, whether a newborn, an athlete, or a grandparent, to enjoy more life. This deepens everyone’s potential to heal biologically and at the core, from above-down-inside-out. In some of our practice members, physical, emotional, or mental challenges may resolve quickly, and in others, the process may be slower. Please keep in mind that within you is a source of perfection and infinite potential. Regular Chiropractic care keeps you connected to your source and promotes health while enhancing your quality of life. Chiropractic is not a substitute, an alternative, or a preventative form of medicine. Chiropractic specializes in the expression of life, wellness, and healing. Whereas medicine specializes in the diagnoses and treatment of symptoms, sickness, and disease. It is not Urban Hippie Chiropractic’s goal or intention to diagnose, treat or attempt to cure any physical, mental, emotional ailment, or to give advice about medical conditions. If at any time you become concerned about symptoms or conditions, we suggest you seek the help of a symptom, sickness, and disease care professional. Our primary goal is for you to be the best version of you! For Massage The care of the body through massage is a joint effort between client and therapist. Each time we work together it is my goal to meet your body’s current needs. In order to accomplish this I depend on you to communicate clearly and truthfully before, during and after massage. For best results please Abstain from alcohol at least 8 hours prior to massage Hydrate with 8-16 ounces of water within hour before massage and again after massage Place phone on silent upon entering the massage room Be present and communicate your needs as they arise during the massage Relax and Enjoy! Massage supports health through improved circulation of blood and lymph fluids as well as relaxation of muscles & myofascial tissues. Massage is not a substitute, an alternative or a preventative form of medicine. Philosophical agreement* I have completely read and understood the above statement and choose to be served at Urban Hippie Chiropractic in agreement with the above scope of practice. EmailThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.