ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -

Transcription

1 ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone: ( ) ext. Cell Phone: ( ) Best way to contact you: Address: Occupation: Employer: Marital Status: S M D W Spouse s Name: Occupation: Name/Age of Children: Emergency Contact: Relationship: Phone Number: ( ) How were you referred to our office? CURRENT HEALTH HISTORY Reason why you came to our office? When did this condition begin? / / How did this condition begin: Gradual Sudden What do you believe caused it? What activities aggravate your symptoms? Is there anything that has relieved your symptoms? Yes No If YES, please describe: Type of Pain: Sharp Dull Ache Burn Throb Spasm Numb Tingling Shooting Does the pain radiate into your: arm leg does not radiate Is this condition getting worse? Yes No How often do you experience these symptoms throughout the day? Constant Intermittent Rate the intensity of your pain (0= no pain; 10= severe pain) At worst At best Current level

2 Do your symptoms interfere with: Work Sleep Hobbies Daily Routine Other: Please explain: Have you experienced this condition before? Yes No If YES, please explain: Have you seen any other healthcare professional for this? Yes No If YES, please provide name & office: What were their recommendations: How did you respond to the recommendation: CHIROPRACTIC EXPERIENCE Have you seen a Chiropractor before? Yes No If YES, please provide name of Chiropractor: Approximately, when was your last visit? What was the duration and frequency of your care? What type of procedures were performed? How did you respond to the procedures and care? Did your previous Chiropractor take before and after x-rays? Yes No LIFESTYLE HABITS Do you exercise? Yes No How many times per week? If YES, what type of exercise or activities do you engage in? Do you smoke? Yes No If YES, how many cigarettes per day? Do you drink alcohol? Yes No If YES, how many drinks per week? Do you drink coffee? Yes No If YES, how many cups per day? Please provide a list if more space is needed for the following: Please list any supplements (i.e. vitamins, minerals, herbs, etc.) you take: Please list any medications you are taking and their purpose: Please list all past surgeries: Please list all previous accidents and falls:

3 REVIEW OF SYSTEMS (Please check all conditions that you have or have had in the past) General Information: Musculoskeletal System: Concentration/Focus Problems Muscle/Tendon/Ligament Tear Loss of memory Disc herniation Low energy Tendinitis Excessive Stress Bursitis Chills Arthritis Convulsions/Seizures Muscle pain Dizziness/Vertigo Muscle cramps/spasms Fainting Lower back pain Fever Neck pain Headaches/Migraines Shoulder/Elbow pain Sleep loss/insomnia Wrist/Hand pain Recent weight loss Hip/Knee pain Recent weight gain Ankle/Foot pain Nervousness/Anxiety Hernia Depression Numbness/Tingling Neuralgia Sciatica Night sweats Scoliosis Tremors Concussion Loss of balance Ringing in Ears Nose bleeds Vision problems Respiratory System Cardiovascular System Asthma High blood pressure Chest pain Low blood pressure Chronic cough Hardening of arteries Difficulty breathing Swelling of ankles Shortness of breath Poor circulation Coughing up blood Irregular heartbeat Wheezing High or elevated cholesterol

4 Urinary/Reproductive System Digestive System Bedwetting Excessive gas Blood in urine Colitis Frequent urination Constipation Difficulty urinating Diarrhea Inability to control bladder Acid reflux/ heartburn Kidney infections Gall stones Urinary tract infections Hemorrhoids Kidney stones Loss of appetite Painful urination Increase in appetite Enlarged prostate Liver problems Painful menstruation Jaundice Hot flashes Nausea Irregular cycle Vomiting Lumps in breast Stomach pain Miscarriages Ovarian cysts Endometriosis Difficulty getting pregnant Immune System Integumentary (Skin and Hair) System Allergies Loss or thinning of hair Frequent colds Eczema Influenza Psoriasis Sinus infections Dry, flaky skin Sore throats Rashes Ear infections Hives Swollen glands Acne Autoimmune disorder Weak or brittle nails Conditions/Diagnosis Hypertension Rheumatoid Arthritis Diabetes Hyperthyroidism Multiple Sclerosis Hypothyroidism Parkinson s Disease Osteoarthritis Fibromyalgia Celiac Disease Ulcerative Colitis Irritable Bowel Syndrome Crohn s Disease Sjogren s Disease Raynaud s Disease Other

