Participant Health Profile

Transcription

1 Participant Health Profile Welcome to Lotus of Life Chiropractic and Wellness Center! Please fill out everything on this form, even if you feel it does not apply to the reason you are coming in for care. Thank you for choosing us as part of your healthcare team. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Type of care desired: Temporary Relief Stabilization Gen Health/ Prevention Doctor s Advice Is this related to an: auto accident injury on the job? (Check with front desk immediately) Who referred you to our office? May we thank them? Yes No ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ General Information Name: Gender: Male / Female / Address: City/State/Zip: Home Phone: Cell Phone: Date of Birth: / / Age: Height: Emergency contact: Name Phone: Relation: (Rate your family s health by writing a number by their name below using the scale: 0 = poor health 10 = excellent health) Married/Life Partner? Yes No Significant Other s Name: Children s Name(s) and Age(s): Occupation: Employer: Do you enjoy what you do? Y N Explain: Duties/ Habits: sit more than 1 hour carry equipment/tools on your body (i.e. utility belt, child) repetitively bend or twist cradle the phone shoulder to ear (which side? L or R) repetitively type drive on the job (car or other) lift more than 10 lbs repetitively 1

2 About Your Health The human body is designed to be healthy. Throughout life events occur and our body has two options: It can either integrate experiences or store them to be integrated at a later time when the body is better capable. These stored experiences eventually become symptoms in the body, thus giving us a lesser quality of life. This case history will uncover the layers of stored experiences in your body. Following the exam, you will get an outline of care that will begin to correct and release these layers and recover your innate health potential! Your Healthcare Team (include all doctors, therapists, trainers, specialists, etc.) Provider s Name Provider Type Last Visit Reason Result Current Health Concerns (Please follow instructions carefully. We will cover all health concerns verbally.) List your top three health concerns: Which is most important to you and why? When/how did this concern first begin? What activities aggravate your concern? What activities alleviate your concern? Is the condition worse during certain times of the day? Y N If yes, when? Does it affect your work / relationships or intimacy / decision making / exercise or play attitude, mood, patience / ability to relax or sleep / day-to-day activities Do you have pain numbness tingling aches Is your pain sharp dull throbbing constant intermittent Do you feel swelling cramping stiffness burning Do you have any other health concerns? 2

3 Your Mom s Pregnancy with You/ Your Birth: (check all that apply) Tobacco Falls/injuries Vaginal Medications Alcohol Abuse (any type) Cesarean Epidural Medications Hospital Vacuum Complications Recreational drugs Home Forceps Childhood (Age 0-18): (check all that apply) Breast fed Formula fed (Dairy or soy?) Abuse (any type) Surgeries Accidents/falls/injuries Dislocations/fractures Scoliosis Orthodontics (braces, etc.) Nightmares/night terrors Played in a hanging/ bouncy swing Crawled before walking Special diet Vaccinations Medications Allergies/Eczema Asthma Ear infections ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Current Health/Stress Diet: (Unhealthy = 0 Extremely Healthy = 10) Your score? Details: Special Diet? Gluten free Paleo Vegetraian Vegan Other: Food sensitivities: Food Allergies: Vitamins or supplements: type, what for, and who recommended? Medications: type and for what? Exercise: Frequency/ type: Water (Type and amount per day): 3

4 How much do you consume per day of the following? Caffeinated coffee: Decaf coffee: with cream? Y N With sugar? Y N Caffeinated tea: Decaf tea: with cream? Y N With sugar? Y N Caffeinated soda: Decaf soda: Regular or diet? (circle one) Energy drinks: Juice: Type: Tobacco: Alcohol: Type: Rate your stress level for each on a scale of: 0 = worst 10 = best (i.e. If you love your job & it s stress-free put a 10 ) Occupational stress Mental/emotional stress Physical stress Chemical stress Adult History (Age 19 to present): Mark all that apply with (N) for Now, (P) for Past Weight Changes Frequent Colds/Flu Asthma/Respiratory Disease Sinus/Allergies Skin Conditions Anemia Neck/Back pain Numbness/Tingling Arthritis (Type: ) High Cholesterol Stroke High Blood Pressure Concussion/Head Injury Digestive Issues Urinary Tract Issues Bowel/Bladder Issues Menstrual Issues/Pain Reproductive System Disorders Menopause Thyroid Disorder Prostate Issues Ears/Hearing Issues Eyes/Vision Issues Dental/Jaw Issues Cancer Depression OCD Bipolar Disorder Autism Spectrum Disorder Pregnancies Surgeries Injuries/Accidents Dislocations/Fractures Abuse (Any type) Tobacco Alcohol Recreational Drugs Vaccinations Chronic Fatigue 4

5 Chiropractic History Have you been to a chiropractor before? Yes No How old were you the first time you were adjusted? Who was your most recent chiropractor? When was your last adjustment? Reason for visit: Result: Describe techniques used: In your own words, what do chiropractors do? Nutrition Response Testing Have you had Nutrition Response Testing before? Yes No If yes, with whom? When was your last visit? Reason for visit: Length of care: Result: In your own words, what is Nutrition Response Testing? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Is there anything else that may help us to understand you, your history, or your needs which has not been discussed on this survey? * Remember, health is a process. Past and present choices affect this process. Thank you for taking the time to provide us with the information we need to best help you achieve your health goals. Congratulations on taking an active step toward health and thank you for giving us the opportunity to participate in this process. Signature: Chiropractor/Intern Name: Date: Date: Chiropractor/Intern Signature: 5

