PATIENT ENROLLMENT FORM

Transcription

1 PATIENT ENROLLMENT FORM Midwest Health & Nutrition / Ted Cox III, DC 421 N. First Street Suite C Odessa, MO Phone: (816) Date / / *First Name Account # Nick Name *Last Name Middle Initial Suffix Address City State *Zip Primary Phone Mobile Phone Secondary Phone By providing my address, I authorize my doctor to contact me via the address provided Contact Method (check one) Primary Phone Secondary Phone Mobile Phone Home Work Date of Birth / / Age SSN - - *Gender (Check one) Male Female Marital Status (check one) Single Married Other Spouse/Parent/Legal Guardian Name Phone Employment Status (check one) Employed FT Student PT Student Retired Self Employed *Occupation Employer Employer Phone Employer Address City ST Zip Race (check one) White Black/African American American Indian/Alaskan Asian Native Hawaiian Other I choose not to specify Multi-Racial (check one) Yes No Unknown Ethnicity (check one) Hispanic or Latino Not Hispanic or Latino I choose not to specify Do you currently smoke tobacco of any kind? Yes No Never been a smoker If Yes, How often do you smoke? Current every day smoker Current sometimes smoker If yes, what is your level of interest in quitting smoking? No Interest Very Interested Current Medications Prescribed by your doctor: If there are no current medications, check here: Does your primary doctor have you on an aspirin regimen? Yes No New Patient PPWK Packet 11/15

2 1 Medication: Dosage Generic Brand Name Unknown 2 Medication: Dosage Generic Brand Name Unknown 3 Medication: Dosage Generic Brand Name Unknown 4 Medication: Dosage Generic Brand Name Unknown 5 Medication: Dosage Generic Brand Name Unknown 6 Medication: Dosage Generic Brand Name Unknown ***** Please use another sheet of paper if necessary to list additional medications you are prescribed***** List any known allergies you have to medications. - If no allergies are known, check here 1) 3) 2) 4) Briefly list your main health problems: Has any doctor diagnosed you with Hypertension (high blood pressure) presently? Yes No If yes, describe: Has any doctor diagnose you with Diabetes presently? Yes No If Yes, what kind? Type I Type II If Yes, to Diabetes, was your blood-work test for hemoglobin A1-C > 9.0%? Yes No Not sure Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes No Primary Care Physician: Provider Name Provider Phone/Fax Provider Address City ST Zip Patient Signature: X Date To be performed by clinic staff: Height Weight lbs. BP: / Heart Rate bpm 02 Temp Resp/min New Patient PPWK Packet 11/15

3 REASON FOR VISIT Midwest Health & Nutrition 421 N. First Street Suite C Odessa, MO Phone (816) Date / / Account # Doctor: MTC PROBLEM AREAS: *Describe your problem(s): *On a scale of 0-10, rate the intensity: Lowest Highest How did your problem begin? Onset date of problem: / / How often do you experience symptoms: What is the nature of your symptoms (mark all that apply) Dull Sharp Throbbing Burning Deep Aching Tingling Stabbing Cramping Numbness Radiating Does it affect other areas of your body: Yes No To what areas does the pain radiate, shooting, travel: What makes the problem worse? (time of day, movements, activities): What have you done to relieve the symptoms? Prescription Medication Over the counter drugs Homeopathic remedies Physical Therapy Surgery Acupuncture Chiropractic Ice Heat Other What should we know about your current condition: PAIN CHART 0 = No Pain / 5 = Medium Pain / 10 = Severe Pain Circle Areas of Discomfort on Figures Neck-Shoulder-Arm Pain On a scale of 0-10, I rate my discomfort as follows: Lowest Highest Mid-Back Pain On a scale of 0-10, I rate my discomfort as follows: Lowest Highest Low-Back and Leg Pain On a scale of 0-10, I rate my discomfort as follows: Lowest Highest New Patient PPWK

4 MEDICAL HISTORY Patient s Name Date ILLNESS: Illness: Start Date End Date Illness: Start Date End Date Illness: Start Date End Date SURGERY: Surgery: Date Surgery: Date Surgery: Date HOSPITALIZATIONS: Reason: Date Duration: Reason: Date Duration: Reason: Date Duration: INJURIES: Injury: Date Injury: Date Injury: Date Have you seen a Chiropractor before? Yes No If yes, list name(s) of doctor(s) and date(s): Did the treatment you received help your condition? Yes No What condition were you treated for? How long were you treated? FAMILY HISTORY Please review the diseases and conditions listed below and indicate the type of disease that are current health problems of the family member listed. Lease those spaces blank that do not apply. Circle your answers if your relatives live around this locality, as some hereditary conditions are affected by similar climates. CONDITIONS FATHER MOTHER BROTHER(S) SISTER(S) SON(S) DAUGHTER(S) Year Born Age/Cause of Death Cancer (Type) Clotting Issues Dimentia/Alzheimer s Diabetes/Pre-Diabetic Gastrointestinal (Type) Heart Disease (Type) High Cholesterol Disc Problems Hypertension Kidney Disease (Type) Lung Disease (Type) Osteoporosis Psychological (Type) Septicemia Stroke / Brain Attack SIDS Arthritis/Gout (Type) Bursitis Headaches Liver Disorder Nerve Pain Scoliosis Sinus Trouble Stomach Trouble Thyroid Other: New Patient PPWK

