The Spinal Tuning Chiropractic Center s Health Profile Application and Practice Entrance & Policy Forms Table Of Contents: Health Profile Application, Pages 1&2: This standard health profile application will help the doctor and therapists determine along with the examination the nature of your specific case. Terms of Acceptance for Chiropractic Care, Page 3: This is a standard informed consent document that explains the purpose of chiropractic care. Both chiropractic and Advanced Neurophysiological Integration patients must sign before receiving care. Standard HIPPA Compliance Form, Page 4: This is a standard HIPPA compliance form that you would receive going into any health care provider s office today. Advanced Neurophysiological Integration (ANI) Consent Form, Pages 5-6: This form is only for those who wish to take part in Dr. Rohlfsen s ANI Program. This does NOT apply to standard chiropractic pain relief or massage therapy patients. Advanced Neurophysiological Integration goes beyond pain relief and works to better enhance your life experience. PLEASE BRING ALL DOCUMENTS WITH YOU ON YOUR INITIAL VISIT YOU CHOOSE! AT THE SPINAL TUNING CHIROPRACTIC CENTER IT S YOUR CHOICE IN GETTING THE TYPE OF CARE YOU WANT, RELIEF, REHABILITATIVE OR WELLNESS CARE
The Spinal Tuning Chiropractic Center Page 1 WELCOME TO ROHLFSEN FAMILY CHIROPRACTIC, P.C. Please print clearly and fill in completely Print Name: E-mail: Street Address: Phone: ( ) City: State: Zip: Date of Birth: / / Please Check Sex: Male Female Marital Status: Married Single Divorced Widowed SSN#: - - Health History: Reason for seeking chiropractic care: Describe any health problems, including how long you've had them: Are you under the care of any other doctor? Yes No If Yes, the conditions being treated for: List any current Medications: List any past surgeries & dates: List any past accidents & dates: Personal & Family History: Your Occupation: Phone: Job Title: Spouse s Name: Spouse s Date of Birth: / / Spouse s Health Status: Poor Fair Good Excellent Children's ages and health status: Chiropractic History: Have you ever been to a Chiropractor before? Yes No If yes Doctor's Name Date of last chiropractic visit / / Reason for care Date of last chiropractic x-rays / / How long were you under care? Are other family members under chiropractic care? - Yes No Who? Wellness Commitment: Please Check Are you open to looking at new ideas in health and wellness? Yes No At Rohlfsen Family Chiropractic we are dedicated toward achieving the goal of total lasting health for our members. To better help you achieve this, we need to understand your commitment toward being healthy. We do not ask for a financial commitment, but we do ask for your cooperative commitment. Based on a scale of 10% to 100%, please circle your personal level of commitment toward obtaining and maintaining your health and wellness. We can offer you two types of care in this office, relief care and wellness development care, the choice is always yours! 10%-----20%-----30%-----40%-----50%-----60%-----70%-----80%-----90%-----100% Where did you hear about our practice, or who referred you? FEMALES: Please Check One Is there a possibility of you being pregnant? Yes No
Page 2 Please Fill In Below If you have had the following, or if you suffer from the following, Please Check Condition, Symptom Or Problem Headache Migraines Neck Shoulder Arm/Hand Mid Back Low Back Hip Leg/Foot Disc Arthritis Other Joint Numbness Joint Swelling Dizziness Nausea Weakness Fatigue Nervousness Insomnia Heart Frequent Nose Colds Bleeds Ringing in Ears Earaches Hearing Loss Cough Chest s Female Allergies Asthma Cancer Symptoms Osteoporosis Diabetes Hypoglycemia Digestive Urinary Skin Other Problem Conditions Constantly or Frequently Sometimes or Occasionally Below, Please Fill In Any Other Health Information You Feel We Might Need For Your Care. Thank you for being complete and thorough. Signature: Date / / If you are planning on utilizing insurance please present your insurance card to the front desk. Please include birth date and SSN of the person responsible for payment. It is our pleasure and privilege to serve you, please tell others of your experience in our office. Our goal is to help inspire you and others in your quest for optimal health! Chad J. Rohlfsen D.C. The600, Spinal Tuning Chiropractic Center 8460 Birchwood CT. STE Johnston, IA 515 727-4000 4685 Merle fax: 515 Hay 727-4027 Road, Ste 206,You Des 50322 canmoines, now makeia your E-mail: appointment@rohlfsen.com 515 727 4000appointments at: AOL instant message: rfcfrontdesk www.spinaltuning.com www.rohlfsen.com
Page 3 THE SPINAL TUNING CHIROPRACTIC CENTER TERMS OF ACCEPTANCE FOR CHIROPRACTIC CARE ONLY When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or Unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider. Regardless of what the disease is called, I do not offer to treat it. Nor do I offer advice regarding treatment prescribed by others. MY ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. My only method is specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. (print name) All questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.!!!!!!!!! (signature) (date) Consent to evaluate and adjust a minor child I, being the parent or legal guardian of have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual period: (signature) (date)