5 HIPAA Form Consent for Purposes of Treatment, Payment & Healthcare Operations Inthisdocument, I and my refertothepatient,and Chiropractor referstodr.justingraforabundanthealth Chiropractic. IconsenttotheuseordisclosureofmyprotectedhealthinformationbytheChiropractorforthepurposeof analyzing,diagnosingorprovidingtreatmenttome,obtainingpaymentformyhealthcarebillsortoconduct healthcareoperationsofthechiropractor.iunderstandthatanalysis,diagnosisortreatmentofmebythe Chiropractormaybeconditioneduponmyconsentasevidencedbymysignaturebelow. IunderstandthatIhavetherighttorequestarestrictionastohowmyprotectedhealthinformationisusedor disclosedtocarryouttreatment,paymentorhealthcareoperationsofthepractice.thechiropractorisnot requiredtoagreetotherestrictionsthatimayrequest.however,ifthechiropractoragreestoarestriction thatirequest,therestrictionisbindingonthechiropractor. Ihavetherighttorevokethisconsent,inwriting,atanytime,exceptthattheChiropractorhastakenactionin relianceonthisconsent. My protectedhealthinformation meanshealthinformation,includingmydemographicinformation,collected frommeandcreatedorreceivedbymyphysician,anotherhealthcareprovider,ahealthplan,myemployerora healthcareclearinghouse.theprotectedhealthinformationrelatestomypast,presentorfuturephysicalor mentalhealthorconditionandidentifiesme,orthereisareasonablebasistobelievetheinformationmayidentify me. IunderstandthatIhavearighttoreviewtheNoticeofPrivacyPracticespriortosigningthisdocument.TheNotice ofprivacypracticesdescribesthetypesofusesanddisclosuresofmyprotectedhealthinformationthatwilloccur inmytreatment,paymentofmybillsorintheperformanceofhealthcareoperationsofthechiropractor.the NoticeofPrivacyPracticesfortheChiropractorisalsopostedinthewaitingroomatAbundantHealthChiropractic. ThisNoticeofPrivacyPracticesalsodescribesmyrightsanddutiesoftheChiropractorwithrespecttomy protectedhealthinformation. TheChiropractorreservestherighttochangetheprivacypracticesthataredescribedintheNoticeofPrivacy Practices.ImayobtainarevisednoticeofprivacypracticesbycallingtheofficeoftheChiropractorandrequesting arevisedcopybesentinth oraskingforoneatthetimeofmynextappointment. Date: SignatureofPatientorGuardianPrintedNameofPatient

6 Authorization+for+Chiropractic+Care+ Thepracticeofchiropracticincludesmanystandardexaminationandtestingprocedures.Theseincludephysical examination,orthopedicandneurologicaltesting,palpation,specializedinstrumentations,laboratorytests, radiologyexaminations,physiotherapy,andrehabilitativeprocedures.additionally,thereisaprocedureuniqueto thechiropracticprofessionmthechiropracticspinaladjustment. Adjustmentsaremadebychiropractorstocorrectspinalandextremityjointsubluxation.Oneofthemostcommon disturbancestothenervoussystemisthevertebralsubluxation.thisconditionexistswhereoneormore vertebraeinthespinearemisalignedsufficientlytocauseinterferencesand/orirritationofthenervoussystem. Theprimarygoalinchiropractichealthcareistheremovalofnerveinterferencebysuchsubluxation(s). Notonlyshouldyouunderstandthebenefitsofchiropracticcareinrestoringandmaintaininggoodhealth,butyou shouldalsobeawareoftheexistenceofsomeinherentrisksandlimitations.theseareseldomenoughto contraindicatecare,butshouldbeconsideredinmakingthedecisiontoreceivechiropracticcare.allhealthcare procedures,includingthoseusedinvaryingdegrees,havesomerisksassociatedwiththem.risksassociatedwith somechiropracticadjustingproceduresmayincludemusculoskeletalsprain/strain,neurologicaldeficits,osseous fracture,vertebralarterysyndrome(vas),includingstrokeandperhaps,deaththroughcomplicatingfactors. Ihavebeeninformedofthenatureandpurposeofthechiropracticcare,thepossibleconsequencesofthecare,and theriskofcare,includingtheriskthatthecaremaynotaccomplishthedesiredobjective.reasonablealternative treatmentshavebeenexplained,includingrisks,consequences,andprobableeffectivenessofeach.ihavebeen advisedofthepossibleconsequencesifnocareisprovided.iacknowledgethatnoguaranteeshavebeenmadeto meconcerningresultsofthecareandtreatment. IHAVEREADTHEABOVEPARAGRAPHS.IUNDERSTANDTHEINFORMATIONPROVIDED.THISINFORMATION HASBEENEXPLAINEDTOMEANDALLQUESTIONSWHICHIHAVEASKEDHAVEBEENANSWEREDTOMY SATISFACTION. HAVINGTHISKNOWLEDGE,IKNOWINGLYAUTHORIZEDR.JUSTINC.GRAFTOPROCEEDWITHCHIROPRACTIC CAREANDTREATMENT. Signature: Relationship: Date: