Functional Mobility Form

Welcome to Homegrown Functional Mobility!

  • ASSITED STRETCH
  • MYOFASCIAL RELEASE
  • POSTURE EXERCISE GUIDANCE


Please fill out our Health Record as completely and accurately as possible. If you have any questions, please don't hesitate to ask one of our qualified team members.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being. 

About this Patient 

Gender*
Please select one option
Marital Status*
Please select one option

About the Spouse 

Reason for this Visit

Is the purpose of this appointment related to:*
Please select one option
Has this condition*
Please select one option
Has this condition occurred before?*
Please select one option
Have you seen other doctors for this condition?*
Please select one option

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point
Does your problem interfere with:*
Please select at least one option

Goals for my Care 


Please check the type of care desired so that we may be guided by your wishes whenever possible.

Medications I Now Take:*
Please select at least one option

Health Habits

Do you exercise regularly?*
Please select one option
Do you wear:

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:*
Please select at least one option
Family Medical History:*
Please select at least one option

FOR WOMEN ONLY:

Are 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?

Authorization for Care


I hereby authorize the Chiropractic Assitant to perform Homegrown Functinal Mobility Services, as he or she deems appropriate. This may include but is not limited to assited stretching, myofascial release techniques and guidance through rehabilitative exercise, 

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Emergency Contact

Nutrition and self-care are just two of the components in obtaining optimal wellness. 


Please let us know what you are currently doing for your health.

Things I do currently to support my health include:
Please indicate which of these you do/have on a consistent basis:

Missed Appointments 


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.
  • In the instance of a no show without 24 hour notice, by phone or text, we reserve the right to charge you a $35.00 fee and we require a credit/debit card (not HSA) be kept on file.


Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Thank you for taking the time to fill out this form.

CONTACT US TODAY

We look forward to hearing from you

Location

Directions: Turn down the side street, Rushland Dr, to get to parking in the rear of the building. There is no direct access on Dorothy Ln. .

Office Hours

Our Regular Schedule

Office Hours

Monday:

8:00 am-5:30 pm

Tuesday:

8:00 am-4:30 pm

Wednesday:

8:00 am-5:30 pm

Thursday:

8:00 am-4:30 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed