Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient understands the type of services we legally provide. Chiropractic care is a separate health care service from the practice of medicine. We do not prescribe drugs, do injections, or diagnose medical conditions, diseases, or cancer. If we ever feel you have a health situation that may require medical attention, we will advise you to consult with your medical doctor. If you ever feel you have a health situation that may require medical attention, please consult with your medical physician. Privacy Policy The new HIPPA laws require us to inform you that your health information will be kept private and not shared with anyone. Make sure you read our tice of Privacy Practices form in our office. I have read and fully understand the above statements. I acknowledge that I have received, reviewed, and agree to the tice of Privacy Practices of this office. I understand the terms of acceptance and privacy policy and accept care at Van Wyk Chiropractic Center on this basis. Your Signature Date
Van Wyk Chiropractic Center Patient Information Date: Legal First Name: MI: Last Name: Street Address: Apt #: City: State: Zip: Age: DOB: Social Security #: - - Marital Status: S M W D Occupation: Employer: Spouses Name: Spouses Occupation: Name of Children and Ages: Have you ever received chiropractic care? Date of last chiropractic visit: Language: English Spanish Indian Japanese Chinese Korean French German Russian Other Race: White American Indian or Alaska Native Asian Native Hawaiian/Pacific Islander Black or African American Hispanic or Latino Decline to Answer Ethnicity: Hispanic or Latino t Hispanic or Latino Decline to Answer Home Phone: Cell Phone: Work Phone: Email Address: Please Check Your Contact Preference: Cell Phone Home Phone Work Phone Email Emergency Contact: Phone Number: Whom Can We Thank For Referring You To Our Office? Health History Are you seeing any other doctors for any health conditions? Yes If yes, who are you seeing and for what? Please list any current medical diagnosis you have or other medical conditions you are experiencing? Check all of the following symptoms that you currently have, or have had in the last year. Headaches Dizziness Loss of Smell Fatigue Neck Pain Stomach Problems Loss of Taste Depression Difficulty Sleeping Neck Stiffness Light Bothers Eyes Ears Ring Back Pain Pins & Needles in Arms Loss of Memory Diarrhea Nervousness Pins & Needles in Legs Cold Sweats Fainting Irritability Numbness in Fingers Muscle Tension Fever Chest Pains Numbness in Toes Constipation Acid Reflux Shoulder Pain Shortness of Breath Loss of Balance Hands Cold Tension Night Sweats Buzzing in Ears Feet Cold Are you having pain, difficulty, or problems with any of the following: Dressing Grooming Walking House Work Sitting to Standing Lifting Standing Driving In/Out of Bed Climbing Stairs Sitting Exercise Do you smoke? Never Former Smoker Current/Every Day Smoker Current/Some Day Smoker
Have you. If yes, include date & provider been hospitalized in the last 5 years? Yes been diagnosed with Diabetes? Yes Type 1 Type 2 been treated for hypertension? Yes Family Health History Is there a family history of: Heart Disease Arthritis Cancer Diabetes Other Father s Side Mother s Side Medications Are you currently taking any medications? Circle one: Yes If yes, what medications are you currently taking? Include vitamins, herbs, minerals List the date started, Brand Name, Generic Name, Strength, Dosage, Frequency, Quantity, Refills Available, Prescribed by Please be as specific as possible: Surgeries Have you had any spinal surgeries or other surgeries? Circle one: Yes If yes, please list the surgeries you ve had and their dates: Surgery: Date: Surgery: Date: Surgery: Date: Allergies Do you have allergies? Circle one: Yes If yes, are they: Food Environmental Medication List the type of allergies you have and their reactions: Allergy: Reaction: Allergy: Reaction: Allergy: Reaction: Major Illness Have you had any major illnesses? Circle one: Yes If yes, list the major illnesses you ve had and the date you had them: Illness: Date: Illness: Date: Illness: Date: Current Health Problem What brings you into our office today? Please fill out the forms on the next pages to give us more information about your current health problem. If you do not have pain in an area, just circle on the first question.
Neck Pain Do you have neck pain or stiffness? (circle one) Yes How long have you had neck pain? Describe the onset (circle one): acute chronic gradual What caused your neck pain? (circle one): unknown accident other: Have you had prior neck pain? (circle one): none on and off for years years ago Which side does your neck hurt? (circle one): left right both sides Describe the pain (circle those that apply): achy burning dull sharp stiff throbbing Is your neck pain (circle one): mild moderate severe On a scale of 1 to 10, how bad is your pain at its worst? How often are you having pain? (circle one) constant frequent intermittent occasional Are you having pain (circle one): hourly daily weekly monthly Does the pain radiate into your back, shoulders or arms? If yes, where? When does the pain feel worse? (circle one) What makes the pain worse? (circle one) nothing resting sleeping walking working movement When does it feel better? (circle one) What makes the pain feel better? (Circle those that apply) nothing cold heat chiropractic care massage medication movement resting sleeping walking stretching Is there any numbness or tingling? Yes If yes, where? Are you having trouble moving your head? Yes Do you have pain when moving your head? Yes What are you doing at home to help with your pain? Have you seen other doctors for your current neck pain? Yes If yes, their recommendations? Headaches Do you get headaches? Yes Where do you get headaches? (circle one) forehead top of head around your temples back of head What time of day are your headaches? (circle one) constant in the morning as day progresses afternoon during the day evening sleep How often do you get headaches? (circle one) daily weekly monthly hourly How long, in minutes or hours, do your headaches usually last?
Back Pain Do you have back pain or stiffness? (circle one) Yes Where is your back pain? (circle those that apply) upper back mid back low back How long have you had back pain? Describe the onset (circle one): acute chronic gradual What caused your back pain? (circle one): unknown accident other: Have you had prior back pain? (circle one): none on and off for years years ago Which side does your back hurt? (circle one): left right both sides Describe the pain (circle those that apply): achy burning dull sharp stiff throbbing Is your back pain (circle one): mild moderate severe On a scale of 1 to 10, how bad is your back pain at its worst? How often are you having pain? (circle one) constant frequent intermittent occasional Are you having pain (circle one): hourly daily weekly monthly Does the pain radiate into your buttocks, groin, or legs? If yes, where? When does the pain feel worse? (circle one) What makes the pain worse? (circle those that apply) nothing resting sleeping walking working movement When does it feel better? (circle one) What makes the pain feel better? (circle those that apply) nothing cold heat chiropractic care massage medication movement resting sleeping walking stretching Is there any numbness or tingling? Yes If yes, where? Are you having trouble moving/bending your back? Yes Do you have pain when moving/bending your back? Yes What are you doing at home to help with your pain? Have you seen other doctors for your current neck pain? Yes If yes, their recommendations?
Extremity Pain Or Problems Do you have pain or a problem with (circle one): shoulder elbow wrist knee ankle foot How long have you had the pain? Describe the onset (circle one): acute chronic gradual What caused the pain? (circle one): unknown accident other: Have you had prior pain at this location? (circle one): none on and off for years years ago Which side is the pain? (circle one): left right both sides Describe the pain (circle those that apply): achy burning dull sharp stiff throbbing Is your pain (circle one): mild moderate severe On a scale of 1 to 10, how bad is your pain at its worst? How often are you having pain? (circle one) constant frequent intermittent occasional Are you having pain (circle one): hourly daily weekly monthly Does the pain radiate anywhere? If yes, where? When does the pain feel worse? (circle one) What makes the pain worse? (circle those that apply) nothing resting sleeping walking working movement When does it feel better? (circle one) What makes the pain feel better? (circle those that apply) nothing cold heat chiropractic care massage medication movement resting sleeping walking stretching Is there any numbness or tingling? Yes If yes, where? Are you having trouble moving/bending your back? Yes Do you have pain when moving/bending your back? Yes What are you doing at home to help with your pain? Have you seen other doctors for your current neck pain? Yes If yes, their recommendations?
Insurance Information We will make a copy of your insurance card/s. However, please complete the following information. Are you the policy holder? Y N If no, who is the policy holder? Policy Holder s Name: Policy Holder s DOB: Policy Holder s SS#: Policy Holder s Employer: Do you have secondary insurance coverage? Y N Assignment & Release Insurance Information I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this doctor s office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees or outstanding balances for services I have received will be immediately due and payable. Patient s/parent/guardian Signature: Consent of Professional Services and Release Information I hereby authorize and release the doctor and whomever he/she may designate as his/her assistants, to administer treatment, physical examination, x-ray studies, laboratory procedures, chiropractic care or any clinic services that he/she deems necessary in my case; I furthermore authorize him/her to disclose all or any part of my patient record to any person or corporation which is or may be liable under a contract to this office or to the patient or to a family member or employer of the patient for all or part of the clinic s charge, including, and not limited to hospital or medical service companies, insurance companies, worker s compensation carriers, welfare funds, or the patient s employer. Patient s/parent/guardian Signature: I hereby certify that the statements and answers given on this form are accurate to the best of my recollection and knowledge. I agree to allow this office to examine me for further examination. I hereby give my permission to the doctor to release any information requested by my insurance company acquired in the course of my examination and treatment. I understand that I am ultimately responsible for all fees for services rendered that my insurance company does not cover, and that fees are payable within 30 days after discovering what the insurance will not pay All other types of payments are to be paid when the services are rendered unless special arrangements are made. Signature: Date: