Reach Chiropractic Health Profile
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- Oscar Barker
- 5 years ago
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1 Reach Chirpractic Health Prfile NameDate / / Age Male/Female Address City State Zip Phne: Hme Cell Cell Phne Prvider Date f Birth / / Address_ OccupatinEmplyer s Name Single/Married/Divrced/Widwed Spuse s Name Number f Children Names, Ages & Gender Wh may we thank fr referring yu? Office&Only LIST YOUR HEALTH CONCERNS BELOW Health Cncerns: List accrding t severity Rate f Severity 1 = mild When did This episde start? If yu had the cnditin befre,when? Did the prblem Begin with an injury? Are symptms cnstant r 10 =unbearable Intermittent? HAVE YOU EVER SEEN OTHER DOCTORS FOR THESE CONDITIONS? YES/NO CHIROPRACTOR? MEDICAL DOCTOR? OTHER WHO AND WHEN? CIRCLE ALL CURRENT PROBLEMS YOU HAVE DIZZINESS THROAT ISSUES KIDNEY PROBLEMS LIVER DISEASE NERVOUSNESS HEADACHES THYROID PROBLEMS MID BACK PAIN SHOULDER PAIN EPILEPSY VERTIGO ASTHMA IRRITABLE BOWEL CHRONIC FATIGUE DISC PROBLEM EAR INFECTIONS ULCERS SCIATICA LUPUS INFERTILITY NAUSEA NUMBNESS IN ARMS NUMBNESS IN LEGS FIBROMYALGIA GASTRIC REFULX TMJ NUMBNESS IN HANDS NUMBNESS IN FEET CHEST PAIN NECK PAIN MENSTRUAL DISORDER LOW BACK PAIN ARM PAIN OTHER MIGRAINES HEART DISORDERS HIP PAIN ADD/ADHD
2 ANXIETY CHRONIC!SINUS STOMACH DISORDERS BLADDER PROBLEMS LEG PAINS KNEE PAIN CIRCLE ANY CONDITION YOU HAVE NOW/HAVE HAD:! STROKE CANCER HEART DISEASE SPINAL SURGERY SEIZURES SPINAL BONE FRACTURE SCOLIOSIS DIABETES LIST ALL SURGICAL OPERATIONS AND YEARS LIST ALL Over the Cunter & PRESCRIPTION MEDICATIONS YOU ARE ON: WHEN WAS YOUR LAST AUTO ACCIDENT HAVE YOU HAD PREVIOUS CHIROPRACTIC CARE? YES/NO IF YOU HAVE, DR. & HAVE YOU EVER BEEN KNOCKED UNCONCIOUS? YES/NO FRACTURED A BONE? YES/NO IF YES, PLEASE DESCRIBE OTHER TRAUMA: IF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOW WRITTEN CONSENT FOR A CHILD. NAME OF PRACTICE MEMBER WHO IS A MINOR/CHILD I AUTHORIZE DR. LORENA JESUS AND ANY AND ALL REACH CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD. AS OF THIS, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY INSPIRE CHIROPRACTIC. WITNESS SIGNATURE _ GUARDIAN SIGNATURE GUARDIAN S RELATIONSHIP TO MINOR / CHILD
3 X-RAY AUTHORIZATION AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF YOUR X-RAYS IN OUR FILES. THE FEE FOR COPYING YOUR X-RAYS ON A DISC IS $ THIS FEE MUST BE PAID IN ADVANCE. DIGITAL X-RAYS ON CD WILL BE AVAILABLE WITHIN 72 HOURS OF PREPAYMENT ON ANY REGULAR PRACTICE HOURS DAY. PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTOR OF INSPIRE CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE. BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS. PRINT YOUR NAME HERE SIGNATURE YOUR AGE FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT INSPIRE CHIROPRACTIC. SIGNATURE DO NOT WRITE BELOW THIS LINE! DO NOT WRITE BELOW THIS LINE! DO NOT WRITE BELOW THIS LINE Sex: M F 3 Lat Cervical 3 Flex/Ext / / / /10 30 MA /15 40 Size 8x10 3 Lwer Cervical 3 Lateral Thracic 3 A-P Thracic / / / / MA 300 Size 8x10 3 APOM Other View / /15 30 CM Kvp / /10 50 MAS MA Size MA 300 Size 8x10 Ntes: / / / / / / / /2 150 MA 300 Size14x / / / / / / / /5 120 MA 300 Size14x17 3 Lateral Lumbar 3 A-P Lumbar / / / / / / / / / / / / / / / / / /5 MA 200 Size 14x /2 CA Initials: 32 MA 300 Size 14x17
4 Practice Member Infrmatin (Must be Cmpleted Befre Services Can Be Rendered) NAME: FIRST MIDDLE LAST PHONE: Hme Cell Wrk SOCIAL SECURITY NUMBER: MARITIAL STATUS: OF BIRTH: CONTACT IN CASE OF EMERGENCY: Phne #: NAME OF PRIMARY INSURANCE CARRIER: Name f Insured Insured Date f Birth Insured Scial Security Number NAME OF SECONDARY INSURANCE CARRIER: Name f Insured Insured Date f Birth Insured Scial Security Number: Insurance Plicies and Fee Schedule Cnsultatin- includes practice member histry. This service is cmplimentary Assessment (new r established practice member)- includes ne r mre f the fllwing: thermgraphy, surface electrmygraphy, range f mtin, mtin and/r static palpatin, leg check. Chirpractic Adjustment- The actual re-alignment f the vertebra dne by hand. Often a sund will be heard, but if there is n auditry result, it des nt mean that the adjustment has nt taken place. X-rays- Specific x-ray views taken f yur spine t determine a misalignment/subluxatin f yur vertebrae. These can als be used t indicate prgress after perid f care. Release f Authrizatin/Assignment f Benefits I authrize and request payment f insurance benefits directly t Lrena Jesus, DC. I agree that this authrizatin will cver all services rendered until I revke the authrizatin. I agree that a phtcpy f this frm may be used in place f the riginal. All prfessinal services rendered are charged t the patient. It is custmary t pay fr services when rendered unless ther arrangements have been made in advance. I understand that I am financially respnsible fr charges nt cvered by this assignment. Signed Date
