PATIENT  PAYMENT  OPTIONS

Family Greatness Chiropractic believes in the value of actively taking control of your health for you and your entire family. We strive to provide the care you need at an affordable rate. To learn more, please call our office at 724-588-3128

jtsn_iconInsurance:

At Family Greatness Chiropractic we realize health insurance is actually crisis insurance and in many cases does not cover true health and instead just very acute cases. We are a cash practice. With the cost of dealing with insurance companies on the rise, we are able to provide the best care at an affordable rate in this manner. We do accept Health Savings Accounts (HSAs).

jtsn_iconNo Insurance:

No insurance, no problem! For patients who have little or no chiropractic insurance coverage, this does not dampen the care you receive. If you have no insurance or do not have chiropractic benefits, don’t worry!  We accept cash, check, and major credit cards as payment. Many patients pay directly for care, as they discover chiropractic to be extremely cost-effective and affordable.

INITIAL HEALTH FORM

PLEASE CHECK ALL ANSWERS AND FILL IN THE BLANKS WHERE APPROPRIATE

NPM Intake Form
Sending

SYSTEMS REVIEW

Name_________________________________________                 Date______________________

Please circle any conditions that are presently causing you a problem and underline those that have caused you problems in the past.

GENERAL SYMPTOMS

  • Fever
  • Sweats
  • Fainting
  • Sleep disturbance
  • Fatigue
  • Nervousness
  • Weight loss
  • Weight gain

RESPIRATORY

  • Chronic cough
  • Spitting up phlegm
  • Spitting up blood
  • Chest pain
  • Wheezing
  • Difficulty breathing
  • Asthma

GENITOURINARY

  • Frequent urination
  • Painful urination
  • Blood in urine
  • Pus in urine
  • Kidney infection
  • Prostate trouble
  • Uncontrollable urine flow

NEUROLOGICAL

  • Visual disturbance
  • Dizziness
  • Fainting
  • Convulsions
  • Numbness
  • Neuralgia (nerve pain)
  • Poor coordination
  • Weakness

CARDIOVASCULAR

  • Rapid beating heart
  • Slow beating heart
  • High blood pressure
  • Low blood pressure
  • Pain over heart
  • Hardening of arteries
  • Swollen ankles
  • Poor circulation
  • Palpations
  • Cold hands or feet
  • Varicose veins

GASTROINTESTINAL

  • Poor appetite
  • Difficult digestion
  • Heartburn
  • Ulcers
  • Nausea
  • Vomiting
  • Constipation
  • Diarrhea
  • Blood in stool
  • Gallbladder/jaundice
  • Colitis

EENT

  • Eye pain
  • Double vision
  • Ringing in ears
  • Deafness
  • Nosebleeds
  • Trouble swallowing
  • Hoarseness
  • Sinus infection
  • Nasal drainage
  • Enlarged glands

MUSCLE & JOINT

  • Neck pain
  • Low back pain
  • Arm pain
  • Shoulder pain
  • Leg pain
  • Knee pain
  • Foot pain
  • Pain/numbness down arms or legs
  • Pain between shoulder blades
  • Swollen joints
  • Spinal curvature
  • Arthritis
  • Fractures

FOR WOMEN ONLY

  • Painful menstruation
  • Hot flashes
  • Irregular cycle
  • Cramps or back pain
  • Vaginal discharge
  • Nipple discharge
  • Lumps in breast
  • Menopausal symptoms
  • Birth control pills
  • Miscarriages
  • Complications with pregnancy
  • Pregnant? Y/N   Week? ___
  • Other:

HEALTH  HISTORY  QUESTIONNAIRE

Name: ________________________________________________________________________

Have you ever been diagnosed or told you have any of the following?

health questionaire
Sending
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20

 

 

CHILD HISTORY FORM

Please complete the following as completely as possible. If you need assistance, please ask the front desk staff and they will be glad to help you.

NPM Child Intake Form
Sending

SYSTEMS REVIEW

Name_________________________________________                 Date______________________

Please circle any conditions that are presently causing you a problem and underline those that have caused you problems in the past.

GENERAL SYMPTOMS

  • Fever
  • Sweats
  • Fainting
  • Sleep disturbance
  • Fatigue
  • Nervousness
  • Weight loss
  • Weight gain

RESPIRATORY

  • Chronic cough
  • Spitting up phlegm
  • Spitting up blood
  • Chest pain
  • Wheezing
  • Difficulty breathing
  • Asthma

GENITOURINARY

  • Frequent urination
  • Painful urination
  • Blood in urine
  • Pus in urine
  • Kidney infection
  • Prostate trouble
  • Uncontrollable urine flow

NEUROLOGICAL

  • Visual disturbance
  • Dizziness
  • Fainting
  • Convulsions
  • Numbness
  • Neuralgia (nerve pain)
  • Poor coordination
  • Weakness

CARDIOVASCULAR

  • Rapid beating heart
  • Slow beating heart
  • High blood pressure
  • Low blood pressure
  • Pain over heart
  • Hardening of arteries
  • Swollen ankles
  • Poor circulation
  • Palpations
  • Cold hands or feet
  • Varicose veins

GASTROINTESTINAL

  • Poor appetite
  • Difficult digestion
  • Heartburn
  • Ulcers
  • Nausea
  • Vomiting
  • Constipation
  • Diarrhea
  • Blood in stool
  • Gallbladder/jaundice
  • Colitis

EENT

  • Eye pain
  • Double vision
  • Ringing in ears
  • Deafness
  • Nosebleeds
  • Trouble swallowing
  • Hoarseness
  • Sinus infection
  • Nasal drainage
  • Enlarged glands

MUSCLE & JOINT

  • Neck pain
  • Low back pain
  • Arm pain
  • Shoulder pain
  • Leg pain
  • Knee pain
  • Foot pain
  • Pain/numbness down arms or legs
  • Pain between shoulder blades
  • Swollen joints
  • Spinal curvature
  • Arthritis
  • Fractures

FOR WOMEN ONLY

  • Painful menstruation
  • Hot flashes
  • Irregular cycle
  • Cramps or back pain
  • Vaginal discharge
  • Nipple discharge
  • Lumps in breast
  • Menopausal symptoms
  • Birth control pills
  • Miscarriages
  • Complications with pregnancy
  • Pregnant? Y/N   Week? ___
  • Other:

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