Address. Street City State Zip. . How did you hear about us?

Transcription

1 Client Information Today's Address Street City State Zip Primary Phone # Secondary # Age Gender: Male Female Other Primary Doctor: How did you hear about us? (Like us on Facebook to obtain nuggets of health info regularly, and leave a review on Google/Facebook if you love your care!) If you are currently pregnant, please provide your guess date here: Emergency Contact Info: Name Relationship Phone If Over 18: Occupation Employer NA: Marital Status: Single Married Divorced Spouse s Name Spouse s Birth-date Under 18 Parent Name Parent Name Signature of Guardian: Person Financially Responsible for Account Self (if chose "self" skip to bottom signature) Name Relationship B-day Address Same as Above Street City State Zip Responsible Party's Signature 1 P a g e

2 Care Information Reason for Care: What do you want to see change? If you are experiencing discomfort, please fill out the below diagram appropriately: How will this change your life if you achieve it? Do you (and your family) want to be healthier? Yes No When did this condition appear? Other providers you've seen for this condition? No Yes If yes, who? Medications Prescribed & Expected End : Is current condition due to an injury? Yes No If Accident, Type of Accident? Auto At Work Home N/A Other To whom have you made a report of the accident: Disabilities? No Yes Condition History complete this box if seeking care for a condition Auto Insurance Employer Work Comp N/A If yes, when and how?_ 1 P a g e

3 What is your: height: weight: Exercise Level: None Minimal Moderate Strenuous times/week Type: Regular Habits: Smoking Packs/Day Alcohol Drinks/Week Caffeine Cups/Day Please circle past and/or now for each item below that applies to your health history: General Digestion Eye/Ear/Nose/Throat Respiratory Allergy Belching/Gas Asthma Chest Pain/Tightness Chills Colon Trouble Tonsillitis Chronic Cough Convulsions Constipation Sinusitis Difficulty Breathing Dizziness Diarrhea Allergies Wheezing Fainting Excessive Hunger Earache Spitting Blood Fatigue Gallbladder Trouble Ear Discharge Phlegm Production Fever Hemorrhoids Ear Noise Bronchitis Headaches Jaundice Frequent Colds Genitourinary Loss of Sleep Liver Trouble Hay Fever Bed Wetting Loss of Weight Nausea Hoarseness Blood in Urine Nervousness Pain in Stomach Nasal Congestion Frequent Urination Nerve Pain Poor Appetite Nose Bleeding Urinary Incontinence Night Sweats Poor Digestion Pain in Eyes Kidney Infection Numbness (arms, legs or hands) Vomiting Poor Vision Painful Urination Unconsciousness Vomiting Blood Crossed Vision Prostate Trouble Muscles/Joints Cardiovascular Skin For Women Only Backache High Blood Pressure Bruise Easily Cramps/Backache Pain Between Shoulder Blades Low Blood Pressure Dryness Excessive Flow Stiff Neck Pain over Heart Eczema Hot Flashes Swollen Joints Poor Circulation Hives Irregular Cycle Foot Trouble Heart Trouble Itching Miscarriage Painful Tailbone Rapid Heart Rate Sensitive Skin Painful Periods Spinal Curvature Slow Heart Rate Skin Eruptions Vaginal Discharge/Odor Tremors Stroke Boils Birth Control Medication Twitching Swollen Ankles IUD Weakness Varicose Veins Hormone Replacement Last Pap Exam? Arthritis Anemia Pregnancy Jaw Pain Guess date Have you had any of the following diseases? (circle all that apply) Diabetes Cancer Hepatitis Tuberculosis Pneumonia Venereal Disease Alcoholism Lupus Measles Goiter Epilepsy Polio Rheumatic Fever Chicken Pox Pleurisy Mental Disorder Rheumatoid Arthritis Whooping Cough Operations & Procedures: (s) (s) (s) (s) Tonsillectomy Gall Bladder Back Surgery Hernia Vaccinations Tubes in Ears Female Organs Thyroid Appendectomy Stomach Cesarean Other Family History- Describe on the line provided below Diabetes Heart Problems Kidney Cancer Autoimmune Disease Other Are you currently taking any medications/supplements/herbs? (please list and for what condition) _ 2 P a g e

4 Please read thoroughly, initial at each applicable section and sign at the bottom. Thank You Personal Information I understand that my information may be used for internal marketing purposes (newsletters, s, etc.). Personal information will not be shared with any other company for marketing purposes. Information about Manual Manipulation You have the right, as a patient, to be informed about your condition and the recommended integrative and complementary procedure to be used so that you make an informed decision whether or not to undergo the procedure after knowing the risks and hazard involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure. Doctors of Chiropractic, Medical Doctors and Physical Therapists using manual manipulations for patients with headaches and cervical spine (neck) complaints are required to explain that there have been rare cases of injury to a vertebral artery as a result of manipulation. Such an injury has been known to cause a stroke, sometimes with serious neurological damage. The rare chance of this happening is estimated to be approximately from 1 per 400,000 treatments to 1 per 10 million treatments. Appropriate tests will be performed to help identify if you may be susceptible to this type of injury; you will be notified if that is the case. If you have any questions about this, please do not hesitate to speak with your practitioner. As with any health procedure, complications may arise during treatment. These complications include soreness, muscle or ligament strain, dislocations, fractures, disc injuries or physiotherapy burns. These are extremely rare occurrences. Consent for Treatment I authorize the performance of diagnostic tests, procedures and treatment deemed necessary by personnel involved in my care. Assignment of Benefits I assign all benefits payable to me for my care to Essence Chiropractic & Health PLLC. I understand that this health care facility will be paid directly by the insurance company or other payer, if eligible. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as the original. Essence Chiropractic does not routinely bill secondary insurance. We can provide you with the necessary documentation for you to bill secondary insurance if needed. Guarantee of Payment I guarantee payment of all charges incurred for treatment in accordance with the rates and terms of this health care facility, despite insurance coverage or reimbursement. I understand that I will provide accurate insurance information and will be billed directly for any charges denied by insurance carrier. I understand it is my responsibility to verify my benefits prior to care and any benefits quoted are an estimate and not guarantee of coverage. Cancelation Policy I am aware that there is a 24 hour cancelation policy and if I cancel within the 24 hour period, I may be charged a partial cancellation fee up to the amount of my visit. Signature of Patient or Responsible Party Relationship to Patient Authorization to Treat a Minor (under the age of 18) I hereby request and authorize my doctor at this clinic to perform diagnostic tests and render chiropractic adjustment and treatment to my minor son/daughter. As of this date, I have legal right to select and authorize health care services for the minor child named above. Under the terms and conditions of my divorce (if applicable), separation or other authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in anyway, I will immediately notify Essence Chiropractic & Health. Signature of Patient or Responsible Party Relationship to Patient Signature of Doctor 3 P a g e

5 Elizabeth J. Berg DC Jillian R. Skluzacek DC Nourish Family Wellness P (651) Main Street, #200 F (651) New Brighton, MN frontdesk@nourishfamilywellness.com (Consent to use PHI) Notice of Privacy Practices - Acknowledgement & Consent Acknowledgement for Consent to Use and Disclosure of Protected Health Information Use and Disclosure of your Protected Health Information Your Protected Health Information will be used by Essence Chiropractic & Health, LLC or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office. Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. You may review the Notice prior to signing this consent. You may request a copy of the Notice at the Front Desk. Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use or disclosure of your Protected Health Information. This office may or may not agree to restrict the use or disclosure of your Protected Health Information. If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Revocation of Consent You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. By my signature below I give my permission to use and disclose my health information. Patient or Legally Authorized Individual Signature Print Patient s Full Name Time Witness Signature 4 P a g e