5 A. Chirpractic is a very specific science, authrized by law t address spinal health cncerns and needs. Chirpractic is a separate and distinct science, art and practice. It is nt the practice f medicine. B. Chirpractic seeks t maximize the inherent healing pwer f the human bdy by restring nrmal nerve functins thrugh the adjustment f spinal subluxatin(s). Subluxatins are deviatins frm nrmal spinal structures and cnfiguratins that interfere with nrmal nerve prcesses. C. The chirpractic adjustment prcess, as defined in the law f this jurisdictin, invlves the applicatin f aspecific directinal thrust t a regin r regins f the spine with the specific intent f re-psitining misaligned spinal segments. This is a safe, effective prcedure applied ver ne millin times each day dctrs f chirpractic in the D. United States alne. A thrugh chirpractic examinatin and evaluatin is part f the standard chirpractic prcedure. The gal f this prcess is t identify any spinal health prblems and chirpractic needs. If during this prcess, any cnditin r questin utside the scpe f chirpractic is identified, yu will receive a prmpt referral t an apprpriate E. prvider r specialist, accrding t the initial indicatins f the need. Chirpractic des nt seek t replace r cmpete with yur medical, dental r ther type(s) f health prfessinals. They retain respnsibility fr care and management f medical cnditins. We d nt ffer advice regarding treatment prescribed by thers. F. Yur cmpliance with care plans, hme and self-care, etc., is essential t maximum healing and ptimal health thugh chirpractic! G. We invite yu t speak frankly t the dctr n any matter related t yur care at this facility, its nature, duratin, r cst, in what we wrk t maintain as a supprting, pen envirnment. By my signature belw, I have read and fully understand the abve statements. All questins regarding the dctr s bjectives pertaining t my care in this ffice have been answered t my satisfactin. I therefre accept chirpractic care n this basis. _ (Signature) (Date) Ntice f Privacy Practices Acknwledgement I understand that I have certain rights f privacy regarding my prtected health infrmatin, under the Health Insurance Prtability & Accuntability Act f 1996 (HIPAA). I understand that this infrmatin can and will be used t: 1. Cnduct, plan and direct my treatment and fllw-up amng the multiple healthcare prviders wh may be invlved in that treatment directly and indirectly Terms f Acceptance In rder t prvide fr the mst effective healing envirnment, mst effective applicatin f chirpractic prcedures, and the strngest pssible dctr-patient relatinship, it is ur wish t prvide each patient with a set f parameters and declaratins that will facilitate the gal f ptimum health thrugh chirpractic. T that end, we ask that yu acknwledge the fllwing pint regarding chirpractic care and the services that are ffered thrugh this clinic: Obtain payment frm third-party payers. Cnduct nrmal healthcare peratins, such as quality assessments and physicians certificatins. I acknwledge that I may request yur NOTICE OF PRIVACY PRATICES cntaining a mre cmplete descriptin f the uses and disclsures f my health infrmatin. I als understand that I!may request, in writing, that yu restrict hw my private infrmatin is used t disclsed t carry ut treatment, payment, r healthcare peratin. I als understand yu are nt required t agree t my requested restrictins, but if yu agree, then yu are bund t abide by such restrictins. _ (Signature) (Date)!
6 INFORMED CONSENT FOR CHIROPRACTIC CARE CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE. PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE. I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT. PRINT PRACTICE MEMBER S NAME HERE PRACTICE MEMBER S SIGNATURE IF PRACTICE MEMBER IS A MINOR/CHILD, PARENT OR GUARDIAN MUST SIGN BELOW. SIGNATURE OF PRACTICE MEMBER OR GUARDIAN RELATIONSHIP TO MINOR/CHILD WITNESS SIGNATURE (OFFICE STAFF)
7 FAMILY HEALTH HISTORY THIS FORM IS TO ASSIST THE DOCTOR BY PROVIDING PAST HEALTH HISTORY INFORMATION FOR HIS REVIEW. PLEASE PRINT YOUR NAME HERE ARM PAIN ARTHRITIS ASTHMA ADD/ADHD ALLERGIES BACK TROUBLE BED WETTING CANCER CARPAL TUNNEL DECEASED DIABETES CONDITION SPOUSE SON DAUGHTER MOTHER FATHER DIGESTIVE PROBLEMS DISC PROBLEMS EAR INFECTIONS FIBROMYALGIA HEADACHES HEARTBURN HIGH BLOOD PRESSURE HIP PAIN LEG PAIN MENSTRUAL DISORDER MIGRAINES NECK PAIN SCOLIOSIS SHOULDER PAIN SINUS TROUBLE TMJ
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phne: Hme Cell_ Date f Birth / / Email Address Fr cnfirming appintments, wuld yu prefer? EMAIL r TEXT CELL PROVIDER IS Occupatin Emplyer s Name Single
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Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
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