The Spinal Tuning Chiropractic Center HIPPA Form Page 4 Consent for Purposes of Treatment, Payment & Healthcare Operations (3/03) In this document, I and my refer to the patient, and Chiropractor refers to The Spinal Tuning Chiropractic Center. I consent to the use or disclosure of my protected health information by Chiropractor for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Chiropractor. I understand that analysis, diagnosis or treatment of me by Chiropractor may be conditioned upon my consent as evidenced by my signature below. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Chiropractor is not required to agree to the restrictions that I may request. However, if Chiropractor agrees to a restriction that I request, the restriction is binding on Chiropractor. I have the right to revoke this consent, in writing, at any time, except to the extent that Chiropractor has taken action in reliance on this Consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I have been provided with a copy of the Notice of Privacy Practices of Chiropractor and understand that I have a right that Notice 's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiropractor. The Notice of Privacy Practices for Chiropractor is also posted in the waiting room at [insert address of Chiropractic practice]. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information. Chiropractor reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of Chiropractor and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. Signature of Patient or Personal Representative Printed Name of Patient Date of Signing Description of Personal Representative s Authority
Page 5 Advanced Neurophysiological Integration Consent Form This form is only for those who wish to take part in the full Advanced Neurophysiological Integration (ANI) Program I hereby request and consent to receiving ANI care, including wellness education in this office by a Dr. Chad Rohlfsen, a chiropractor who is in the process of developing a new technique called Advanced Neurophysiological Integration or ANI, a low/no force approach which has unique outcomes and clinical results. This practitioner chooses to practice Spinal Tuning, as he is professionally and personally confident in regard to the safety and effectiveness of this form of care. This office provides care in accordance with the Council on Chiropractic Practice Guidelines. Along with ANI I understand that Standard Chiropractic analysis and adjustments are given to remove the restricting subluxations within my spinal column to enhance the ANI experience. Advanced Neurophysiological Integration IS NOT a chiropractic technique and that is NOT taught in any chiropractic institution. It is very important that all ANI Participants understand this fact. The purpose of this consent form is to help me better understand the nature of the services offered in this office and our mutual responsibilities. This fosters a more effective relationship and avoids misunderstandings regarding expectations. Having well understood expectations is anticipated to promote a greater sense of safety and healing. Advanced Neurophysiological Integration does not attempt to manually, or by instrument, manipulate spinal fixations structurally (often associated with a snapping or popping sound), nor does it directly treat painful areas of the spine and body. Instead, by enhancing my body s awareness of itself and specifically my spine, I understand I can develop new strategies for healing, adapting to stress, and experiencing wellness. These strategies promote spontaneous self-correction and self-regulation of spinal tension patterns which allow me to adapt to stress much more effectively. Advanced Neurophysiological Integration consists of gentle touch contacts along the neck, back, pelvis and extremities to achieve greater communication between the brain and body, and new sensory and motor strategies. ANI also utilizes the aid of different pitches of tuning forks placed on different parts of the spinal column and extremities to calm the body and then to help elicit different autonomic muscular contraction patterns. ANI adopts an approach associated with somatic (body/spinal awareness) training. I understand there is another similar form of this care called Network Spinal Analysis and There is a body of research characterizing Network Spinal Analysis care and documenting its unique and significant wellness benefits. I understand I may obtain copies of published research articles and/or abstracts at www.associationfornetworkcare.com & www.jvsr.com I am aware that I will be receiving gentle touch ANI contacts along my entire spinal column and extremities. Assessments of my progress will include monitoring of my spine and body awareness, responsiveness to inner rhythms, tension, and ease patterns. At regular intervals, following commencement of care, reassessment will be performed using thermal measurement devises. These other assessments will include my personal perception of my wellness and my awareness of my spine and body-mind changes. My chiropractor will report to me the improvement in my spinal and nervous system integrity and my ability to self-regulate tension and to reorganize my spine. Advanced Neurophysiological Integration is advanced through a series of 3 known Levels of Care. These levels are called, Passive, In-coordinated Active, Coordinated Active. Each Level of Care involves the development of new and unique levels of relaxation as well as possible spontaneous muscular contractions & spinal wave motions, other body movements, and oscillations. These waves, which are suggested to be associated with greater spinal stability, the redistribution of energy, and the transfer of internal information are also associated with greater wellness, improved quality of life, and increased life enjoyment. I also understand that, in addition to Advanced Neurophysiological Integration care and wellness education, my practitioner may perform additional examinations or assessments and offer health/spinal care or advice that is consistent with my individual chiropractic needs. CONTINUE TO NEXT PAGE PLEASE INITIAL CONFIRM YOUR READ THE ABOVE PAGE.
Please Read and Sign the Following Page 2: Page 6 It has been explained to my satisfaction, and I understand that the care offered at this office is not a form of, or replacement for, the diagnosis or treatment of any symptom, disease, or malady. Instead, it is a form of wellness care and self-education that empowers my connection with my body-mind and develops new strategies for spinal and nervous system integrity and wellness. It develops new capacities in my body for the identification of, spontaneous release of, and redirection of tension, including those that are unique to Advanced Neurophysiological Integration as well as Network Spinal Analysis care. It is common for people receiving ANI care to breathe more deeply and more fully, engaging the spine with their respiration, to spontaneously adapt postures that release or redistribute tension, to bust stress, and to experience more of their inner life energy. I understand it is common to experience a wider range of motion and emotion during care. It is common, as care progresses, to find new options in the body and in life, which often lead to significant life changes. This form of care is NOT suggested for those individuals who wish to remove a symptom or condition without the occurrence of other fundamental changes in their lives. The care in this office often promotes significant changes in health choices, lifestyle, experience of the body-mind, emotion, and consciousness. Rather than attempting to simply return me to my previous state minus a symptom, this chiropractor instead chooses to help me achieve new levels of wellness and life potential that I may never have had before. Although in this office we seek to help you develop new strategies for wellness and spinal and nerve system integrity, as a chiropractor the sole condition of concern is that of the vertebral subluxation. In Advanced Neurophysiological Integration, we categorize these subluxations into two categories, a structural segmental distortion and a spinal cord/nerve elongation or stretching. Through the gentle force applications at the spine to enhance spinal and nerve system integrity, subluxations are corrected. This is the only condition that we address in our office. The only condition we offer to diagnose and correct is the vertebral subluxation and loss of spinal and neural integrity in relationship to this. We do not offer to diagnose or treat any other condition, disease, or symptom. If during the course of our spinal assessment/examination we encounter non-chiropractic or unusual findings, we will advise you of this. If you desire advice on further diagnosis or treatment of this condition, situation or circumstance, we will recommend that you seek the services of another health care provider whose practice is geared towards such differential diagnosis and treatment. I have read, or have had read to me, the CONSENT TO RECEIVE Advanced Neurophysiological Integration care and understand that the care in this office is still under development and is different from what many consumers may expect from chiropractors practicing manipulative therapy. I agree to receive care, which consists of or includes STANDARD CHIROPRACTIC & ANI and wellness education. I understand that I am not passive in the process, that I am an active participant in my care and in my healing. PRINTED NAME OF PRACTICE MEMBER SIGNATURE OF PRACTICE MEMBER " " DATE Chad J. Rohlfsen D.C. PRINTED NAME OF DOCTOR