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Comprehensive
Life & Health Profile
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Congratulations
on taking your next step on your journey towards vibrant health!
Please complete
this Comprehensive Life and health profile thoroughly, as it will give us an
opportunity to get to know you better and understand your needs before you
arrive at Living Inline.
If you have not
already done so, please take a moment to read the page on our Living Inline
Balancing
sessions
as well as our
Coaching
Programs
so that you are familiar with how you will benefit from this care.
Thank you kindly
and we look forward to meeting you!
Dr. Jason Kolber
and Dr. Elissa Katz
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First Name:
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Last Name:
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Address:
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Email Address:
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Today's Date:
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Home Phone:
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Work Phone:
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Mobile Phone:
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Date of Birth:
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Do you have any children?
Yes
No
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If Yes, Names & Ages:
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Profession:
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How did you discover our office and the professional
services we offer?
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What do you know about how we serve the public?
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Please complete this general health history,
as it will provide us as your doctors’ with important information to better
understand your history, your present and longer term needs, and any compromise
to your health, wellness, and overall quality of life that you may be
experiencing now, or may have experienced in the past.
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PART
1: Your Involvement in your
Health, and any Health Concerns that you may have, and how they may affect
your life:
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1.
On a scale of 1-10, how involved in your health are you, and how
motivated are you to reach an optimal level of health? (1 meaning not very
involved and not motivated, 10 meaning extremely involved and extremely
motivated) or possibly anything else that you may want to share:
1
2
3
4
5
6
7
8
9
10
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Additional comments:
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2.
What is your personal definition of health?
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3.
When you are at your best, why do you feel that way and what is generally
occurring in your life at that time?
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4.
Please list the five most health enhancing things that you do for
yourself and your life:
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(1)
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(2)
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(3)
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(4)
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(5)
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5.
Please list the five things that you feel detract from your ideal health (if
applicable):
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(1)
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(2)
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(3)
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(4)
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(5)
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6.
So that we may best serve you, please tell us a little bit about what is going
on in your life right now ( i.e. are you a full time student, working
full-time, recently married, going through a stressful time personally,
professionally, recently started a new hobby etc...
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7.
Who do you consider to be your support system (i.e.. loving partner,
best friend, spiritual services, coworkers, family, etc.É)?
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8.
In your own words, can you please share with us what gives you the
greatest amount of energy in your life right now?
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9.
Conversely, what absolutely drains you, zaps you and takes away from you
being at your best?
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10.
If applicable, do you currently have any health concerns, or have you
had any health concerns in the past?
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(a)
When did this situation begin?
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(b)
Have you ever experienced this health challenge previously?
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(c)
If applicable, please grade the level to which this health concern(s) has on
your overall quality of life and health.
Please use the following scale of 1-4; 1 being only a
mild affect, and 4 having a significant effect:
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Affect on Work
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None 1
2 3
4
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Affect on Exercise
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None 1
2 3
4
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Affect on Social Life
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None 1
2 3
4
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Affect on Recreation/Play
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None 1
2 3
4
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Affect on Walking
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None 1
2 3
4
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Affect on Eating
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None 1
2 3
4
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Affect on Rest/Sleep
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None 1
2 3
4
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Affect on Sitting
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None 1
2 3
4
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Affect on Love Life
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None 1
2 3
4
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Affect on Overall Concern about
Health
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None 1
2 3
4
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Awareness of Concern During the
Day
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None 1
2 3
4
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Awareness of Concern During the
Night
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None 1
2 3
4
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(d)
Is there any time of the day, or when you are involved in any specific
activity, in which you totally forget about your health challenge or symptom?
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(e)
Have any of your other family members ever had a similar health concern?
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(f)Why do you
think this has happened or continues to happen?
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(g)Do you think
this is the sole cause?
Yes No
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(h)If No, What
else may be involved?
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(i)What are you
doing in your life that is different now than if you did not have this
condition/health concern?
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11.
Of these few statements, which best describes how you feel about
yourself and your current situation? Please check one.
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I feel helpless like little or nothing works.
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This is terrible, really bad, and you hope that we can fix it for you.
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I feel stuck, and I can’t help myself right now.
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I deserve more than what I am experiencing and I would like assistance in my
healing.
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Other:
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PART
2:Health / Trauma / Medical / Healing
History:
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1.
Have you ever injured your spine (Head, Neck, Back, Hips)?
Yes
No
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(a)
Date of most significant injury:
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(b)
What happened?
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(c)
Date of most recent injury:
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(d)
What happened?
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2.
Please list any medications that you are currently taking, or may have possibly
taken over this past year, and please state the reason for taking them:
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3.
In the past, have you ever taken medication for a period of three months or
longer? Yes
No
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(a)
If Yes, What was the reason for taking this medication?
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4.
Do you regularly utilize aspirin, Advil, Tylenol, sleeping pills, Motrin, etc.?
Yes
No
(a)
If Yes, please state the reason for taking this medication:
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5.
Have you had any x-rays, Cat Scans, or MRI Images taken of your spine
(Head, Neck, Back, or Hips)?
Yes No
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(a)
If yes, please specify:
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(b)
What were you told about these films/x-rays?
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(c)
Where are these x-rays now?
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6.
Do you have all of your body parts?
Yes No
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7.
Have you ever had any surgeries?
Yes No
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8.
Please list any bones that you have broken or any part of your body that you
have severely strained/ sprained:
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9.
Please list any nutritional supplements/ Vitamins/ herbs that you take
regularly:
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10.
Have you consulted with a physician or any other health care provider in the
past three months?
Yes No
If yes, please state why:
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11.
Has you spine ever been professionally addressed by a chiropractor or
other practitioner?
Yes No
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(a)
If Yes, By Whom and When?
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(b) Why
did you go?
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(c)
Are you still going?
Yes No
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12.
Does your family receive chiropractic care?
Yes No
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(a) If so,
why do they go?
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13.
Do you consult with a physician for other than routine evaluations?
Yes
No
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(a)
If Yes, What is the reason for those visits?
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(b)
When was your last visit and who did you see?
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(c)
What was done or suggested?
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14.
Have you had any experience with the following health, treatment or healing
modalities? (Please check all that apply and describe why you went and the
results you experienced):
Massage/Bodywork:
Emotional
Therapy/Psychotherapy:
Occupational
Therapy/ Physiotherapy:
Homeopathy/
Herbalist:
Acupuncture:
Nutritional
Counseling:
Breathwork:
Yoga/Tai
Chi/Chi Gong:
12 Stages
of Healing:
Other:
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15.
Do you have an exercise program?
Yes No
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(a)
If Yes, please describe:
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16.
Do you have a meditation/ Prayer program?
Yes No
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(a)
If Yes, please describe:
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17.
Do you have a nutritional program?
Yes No
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(a)
If Yes, please describe:
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18.
When you are stressed, how do you "center yourself" or "regroup"?
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19.
When you are well, why do you feel well?
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20.
When you are not well, why are you not well?
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PART 3: The Stress
Survey
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Please rate each category from one to five,
one being the lowest and five the highest. Also, please check
all experiences that may apply.
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1. Cumulative Physical Stress /
Trauma:
1 2
3 4
5
(Check those that apply):
Falls
Accident
injuries
Repeated
postural stress
Impacts
A difficult
birth
Traction
Physical
abuse
Ackward
work hours
Driving
stress
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2. Cumulative Emotional / Mental
Stress:
1 2
3 4
5
(Check those that apply):
Loss of
loved ones
Rapid
change in life situation
Mental
Emotional
Sexual
abuse
Legal
concerns
Financial
concerns
Move of
home/school
Separation
Divorce
Relationship
stress
Stress of
being ill
Single
parent
Commuting
stress
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3. Cumulative Chemical Stress:
1 2
3 4
5
(Check those that apply):
Exposure to smoke
Fumes
Chemicals
at work
Food
additives
Cigarette
smoke
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4.
Have you ever been injured at work or had a vehicular related injury?
Yes
No
(a)
If Yes, please explain:
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5.
We are very grateful to announce that The Medical School at
The University of California-Irvine just completed a thorough study
of 2,818 patients receiving Network Care, the hands on care
provided at Living Inline. These patients reported an overall
improvement in all of the categories of health and wellness listed
below. How do you hope to benefit from care in the office?
Please use the following scale provided:
1 Not Very important to me
2 Slightly important to
me
3 Important to me
4
Extremely important to
me
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(a)
Improvement of my physical
symptoms:
1
2 3
4
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(b)
Improvement of my emotional/mental
well-being:
1
2 3
4
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(c)
Improvement of my ability to react to
or respond to stress:
1
2 3
4
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(d)
Improvement of my enjoyment in life, and my ability to make constructive
choices:
1
2 3
4
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(e)
Improvement in my overall quality of life:
1
2 3
4
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6.
Is there some aspect of your life that very much pleases you or brings
you joy, and helps you feel better about yourself?
Yes No
(a)
Please explain:
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7.
Are there any particular factors or elements about your life that you feel hold
you back, restrain you, or impair your opportunity for reaching full glowing
health? ( Ex: family, past experiences, genetics, thought patterns, work life,
past injuries) Yes
No
(a)
Please explain:
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8.
Are there any particular factors or elements about your life that you feel give
you an added edge, or that you feel that this may add to your health and well
being? ( EX: family, past experiences, genetics, upbringing, thought patterns,
work life, exercises, health program)
Yes
No
(a)
Please explain:
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9.
When communicating to you about how your health is changing,
how your spine is changing, how your nervous system is changing,
How would you best like for us to communicate with you?
Please check one:
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Visually:
i.e. Show you pictures, graphs, put in writing how you are improving?
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Auditory:
i.e. Mostly speak with you about the clinical changes you are making, and let
you hear about your progress?
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Kinesthetic:
i.e. Mostly let you get a sense of the difference you are feeling in your body?
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10.
Is there anything else which may help us better understand you?
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11.
What would motivate you to tell others about the care that you are receiving in
this office, and encourage others to get care?
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DEAR FRIEND,
Please Read and Fill in the blank before you hit send.
We look forward to meeting you in person!
Dr. Jason and Dr. Elissa
Our Purpose: A Statement of Clinical
Objectives
Our purpose in sharing this
statement of clinical objectives is to clearly define our approach to
Chiropractic, healing and those we serve in this office. We wish to clearly
communicate our responsibilities in this exciting relationship.
The following concepts are
central to the way in which we practice Chiropractic. We are pleased to share
these ideas with you so our purpose can be in alignment from the very
beginning.
There is intelligence within each
individual that not only keeps that person alive, but also coordinates,
repairs, renews and heals every cell of the body.
The nervous system is the main
distribution center and coordinating system for this innate intelligence.
Proper coordination, repair,
movement, healing and genetic potential cannot be fully expressed when this
life power and intelligence is blocked or redirected.
The purpose of chiropractic
adjustments given in this office is to correct vertebral subluxations, allowing
a greater communication of this life power and coordinating intelligence thus
promoting better health.
Everyone, in spite of specific
symptoms or ailments, can benefit from a more flexible and subluxation-free
spine and nervous system.
Symptoms are not necessarily a
sign of illness, they can occur to alert the individual of the need for change.
Specific location of symptoms
does not correlate to specific subluxations needing to be adjusted. Severity of
symptoms does not correlate to severity of subluxations. The reduction of
symptoms is not an effective indicator of improved health.
An individual may have symptoms
and not need an adjustment on a particular visit. An individual may have no
symptoms and may require extensive adjustments on a particular visit. A
person's symptoms are not necessarily in direct relationships to his or her
prognosis.
We do not treat specific
symptoms, conditions or aliments, other than vertebral subluxations. We do not
imply that any particular adjustment or series of adjustments will have a
direct effect on any symptoms or condition a person may be presenting. Research
studies show thousands of patients receiving chiropractic adjustments report
improved physical and emotional health and well-being.
We encourage any individual
having concerns about symptoms or ailments to consult with a disease or symptom
care specialist.
By their very intent, various
treatments may interfere with the functioning of the nervous system. This may
include drugs such as pain relievers, muscle relaxers, anti-inflammatory
compounds and mood altering medication. This can often prolong the time
required for spinal correction.
Medication levels for an
inflexible body-mind stuck in sickness are not necessarily the same as for a
body becoming well.
We will not venture into the
practice of medicine by advising about the need for reduction of medications.
We suggest you speak with your physician to determine the objective and goal to
be obtained by receiving a particular medical treatment. Determine if this is
consistent with your desire for wellness at this point in time. Your physician
may guide you in changing any medication or treatments you are presently
utilizing to accommodate for our changing body-mind.
Consistent with the above
concepts, we locate and adjust vertebral subluxations using the techniques we
believe to be the most honoring and effective.
Sincerely,
Dr. Jason M.
Kolber & Dr. Elissa Katz
I
have read this
statement of purpose and understand its
contents and I understand that by typing my name as opposed to physically
signing my name, I have been fully informed and I agree to this document's
terms. In addition, I understand that the spinal adjustments offered in
this office are not a replacement for any form of treatment provided by
other types of practioners. I understand that I am not being treated for
any condition or symptom other than vertebral subluxation. This office
offers chiropractic as a form of health and wellness care, to promote the
natural mechanisms for self-healing and empowerment, as compared to
specific target treatment.
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THANK YOU
for giving us the opportunity to
serve you.
We look forward to assisting you
on your journey
towards experiencing vibrant health
and creating your ideal life.
Dr. Jason
and Dr. Elissa
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