Welcome to Studio Chiropratica Benessere

This health questionnaire helps the doctor get an overview of your current health and wellness. For this we need some information from you. This data is securely stored and subject to medical confidentiality and data protection.

First, please fill out the form with your personal data and chiropractic history from.

After each appointment, we ask for direct payment. We offer you the opportunity to this to make either in bank transfer, cash, pos or cheque.

The price of your first visit is € 125 (and includes for a complete Chiropractic exam including a Posture Pro, one chiropractic adjustment and review the result on the second visit.)

A chiropractic treatment after that are €50.

For children (2-12) €35 and Infant €20.

Pilates/Fitness Training/TRX Group Leasons €20 / Individual €60

In order to ensure the clinic runs smoothy, we have to designated specific times soley for Chiropractic adjustment. If you have questions or would like to important events (eg, new accidents, new sporting injury, etc.) discuss we kindly ask you to inform us by phone in advance so we have enough time can plan for a more extensive appointment.

Please give 24 hours notice if you need to rescudule an appotointment, failure to give 24 hours notice will mean you will be billed for the full appoitnemnt/Pilates charge.

We regularly send you newsletter and emails about the latest in chiropractic, health and wellness. If you would prefer no to receive this information please let the Chiropractic Assistant know.

It is the practice of this office to provide chiropractic care in an “open adjusting” environment. This “open adjusting” involves several patients being seen in the same adjusting area at the same time. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting.

Please turn off your mobile phone before entering the centre.

IN CASE OF EMERGENCY, CONTACT

HOW CAN WE HELP YOU?

GENERAL DISABILITY FORM

For each of the six categories of daily living listed PLEASE CIRCLE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF

ACTIVITIES.

A score of 0 means no disability at all and a score of 10 signifies that all of the activities in which you would normally be

involved have been totally disrupted or prevented by your pain.

On the arrow diagram above

What are your health goals?

CHILDREN & PREGNANCY

HEALTH & ILLNESS HISTORY

Please check the box beside any conditions that you have or have had.

ALLERGIES, MEDICATIONS & SUPPLEMENTS

Sleeping improperly can create misalignment of the spine.

We walk an average of 10,000 steps per day, and foot sustains alot of strain during the day.

A balanced diet is important for maintaining a healthy nervous system.

Personal Development:

Health and Well-being:

Relationships:

Career or Work:

Finances:

Are there any other areas in your life that are unblanaced?

SCIENTIFIC RESEARCH

We would like to inform you that, in accordance with current regulations, the processing of data will be based on the principles of correctness, lawfulness, and transparency, while protecting your privacy and rights. The data you provide us when undergoing chiropractic services will be used to assess your current health status, for administrative purposes, and for scientific research. They will be stored in both our paper and electronic archives.

Please note the following:

1. Authorization for the processing of sensitive data (clinical data, photographic images, diagnostic tests) is strictly necessary to enable chiropractic services.

2. If you authorize the processing of data for clinical research purposes, they will be used strictly anonymously.

3. The data controller and processor is STUDIO CHIROPRATICA BENESSERE/SILLIPP RICHARD CHIRSTOPHER B.Sc, D.C., with legal headquarters at Via Magellano 14, 10128 Turin.

4. Clinical data and collected clinical material will be managed in compliance with current regulations and professional ethical codes.

5. You may contact the data controller to exercise your rights as provided by Article 7 of Legislative Decree 196/03, including the right to obtain information about the origin of personal data, the purposes and methods of processing, the logic applied in processing carried out with the aid of electronic tools, the identification details of the data controller and processors, the subjects or categories of subjects to whom personal data may be communicated, updating, correction, or integration of data, and the deletion or blocking of data processed in violation of the law.

Consent Form for the Processing of Sensitive Data and Anonymous Scientific Research

I, the undersigned, having received the information pursuant to Article 13 of Law 196/03, consent to the processing of personal data, declaring in particular that these data fall under the category of "sensitive" data as defined in Article 4 of the aforementioned law. I consent to the processing of personal data for observational and educational scientific research purposes, in a manner that ensures complete anonymity.

Great, all done! The next step is to schedule an appoitment with Dr. Richard Sillipp to go through your results.

Click submit to submit you information

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