5 Midwest Health & Nutrition a division of TNT & Associates, Inc. Appointment Reminders and Health Care Information AUTHORIZATION Your doctor and members of the staff may need to use your name, address, phone number, and your clinical records to contact you with appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. If this contact is made by phone and you are not at home, a message will be left on your home answering machine and or cell phone. By signing this form, you are giving us authorization to contact you with these reminders and information via, but not limited to: Phone Messaging (Home, Mobile, Work, Spouse), Text, , US Postal Service. You may restrict the individuals or organizations to which your health care information is released or you may revoke your authorization to us at any time; however, your revocation must be in writing and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. Information that we use or disclose based on the authorization you are giving us may be subject to redisclosure by anyone who has access to the reminder or other information and may no longer be protected by the federal privacy rules. You have the right to refuse to give us this authorization. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care. You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time ( ) This notice is effective as of. This authorization will expire seven years after the date on which you last received services from us. I authorize you to use or disclose my health information in the manner described above. I am also acknowledging that I have received a copy of this authorization. Signature of Patient or Personal Representative Printed Name of Patient Date of Signing Description of Personal Representative s Authority

6 CONSENT TO TREAT WITH ACUPUNCTURE: CONSENT TO TREATMENT PRINT PATIENT NAME HERE I,, hereby authorize and consent to the performance upon me of the treatment of Acupuncture by Dr. Milton T. Cox III, or any of the physicians who may become associated with them in the practice of acupuncture and to the employment of such assistants as they may deem necessary to carry out such treatment. Acupuncture has been explained to me as a chiropractic specialty treatment performed by the insertion of special needles (with or without the application of small pulses of electric current to the needles) through the skin into underlying tissues at certain indicated points on the surface of the body, for the purpose of seeking the alleviation, for an undetermined time, of pain or of bodily disorders. Other methods of acupuncture treatments may include: cold laser (532 nm and 732 nm), teishin, activator, moxa, ion balls or any other means by which acupuncture points may be stimulated/sedated to cause a physiological effect on me as deemed necessary by the doctor. POSSIBLE HAZARDS of ACUPUNCTURE NEEDLE USE may include, but not be limited to: Skin Irritation & Redness, Bruising, Bleeding, Infections of the skin or other bodily tissues and/or organs, Pneumothorax (Collapsed Lung) and Needle breaking off under the skin (which would need to be removed by a medical practitioner). All Needles in our clinic(s) are brand new, sterile packaged needles. Needles are NEVER re-used. All needles are discarded into a medically approved sharps container (Such as used in Hospitals and other types of Doctor s offices for their needles). I am aware that it is IMPERRATIVE that while I am retaining needles that I am to remain completely still. Any moving or getting up and around could cause severe injury to me from needles being bumped, hit, embedded, etc Therefore; I agree to remain still and without motion. I am aware that the use of acupuncture is not a common practice in this country. The nature and purpose of my treatment and the hazards and potential complications have been explained to me and no warranty or guarantee has been made to me as to any result of a cure. I have been advised that acupuncture is not covered by Medicare policies and, thus, Dr. Cox and any associates are not participating physicians. I understand that I am responsible for the payments of all the professional services rendered by them at time of service. CHIROPRACTIC CARE: Although Chiropractic is reported to be the safest health care system in the world, some say there are very slight risks associated with it. We feel that it is responsible to let you know: 1. Risk of stroke is reported to be 1 in 5-8 million or so... and the cause has yet to be determined. 2. While extremely rare, there have been reports of ligament sprains, and even rib fractures reported. 3. There have been rare reports of disc injuries although no clinical scientific study has ever demonstrated chiropractic care to be the cause. Chiropractic care has been proven to be both, clinically and very cost effective. The risk of injuries and complications is so small that chiropractors carry the lowest malpractice insurance premiums of all the health care professions in the world. Compared to traditional medical/drug/surgical care, which has a yearly death rate of approximately 200,000 people in North America, Chiropractic is your safest health care system. Midwest Health & Nutrition Dr. Milton T. Cox III, DC 421 N. First St. Suite C Odessa, MO (816)

7 I have read and understand the above consent, and have had the opportunity to discuss it with my chiropractor. I consent to the care recommended by my chiropractor and extend this consent to include all doctors of this Health & Nutrition Center. This consent applies to all present and future care for me and my family. AGREEMENT TO DO A MUSCLE TESTING PROGRAM I specifically authorize Dr. Milton T. Cox to do health analysis and to develop a natural, complementary health improvement program for me which may include dietary guidelines, nutritional supplements, etc. in order to assist me in improving my health, and not for the treatment, or cure of any disease. I understand that Nutrition Response Testing is a safe, non-invasive, natural method of analyzing the body s physical and nutritional needs, and that deficiencies or imbalance in these areas could cause or contribute to various health problems. I understand that this is not a method for diagnosing or treating of 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 this testing or any natural health, nutritional or dietary programs recommended, but rather I understand that it is a means by which the body s natural reflexes can be used as an aid to determining possible nutritional imbalances, so that safe natural programs can be developed for the purpose of bringing about a more optimum state of health. I understand that I am to adhere to the program guidelines. These guidelines have been fully laid out before me and discussed in detail. If I do not fully comply, I understand that this will greatly impact my results and success. I have read and understand the foregoing. This permission form applies to subsequent visits and consultations. APPOINTMENT CANCELLATION POLICY: I understand that should I need to cancel my appointment, I must give this office a 6 hour notification prior to my appointment. Should I fail to give this office a 6 hour notification, or simply not show up for any reason, I understand that I will be responsible for a $25 Failure to Cancel Fee. In the event of a medical emergency the office manager has the right to waive this fee. PARENTAL/GUARDIAN CONSENT: My child is under 18 years of age. I have read the above and am agreeing, by my signature below to your Examination, Evaluation, Recommendation and Treatment of my son/daughter (other if I am the guardian). I acknowledge that I may or may not be present at the time of evaluation and/or treatment and I hereby give Dr. Milton T. Cox III, DC my permission to treat my son/daughter, who s name is printed below, without my presence. X Patient Signature (over 18 years of age) Today s Date Relationship to Parent/Guardian X Parent/Guardian Signature Today s Date Witness Signature Midwest Health & Nutrition Dr. Milton T. Cox III, DC 421 N. First St. Suite C Odessa, MO (816)

8 PATIENT S HIPPA COMPLIANCE NOTIFICATION The purpose of this notice is to detail to our patients how our clinic may utilize and disclose their personal medical information. After reading this notice, you will be asked to sign a consent form. This consent will allow us to use your personal health information for the purpose of treatment, receiving payments and for the daily operations of our office. It is our policy to release the minimum information to any source not directly linked to the care of our patients as defined by the Health Insurance Portability Accountability Act (HIPPA). In the case of third party payers, your signed consent form permits us to release information necessary to complete the health insurance claim form. When a patient wishes to have their protected information released, a release form signed by the patient will be necessary before we will release any protected information. In the case of public health, HIPPA does not protect certain information. When a law enforcement or public health agency requests any information, we will release the minimum information required by the law. Patients have the right to view their personal medical information. Our office may use your personal medical information to remind you of appointments, send you birthday cards, mailings, newsletters and other information about our practice. We will not release mailing lists of our patients to outside parties. Notifications to contact me with my permission include, but not limited to: Telephone (Home, Cell, Work) Texting, ing, Snail (USPS) Mail. We reserve the right to modify these policies in accordance with legal or practice requirements. We will provide you notice of such change. PERSONAL MEDICAL INFORMATION CONSENT FORM The Health Insurance Portability Act of 1996 (HIPPA) requires that we receive your permission before we use personal information in your medical records for any reason. This consent form gives us permission to use your protected health information to carry out treatment, to receive payment and as part of health care operations of our practice. HIPPA also requires us to have a written notice of our privacy policy describing how medical information about you may be used and disclosed. If you so desire, this written notice is available from our staff. HIPPA gives the patient the right to add restrictions to the release of protected health information. You have the right to revoke this consent at any time; though services performed prior to the revocation are covered by this consent. PATIENT NAME: X DATE: Patient/Guardian Signature PATIENT REQUESTED RESTRICTIONS: (if any, must be initialed by patient/guardian) Midwest Health & Nutrition / Milton T. Cox III, D.C. 421 N. First St. Suite C Odessa, MO (817)

9 Midwest Health & Nutrition 421 N. First Street Suite C Odessa, MO Phone: (816) This Form will be retained in your medical record NOTICE TO PATIENT Acknowledgement of Receipt of Notice of Privacy Practices We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. (If printing this from website, policy available for viewing on the website) Patient Name: Date of Birth: I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of Midwest Health & Nutrition, a division of TNT & Associates, Inc. I understand that the Notice describes the uses and disclosures of my protected health information by Midwest Health & Nutrition and informs me of my rights to my protected health information. Patient s Signature or that of Legal Representative Printed Name of Patient or that of Legal Representative Today s Date If Legal Representative, Indicate Relationship FOR OFFICE USE ONLY We have made every effort to obtain written acknowledgement of receipt of our Notice of Privacy from this patient but it could not be obtained because: The patient refused to sign. Due to an emergency situation it was not possible to obtain an acknowledgement. Communication barriers prohibited obtaining the acknowledgement. Other (please specify): Employee Name Today s Date New Patient PPWK