6 History on Past and Current Pregnancies and Births (Include if you have ever been pregnant) Are you currently pregnant? Yes No How many weeks are you? Guess Date: Do you plan on birthing at: Home Birthing Center Hospital If not birthing at home, please name birthing location: Do you plan on using a: (check all that apply) Doula Midwife Nurse Midwife OB Names: Do you plan on breastfeeding? (Please answer assuming there are no unexpected issues.) Yes: For how long and why? No: Why not? Do you plan on vaccinating this child? Yes No If yes, what type of schedule are you choosing: CDC Full Delayed Full Modified Why? Have you done your own research on vaccinations? ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Have you ever had an abortion? Yes No Have you ever had a miscarriage? Yes No Complications? Complications? Past Deliveries: How many? *Please answer the following questions regarding your most recent birth. Third Trimester Presentation: Vertex (head down) Breech Transverse Face/Brow Posterior Type of Birth: Vaginal Forceps Vacuum Cesarean (ER or planned?) Interventions: Medication Epidural Ruptured Membranes Episiotomy Assisted Pushing Delivery Location: OB/Midwife Name: 6

7 PERMISSION AND AUTHORIZATION FORM REGARDING THE USE OF CHIROPRACTIC AND NUTRITION RESPONSE TESTING PLEASE READ BEFORE SIGNING: When a participant seeks chiropractic and/or nutrition care and we accept a participant for such care, it is essential for both to be working toward the same objectives. It is important that each participant understand both the objectives and the methods that will be used to attain said objectives. This will prevent any confusion or disappointment. You have the right, as a participant, to be informed about the condition of your health and the recommended care and management to be provided so that you may make the decision whether or not to undergo chiropractic and/or nutrition care after being advised of the known benefits, risks and alternatives. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Therefore, symptoms are NOT a valid measure of health. Chiropractic is a science, art and philosophy that concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may affect the restoration and preservation of health. Subluxation is the physical manifestation of an un-integrated life experience. When one or more of the 24 vertebrae of the spinal column are misaligned or there is abnormal tension on ligamentous or muscular structures the system as a whole can be affected: outside and inside, in obvious ways or subtle ones. These resulting interferences lead to a decrease in the body s overall healthy performance in all levels of physiology. An adjustment is the specific application of forces to correct and/or reduce subluxation. Our chiropractic method of correction is by specific adjustments of the spine and related structural components. Adjustments are usually done by hand but may be performed by handheld instruments or specialized tables. Nutrition Response Testing is a means by which the body's natural organ responses can be used as an aid in determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health.

8 I understand that Chiropractic and Nutrition Response Testing are safe, non-invasive, natural methods of analyzing the body's physical, neurological, and/or nutritional needs, and that deficiencies or imbalance in these areas could cause or contribute to various health problems. I understand that Chiropractic and Nutrition Response Testing are not methods for "diagnosing" or "treating" any disease including conditions of cancer, AIDS, infections, or other medical conditions, and that these are not being tested for or treated. No promise or guarantee has been made regarding the results of Chiropractic and/or Nutrition Response Testing or any natural health, nutritional or dietary programs recommended. I specifically authorize the Doctor of Chiropractic and/or natural health practitioners at Lotus of Life Chiropractic to perform a Chiropractic and Nutrition Response Testing health analysis and to develop a natural, complementary health improvement program for me which may include chiropractic care, dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for the treatment, or "cure" of any disease. If during the course of care we encounter non-chiropractic/nutrition or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I have read and understand the foregoing. This permission form applies to subsequent visits and consultations. Print Patient Name: Date: Signature: (If minor, signature of parent or guardian required)

9 HEALTHCARE AUTHORIZATION FORM I have been provided with a copy of the Notice of Privacy Practices for Protected Healthcare Information (PHI). The Notice of Privacy Practices describes the types of uses and disclosures of my PHI that will occur in my treatment, payment of my bills or in the performance of health care operations of the chiropractic office. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information. I hereby give permission to Lotus of Life Chiropractic to use and/or disclose PHI in accordance with the following: SPECIFIC AUTHORIZATIONS: I give permission to Lotus of Life Chiropractic to use my address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, newsletters, other practice related correspondence, information about treatment alternatives or other health related information. If Lotus of Life Chiropractic contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail. I give permission to Lotus of Life Chiropractic to contact, share, and discuss my PHI with my other healthcare providers for the purpose of integrative care between offices and providers. I give Lotus of Life Chiropractic permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, the doctor will provide a room for these conversations. By signing this form you are giving Lotus of Life Chiropractic permission to use and disclose your PHI in accordance with the directives listed above. The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information. This authorization will remain in effect for the duration of my care at Lotus of Life Chiropractic plus 7 years or until revoked by me. HEALTHCARE AUTHORIZATION I have read and understand this Healthcare Authorization Form and acknowledge receipt of The Notice of Privacy Practice for Protected Health Information. My signature below represents agreement with these practices. Participant s Name (please print): Participant s/ Guardian s Signature: Date:

10 RIGHT TO REVOKE AUTHORIZATION: You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official of Lotus of Life Chiropractic. The written notice must contain the following information: your name and date of birth; a clear statement of your intent to revoke this AUTHORIZATION; the date of your request; and your signature. The revocation is not effective until it has been received by the Privacy Official. This AUTHORIZATION is requested by Lotus of Life Chiropractic for its own use/disclosure of PHI. (Minimum necessary standards apply.) I have the right to refuse to sign this AUTHORIZATION. If I refuse to sign this AUTHORIZATION, Lotus of Life Chiropractic will not refuse to provide treatment however, it will not be possible for Lotus of Life Chiropractic to contact me to schedule appointments or discuss my care. Additionally, any collection activity as permitted by law is not waived by refusal to sign the authorization. I have the right to inspect or copy, within boundaries, the PHI to be used/disclosed. A reasonable fee for copying will apply. A copy of the signed AUTHORIZATION will be provided to me.