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Dynamic Spine Center
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11 Tapion St. Lucia . –
(758) 518-5000
| Port St. Lucie. –
(305) 728-
2062
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About Us
Meet Our Teams
Why Patient See Us?
Spinal
Neck Pain
Low Back Pain
Joint problems
Disc problems
Degeneration
Stenosis
Spondolysis
Arthritis
Head & Neck
Headaches
Migraines
Dizziness
Sinusitis
Allergies
Sensitive Teeth
TMJ
Stiff Neck
Shoulders, Arms, Hands
Stiff Shoulders
Pain Raising Arm
Tennis Elbow
Wrist Pain
Carpal Tunnel
Numbness
Lower Back & Legs
Hip Pain
Sciatica
Painful Knees
Leg Cramps
Poor Circulation
Nerves & Functions
High Blood Pressure
Short of Breath
Acid Reflux
Irritable Bowel
Low energy
Chronic Fatigue
Fibromyalgia
Irritability
Difficulty Sleeping
Children
Parental Rights & Child’s Health
Frequent Ear Infections
Digestive Disturbances
Attention Disorders
Hyperactivity
Health
Auto Accidents
Work Injuries
Slip and Falls
Sport
Sport Performance Enhancement
Sport Rehabilitation
Clinical Nutrition
NutraMetrix
Science Base Nutrition
Standard Processing
Nutri Dyn
Dynamic Nutrition
Dynamic Nutritional
Scoliosis
What is scoliosis?
Physics of scoliosis
Types of Scoliosis
Levoscoliosis
Scoliosis In Youth
Scoliosis in Adults
Bracing & Surgery alt
Scolibrace
Spinecor Brace
Scoliosis Surgery
Schroth Exercise Program
Resources
For Patient
Subluxation
Wellness Glossary
The Wellness Approach
Rehab Exercise
Our Wellness Partners Recommended Reading
Shops
Contact US today
Online Forms
Make an Appointment
Menu
Home
About Us
Meet Our Teams
Why Patient See Us?
Spinal
Neck Pain
Low Back Pain
Joint problems
Disc problems
Degeneration
Stenosis
Spondolysis
Arthritis
Head & Neck
Headaches
Migraines
Dizziness
Sinusitis
Allergies
Sensitive Teeth
TMJ
Stiff Neck
Shoulders, Arms, Hands
Stiff Shoulders
Pain Raising Arm
Tennis Elbow
Wrist Pain
Carpal Tunnel
Numbness
Lower Back & Legs
Hip Pain
Sciatica
Painful Knees
Leg Cramps
Poor Circulation
Nerves & Functions
High Blood Pressure
Short of Breath
Acid Reflux
Irritable Bowel
Low energy
Chronic Fatigue
Fibromyalgia
Irritability
Difficulty Sleeping
Children
Parental Rights & Child’s Health
Frequent Ear Infections
Digestive Disturbances
Attention Disorders
Hyperactivity
Health
Auto Accidents
Work Injuries
Slip and Falls
Sport
Sport Performance Enhancement
Sport Rehabilitation
Clinical Nutrition
NutraMetrix
Science Base Nutrition
Standard Processing
Nutri Dyn
Dynamic Nutrition
Dynamic Nutritional
Scoliosis
What is scoliosis?
Physics of scoliosis
Types of Scoliosis
Levoscoliosis
Scoliosis In Youth
Scoliosis in Adults
Bracing & Surgery alt
Scolibrace
Spinecor Brace
Scoliosis Surgery
Schroth Exercise Program
Resources
For Patient
Subluxation
Wellness Glossary
The Wellness Approach
Rehab Exercise
Our Wellness Partners Recommended Reading
Shops
Contact US today
Online Forms
Make an Appointment
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Office Hours Mon, Wed, Fri: 8:00am – 5:30pm, Tues appt only, Sat: 8-11 am
Several locations to serve our community. L D A G V P
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Employer Information
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Reason for this Visit
Is this injury related to an auto accident or workman's compensation?
Auto Accident
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No
If job related, have you made a report of your accident to your employer?
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Please explain reason for visit.
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Has this condition
Gotten Worse
Gotten Better
Stays Constant
Have you experienced this before?
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Frequency of pain:
Stays Constant
Frequent (75%-100%)
Occasional (50%-75%)
Intermittent (25%-50%)
Random (less than 25%)
When did your symptoms begin?
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Type of pain:
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Dull
Throbbing
Numb
Aching
Shooting
Burning
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Rate the severity of pain on a scale from 1 (mild) to 10 (severe):
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Have you seen other doctors for this condition?
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Yes
Doctor's Name (s)
Undo
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Experience with Chiropractic
Who referred you to this office?
Have you been adjusted by a chiropractor before?*
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Reason for those visits?
Doctor's Name
Approximate date of last visit?
Goals for my Care
Please list below any activities you are unable to perform or are having difficulty performing.
Activity 1
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Please rank your ability to perform the activity on a scale of 0 to 10 with "0" being no difficulty and "10" being unable to perform the activity.
Activity 2
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Please rank your ability to perform the activity on a scale of 0 to 10 with "0" being no difficulty and "10" being unable to perform the activity.
Activity 3
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Please rank your ability to perform the activity on a scale of 0 to 10 with "0" being no difficulty and "10" being unable to perform the activity.
Health Habits
Do you smoke? If yes, how many packs per week?
Do you drink alcohol? If yes, how many drinks per week?
Do you drink caffeinated beverages? If yes, how many cups per day?
Do you exercise regularly? If yes, what type of exercise?
Do you exercise regularly? If yes, what type of exercise?
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Moderate
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Please list any medications and/or supplements you are currently taking:
Health Conditions
Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.
Health Conditions:
AIDS/HIV
Alcoholism
Allergy Shots
Anemia
Anxiety
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorder
Breast Lump
Bulimia
Cancer
Cataracts
Chemical Dependency
Depression
Diabetes
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Epilepsy
Glaucoma
Gout
Heart Disease
Hepatitis
Hernia
Herniated Disc
High Blood Pressure
High Cholesterol
Kidney
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Measles
Mental Health
Migraines
Multiple Myeloma
Mumps
Osteoporosis
Pacemaker
Parkinson's
Pinched Nerve
Pneumonia
Polio
Prostate Issue
Prosthesis
Rheumatoid Arthritis
Rheumatic Fever
Scarlet Fever
Sexually Transmitted Disease
Stroke
Thyroid Issue
Tonsillitis
Tuberculosis
Tumors/Growths
Typhoid Fever
Ulcers
Vaginal Infection
Whooping Cough
Other
Please list any allergies:
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Family History:
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Have you ever been in an auto accident? If yes, please explain
Have you ever had any falls or other significant injuries? If yes, please explain
Have you ever had any surgeries? If yes, please explain
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FOR WOMEN ONLY:
Are you pregnant?
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Are you nursing?
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Assignment and Release
I certify that I and/or my dependent(s) have insurance coverage and assign directly to
Dynamic Spine Center
Office all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
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Phone Number
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Social Security #
Date of Birth
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