Elevation Health Patient Application

Transcription

1 Elevation Health Patient Application WELCOME TO OUR OFFICE. WE THANK YOU FOR YOUR TRUST! (Please print using black or blue ink. If there is something that does not apply to you please put N/A on the line.) Section 1: Patient Information Appt. Referred By: Name (First Middle Last): Preferred Name: Male Female Date of Birth: Age: Address: City: State: Zip: Cell Phone: Home Phone: Work Phone: Social Security #: Marital Status: Married Single Divorced Widow Name of Spouse/Significant Other: Name & Ages of Children: Employer: Occupation: Emergency Contact: M/F: Relationship: Phone: List any medications you currently take (prescription and non-prescription): Section 2: History of Complaint Primary Complaint(s): Secondary Complaint(s): Are your complaints due to an accident? Yes No If yes, what type? Work Auto Personal Date of Accident: If Work/Auto accident, have you reported this accident to anyone? Yes No Who was it reported to? Have you seen any doctors for this condition? Yes No Please list the doctor specialty & for how long you were seen: Section 3: Family History Does anyone in your family suffer with the same condition(s) or other chronic illnesses? Yes No If yes, whom & what condition(s): Section 4: Chiropractic History Have you ever seen a Chiropractor before? Yes No When? For what reason(s) were you seen? Were you helped? Yes No Doctor Signature: Date Form Reviewed:

2 Patient Name: Date of Birth: Section 5: Past Trauma History: Starting from birth, we all experience thousands of physical, mental, & chemical stresses. These stresses can cause Postural Distortions (misalignments of the spine) and lead to our current health problems. Please write down some of the falls, injuries, & traumas that you ve experienced. (Please put NA if it doesn t apply to you. A. Car Accidents (List even minor ones. A 5mph crash from a 3000lb vehicle can cause damage to your spine even if you didn t feel injured.) Ex.: Type of Collision: Front Side Rear Speed: 10 mph Injuries: Neck Whiplash Lt Rt Date: Type of Collision: Front Side Rear Speed: Injuries: Lt Rt Date: Type of Collision: Front Side Rear Speed: Injuries: Lt Rt B. Sports Injuries (If there are too many to list, please write the names of the sport and MANY next to it.) Ex.: Type of Sport: Basketball Type of Injury: Sprained Knee Lt Rt Date: Type of Sport: Type of Injury: Lt Rt Date: Type of Sport: Type of Injury: Lt Rt C. Slips, Falls, & Bike Accidents (We understand there may have been a lot of slips & falls, so please list the major ones.) Ex.: Type of Injury: Slipped on Ice & Bruised Left Elbow Lt Rt D. Repetitive Injuries (Please list all repetitive injuries you ve had in the past.) Ex.: Type of Injury: Injured Lower Back Lifting Boxes Lt Rt Section 6: Current Symptoms: PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling Doctor Signature: Date Form Reviewed:

3 Patient Name: Date of Birth: Section 7: Present and Past Conditions Complete the following, leaving no blanks. Using the codes listed below, please fill in EVERY blank with the applicable letter. Check to indicate if you have Pain or Stiffness and on which side of your body. If both sides apply, please check R & L. P = Past Health Issue C = Current Health Issue N = Never had this Health Condition Example: C Shoulder Pain Stiff R L Extremities Respiratory Other Conditions Male Hip Pain Stiff R L Asthma Headaches/Migraines Impotence Knee Pain Stiff R L Chest Pain Trouble Sleeping Prostate Problems Foot Pain Stiff R L Difficulty Breathing Excessive Sweating Female Shoulder Pain Stiff R L Lung Problems Cancer & Type: Menopausal Problem Elbow Pain Stiff R L COPD Emotional / Mental Disorders Menstrual Cycle Digestion Learning Disability Problems Wrist Pain Stiff R L Heartburn Nervous / Irritable Jaw Pain Click Pop R L Digestion Problems Loss of Memory Social History Swollen or Painful Joints Gallbladder Problems Dizziness / Loss of Balance Spine Colon Trouble Arthritis Smoking Head Shoulders feel Heavy Tired Diarrhea / Constipation Epilepsy / Convulsions How Much Neck Pain Stiff R L Hemorrhoids Knocked Unconscious Upper Back Pain Stiff R L Immune System Frequent Ear Infections Alcoholic Beverage Mid Back Pain Stiff R L Skin Problems Ringing in Ears R L Consumption Occurs: Low Back Pain Stiff R L Sinus Problems / Allergies Hearing Loss R L Pain with cough, sneeze, or strain with bowel Frequent Colds / Flu Trouble Concentrating Recreational Drugs Movement. Location of Pain: Anemia AIDS / HIV What Used Other: Fracture / Dislocation of Bones: How Often Other: Organ Problems or Dysfunction Other: Exercise Numbness / Tingling / Pain in: Diabetes Urinary Tract Type Arm Numb Ting Pain R L Liver Trouble Kidney Trouble How Often Hand/Fingers Numb Ting Pain R L Hepatitis Frequent Urination Legs Numb Ting Pain R L High / Low Blood Pressure Bedwetting Foot/Toes Numb Ting Pain R L Heart Other: Doctor Signature: Date Form Reviewed:

4 Patient Name: Date of Birth: Section 8: Functional Assessment Check any activities of life that your current conditions are affecting: Bending Carrying Climbing Concentrating Dancing Doing Chores Doing Computer Work Dressing Driving Gardening Lifting Performing Sexual Activity Playing Sports Pushing Reading Recreating Rolling Over Running Shoveling Sitting Sit to Standing Sleeping Standing Walking Watching TV Working Other: Doctors Notes: Section 9: Past Health Conditions Transfer conditions from page 3 marked with a P for past health issue. Please list: When, How long it lasted, Description of symptoms (ex. Sharp, pain, burning), How often (ex. Weekly, daily), severity (0=no pain; 10=worst pain) Are any of these past conditions due to an accident? Yes No If yes, what type? Work Auto Personal Date of Accident: Have you seen any doctors for this condition: Yes No Please list the doctor specialty, & for how long you were seen: List any past hospitalizations and/or surgeries: Surgeries: Hospitalizations other than surgeries: Doctor Signature: Date Form Reviewed:

5 Elevation Health North Richland Hills, LLC Consent for Treatment You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as informed consent and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. We may conduct some diagnostic or examination procedures, if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. We use our hands, or an instrument, to reposition anatomical structures such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functionaning and overall well-being. It is important that you understand, as will all types of health care approaches, results are not guaranteed and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including but not limited to: muscle spasms, aggravating and/or temporary increase of symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an arterial dissection that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke. The reported association between chiropractic visists and stroke is exceedingly rare and is estimated to be related to 1 in 1,000,000 to 1 in 2,000,000 cervical adjustments. For comparison, the incidence of hospital admission attribute4d to aspirin use from major GI events of the entire (upper and lower) GI tract was 1,219 events per 1,000,000 persons per year and risk of death has been estimated as 104 per 1,000,000 users. It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. I have read or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about this consent and, by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in theis office for my present condition and for any future condition(s) for which I seek chiropractic care from this office. Print Patient Name Date of Birth 0Witness Initials Patient or Authorized Person s Signature Date Rev

6 Elevation Health, LLC HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act 45 CFR Parts 160 and 164) This authorization affects your rights regarding the privacy of your personal healthcare information. You have the right to receive a copy of this HIPAA Privacy Authorization Form Please read it carefully before signing. I understand that my treatment, payment, enrollment or eligibility for benefits will not be affected by my signing or not signing this release. Disclosure of Protected Health Information: (Select Option A or B) A. I hereby authorize Elevation Health, to use and/or disclose the protected health information described below for the purpose(s) of treatment and care. (Select one of the options below) I hereby authorize the release of my complete health record. I hereby authorize the release of my complete health record with EXCEPTION of the following information: Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Other: Complete this Section if you checked either of the options above I hereby authorize Elevation Health or its Business Associates to release all information to the following family members or friends: Name Relationship Name Relationship B. Do not discuss/release my medical records or private information to anyone (including family members) or any entity. This option is not available for our minor patients; we must have written documentation indicating the adult caregiver(s) with whom we may discuss the child s care. Patient Preferred Communication: I hereby authorize the Elevation Health to communicate with me using the following modes of communication about all matters which relate to my treatment, appointments, billing/financial, and office notifications and operations. Call. Cell: Home: Work: Text. This authorization shall be in force until properly revoked by me at which time this authorization expires. To revoke my authorization, I must submit a Revocation of Authorization Notice to Elevation Health, Attn: Medical Records Manager. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct or as permitted by law. Elevation Health and its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that information used or disclosed according to this authorization may be disclosed by the recipient and may no longer be protected by HIPAA, federal or state law. Print Patient Name Date of Birth Patient or Authorized Person s Signature Date Rev

7 Elevation Health North Richland Hills, LLC X-Ray Consent The doctor has explained that the purposes of the x-rays about to be taken are to analyze the spine for vertebral subluxation and to determine the appropriateness of chiropractic spinal adjustments. If the doctor discovers a non-chiropractic unusual finding when reviewing the x-ray, I will be informed. I understand that I must then make a determination, to seek additional advice, diagnosis, or treatment for the unusual finding from a health care provider. I understand that seeking advice from another type of health care provider should not interfere with the subluxation correction care provided by this office. CONSENT TO EVALUATE A MINOR CHILD I, Parent/Legal Guardian, of child, hereby grant permission for my child to receive chiropractic examinations and x-rays. PREGNANCY RELEASE FEMALES ONLY Please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation. The first day of my last menstrual cycle was on (Date) I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant. By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case. Print Patient Name Date of Birth 0Witness Patient or Authorized Person s Signature Date Rev