Step 1 of 4 25% Todays Date* Date Format: MM slash DD slash YYYY Tell Us About Yourself....Name* First Last What Name Should We Call You?* First Date Of Birth (day/month/year)*Age*Please enter a number less than or equal to 99.Height*Under 5'05"05"15'25'35'45'55'65'75'85'95'105'116'06'16'26'36'46'50ver 6'5Weight (lbs)*Under 100101-110111-120121-130131-140141-150151-160161-170171-180181-190191-200201-210211-220221-230231-240241-250251-260261-270271-280281-290291-300301 +Gender*MaleFemaleMarital Status*SingleIn a committed relationshipMarriedDivorcedWidowedContact InformationBest Phone Number To Contact You*Email* Enter Email Confirm Email Preferred Method Of Contact. (We will use this to confirm all appointments)*CallTextEmailHome AddressHome Address (please put your home address here even if this is not where appointments will be)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code About The Location Of Your AppointmentsWill appointments be at your home address listed above?*YesNoWhich of the following best describes this address*Single family homeTownhome/duplexCondo/apartmentWhere will our appointment take place? (please include the address and any pertinent details)*Is parking available within close proximity?*YesNoIf no, please describe where we will need to park.*Will we need to pay for parking?*YesNoIf yes, what are the parking fees?*Will we need to go up stairs?*YesNoPlease describe any special instructions needed for our doctor to get to your location? (parking, gate code, directions, etc...)About Your JobAre you currently working?*Full timePart timeRetiredHome makerStudentCurrently not workingEmployer*Job title/description*Emergency Contact InformationName* First Last Phone*Thank You For Choosing Us!Where did you hear about us?Internet searchYelp searchGoogle searchMet our doctorReferral from patient, health care provider, family or friendHave you been to a chiropractor before?*YesNo Tell Us About Your Symptoms Please describe the symptoms and/or health issues (if any) that you are experiencing. Be as detailed as possible*This is your chance to tell "your story" of the symptoms that you are experiencing. Please explain what your symptoms are, how they started, how they're progressing, what makes them better/worse, etc...Please click the box next to ALL of the symptoms you have been experiencing, whether they're your main complaint or not.* Headaches/Migraines TMJ issues Neck pain/stiffness Upper back pain/stiffness Mid back pain/stiffness Lower back pain/stiffness Problems with Shoulders Problems with Elbows Problems with Hands/Wrists Problems with Hips Problems with Knees Problems with Feet/Ankles Tingling, numbness, weakness and/or pins & needles Pain that radiates to other areas such as down your arm(s) or leg(s) I do not have any symptoms About Your Main ComplaintWhat is your main complaint? This is the symptom that you are most concerned about.*Neck pain/stiffnessUpper/mid back pain/stiffnessLow back pain/stiffnessI do not have a main complaint. My symptoms are mild and generalizedMy main complaint*Just started recentlyIs an ongoing, recurring problemHow long have ago did this problem first start?*Less than a weekLess than a monthLess than a yearLess than 5 years5-10 yearsOver 10 yearsHow did your main complaint start?*Unsure (came out of nowhere)Accident, injury or fallLifting, bending or twistingProlonged static positionHow often do you experience this problem?*Constantly (it never stops)It comes and goes but is present every dayIt's present a few time per weekIt's only present a few times per monthIt's very infrequent (present a few times per year)Regarding your main complaint, IN THE PAST 4 WEEKS how would you rate the severity of the pain ON AVERAGE on a scale of 0-10 with 0 being no pain and 10 being worst pain ever*0-1 Little or no pain2-34-56-78-910 Worst pain everRegarding your main complaint, IN THE PAST 4 WEEKS how would you rate the severity of the pain AT IT'S WORST on a scale of 0-10 with 0 being no pain and 10 being worst pain ever*0-1 Little or no pain2-34-56-78-910 Worst pain everIf there is anything else you would like our doctor to know about your main complaint or other symptoms please explain it here.What treatments, if any, have you tried for this problem? Check all that apply.* Chiropractic Surgery Epidural injections Prescription pain medications Over-the-counter pain medication Laser therapy, electric stimulation, ultrasound, acupuncture, Physical therapy Other I have not tried any treatments for this problem What imaging studies, if any, have you had for this problem? Check all that apply.* X-ray MRI CT scan Ultrasound Other None Tell Us About Your Medical HistoryHow would you rate your current level of health?*ExcellentGoodFairPoorOther than the symptoms you listed on the previous page, please describe any other health issues we should be aware ofHave you recently had an accident or injury? (within last 3 months)*YesNoIf yes, please describe in detail*Have you had ANY surgeries within the last 6 months? (including cosmetic, eye or dental)*YesNoIf yes, please list them with dates if possible*Do you have cancer?*YesNoIf yes, please describe type(s) and any treatments you have had*Are you currently pregnant or post-partum?*YesNoIf yes, how far along are you? Or how long ago did you give birth?*Do you have any contageous skin conditions?*YesNoIf yes, please explain type and location*Do you have any spinal defects that you are aware of?* Spinal tumor Acute or unstable fracture Spondylolesthesis Spinal stenosis Severe osteoporosis Severe or progressive scoliosis Spinal infection Inflammatory arthritis Other None Please expain:*Do you have, or have you had, any cardiovascular issues?* Heart disease Stroke High blood pressue Low blood pressure Shortness of breath with mild exertion Chest pain (Angina) Arteriosclerosis Aneurysm Other None Please explain*Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*YesNoDo you feel pain in your chest when you perform physical activity?*YesNoDo you lose your balance because of dizziness or do you ever lose consciousness?*YesNoDo you have a bone or joint problem that could be made worse by a change in your physical activity?*YesNoIs your doctor currently prescribing any medication for your blood pressure or for a heart condition?*YesNoDo you know of any other reason why you should not engage in physical activity?*YesNoIf yes, please explain.*Do you have any of the following conditions?* Abnormalities in bowl or bladder function (hesitency, incontinence, retention...) AIDS Alcoholism Allergies Anxiety Asthma Diabetes Depression Dizziness Epilepsy Excessive bruising Fatigue Glaucoma Goiter None Do you have any of the following conditions (cont')* Gout Hepatits HIV positive Lyme disease Multiple sclerosis Polio Rheumatic fever Scarlet fever Sudden weight loss/gain Swollen glands Tuberculosis Ulcer General weakness None Are you taking any prescription medications?*YesNoPlease list you prescription medications. Please list ONE medication per line. Click the "+" to add a medication*Name of medicationReason for taking Family Health HistoryFamily Health History*Some health problems are hereditary. Please describe any health issues your parents or siblings are experiencing (or have experienced). General PoliciesLocations we service: Although we service most of Indiana, when and where we schedule appointments is completely up to the discretion of Dr. Kroft. Appointment verification: We verify every appointment by text message unless an alternative contact method is requested. If we do not receive a response prior to your appointment, we will consider the appointment canceled and a cancellation fee of $50.00 will be charged. Be prepared and on time: We will be prepared and on time for your appointment and ask the same of you. You have a dedicated time slot for your appointment that starts at your scheduled appointment time and ends 30 minutes from that time regardless of when treatment commences. We ask that you wear comfortable, relaxed-fitting clothes during your appointment. Canceled or missed appointments: Please give 24 hr or "day before" notice for an appointment that needs to be canceled or rescheduled. If appropriate notice is not given, you will be charged a $50.00 cancellation fee. Right of refusal: We reserve the right to refuse service to anyone at any time for any reason.Financial PoliciesFees: Our fees are located on the home page of our website and are stated as $80 per individual, per initial visit. By clicking "I agree" at the end of this form, you are agreeing to the fees as listed. Payment methods: All payments are due prior to, or at the time of your appointment. Payments can be made by cash, local check or credit card. Checks not honored by your bank will be subject to an additional $30 fee. Health insurance: We do not accept health insurance and do not assist with any attempt at reimbursement for our services. Refunds: Completed appointments are not refundable. Receipts: Receipts are available by email when requested. Additional fees: Additional fees may apply for appointments outside of our normal service area or normal hours. However, we are 100% transparent with our fees and you will never be charged an additional fee without discussing and agreeing to these fees with Dr. Kroft. Privacy PoliciesOur privacy policies can be found on here our website. You can also request a copy of privacy policies which will be send by email only. Also see our Practice Policies. Informed Consent For TreatmentCongratulations on choosing one of the safest and most natural healthcare programs available! Please read the following statement carefully as it pertains to your informed consent to be treated. "I hereby acknowledge that all information submitted pertaining to my case is true and correct to the best of my knowledge. I understand that I am responsible for full payment of all services rendered by Kroft Chiropractic, LLC. I have read and understand the preceding statements and hereby consent to myself or those I claim as dependent voluntarily participating in chiropractic care and/or physiotherapeutic rehabilitation procedures as deemed appropriate by my doctor. If at any time I decide that I am unwilling to engage in these procedures, I reserve the right to inform my doctor of such and not participate in these forms of evaluation and treatment. I understand that results are not guaranteed and that I have the opportunity to discuss the purposes and risks associated with all recommended evaluation and treatment procedures at any time."By clicking "I agree" below you are acknowledging that all of the information in this form was completed accurately and honestly and that you have read and agree to our "Policies" and "Informed Consent For Treatment":*I agreeI do not agreeBy typing in your complete full name below, this will serve as your electronic signature. 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