Welcome to the Dynamic Essence tribe! 746 Wealthy St SE Grand Rapids, MI 49503 P: 989.573.1170 DynamicEssenceChiropractic@gmail.com We empower you to reclaim your power. Elevate your unique expression. New Patient History Today s Date: Name: Birth Date: Sex: Mailing Address: Home Phone: How did you hear about us? Cell Phone: e-mail: Spouse/Partner s name: Phone: Names and ages of children: Emergency contact: Phone: If you were referred by someone, who can we thank? What are your objectives in consulting with us? Insurance Information Primary Insurance: Member ID #: Policy holder s name: Policy holder s date of birth: Policy holder s employer: Secondary Insurance: Member ID #: Policy holder s name: Policy holder s date of birth: Policy holder s employer: Current health goals: Rate your level of stress (0-10; 10 is highest): Rate your level of overall vitality (0-100%) What causes your stress? (ie. Health, family issues, work, etc) If less that 100%, why? At what point in your life did you feel best? Reason for visit Are you here for: foundational wellness checkup OR specific concern
What are your current health concerns: Have you received care for this before: If yes, explain: When did this begin: How and when did this start: What makes it worse: Better: Rate your severity of discomfort (scale 0-10 where 10 is worst): During movement: During rest: In the diagram to the below, mark the figures in relation to where you experience symptoms on your body. Use the symbols below to show what you are experiencing A = Aching B = Burning I = Stiff & Tight N = Numbness P = Pressure R = Radiating S = Sharp & Stabbing T = Tingling Personal history of stress and injuries The majority of health challenges that we face in life come from an accumulation of stress and injuries. Stress builds up from the very beginning of life, long before we experience any symptoms. Since we focus on addressing the cause of health challenges, not just the symptoms, it is important to have a clear sense of the stress your body has endured. The following are the most common stressors that can impact your nervous system. Please think back through your life and mark if you have experience any of the following and at what ages. Physical Stressors Childhood; 0-18 Adulthood; 18 Present Notes Birth Trauma Significant Falls Broken Bones Sports Injuries Physical Abuse
Surgeries Car Accident Physical Labor Sitting/Computer use Other: Emotional Stressors Childhood; 0-18 Adulthood; 18 Present Notes Abuse/Neglect Teasing/Bullying Moving Loss of Loved Ones Family Stress Relationship Stress Financial Stress Sexual Abuse School/Work Stress Other: Chemical Stressors Childhood; 0-18 Adulthood; 18 Present Notes Sugar/Junk Food Diet Sweeteners Medications Vaccinations Environmental Toxins Tobacco Caffeine Recreational Drugs Alcohol Other: HOW DO YOU RATE YOUR OWN WELLBEING? Please rate each of the following areas of your current life from 0-10 (1=dissatisfied; 10=totally satisfied) Energy level Quality of sleep Financial abundance Ease of movement Spirituality / Connection Time in nature Ease of respiration Clarity of thought Amount of sleep Overall wellness Happiness / joy Job satisfaction Excitement about future Ease of digestion Sense of purpose in life Time with family Peace of mind How loved do you feel Time for yourself Relationships Safety
Current weight: 6 months ago: One year ago: Would you like your body to be different? YES NO If so, what? What creative outlets do you currently have? Do you want to be more creative? YES NO If so, how? Do you have a sense of life purpose? YES NO What is it? Do you practice goal setting? Do you feel part of a supportive social network (family, friends, coworkers)? Do you have a sense of spiritual connection (religious or otherwise)? How much time do you regularly spend in nature (grass, lakes, ocean, woods, etc)? How many glasses of pure water do you drink per day? Do you have good eating habits? YES NO What is a typical: Breakfast Lunch Dinner Snack (include frequency) Indicate how much and how often you consume the following Fresh fruit White sugar Whole grains Fruit juice Fresh vegetables Sweets Green vegetables Soda Salad/raw vegetables Alcohol Red meat Dairy products Seafood Junk food Caffeine Non-medical drugs Does your diet include any sources of Omega-3 Essential Fatty Acids? Please provide source, frequency, and amount Does your diet include any sources of probiotics (fermented foods or supplemented)? Source, frequency, amount What percentage of your food is home cooked? Do you cook? Where does the rest come from? Are there any dietary improvements that you would like to make or are currently working on? What foods did you eat often as a child? Do you crave sugar, coffee, cigarettes, or have any major addictions? List any medications, supplements, or medicinal herbs and reasoning where applicable :
Do you have any allergies? (drugs, chemical, foods, environment, etc) Do you do any daily or regular activity for your health and well-being or stress management? If yes, what and how often? What roles do sports and exercise play in your life? Sleep: average numbers of hours per night Is it enough? Position (side, back, stomach): Number of pillows under head: Quality of sleep: How much sunshine do you get? Do you wear sunscreen? What kind? Occupation: Employers name and address: Does your work involve : Prolonged sitting At a computer? Heavy lifting Mental pressure? Exposure to chemicals Repetitive motions Do you enjoy your work? If money were no object, what would you do with your life? Trauma history Please note date or age, what was injured, and treatment (if any) Accidents/Falls/Injuries: Auto accidents (please list ALL accidents, even minor fender benders): Severe Illness: Surgeries: Hospitalizations of any other reason: Date of last x-ray: Area(s) x-rayed: Reason, if not already listed: History of high impact or contact sports:
Terms of Acceptance Please read the policies outlined below, let us know if you have any questions, and sign the acknowledgement. Informed Consent We encourage and support a shared decision making process between us regarding your health needs. As a part of that process, you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed to knowledgably give or withhold your consent. Chiropractic is based on the science, which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health. Adjustments are made by chiropractors in order to correct or reduce spinal and extremity joint subluxations. Vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and/or does not move properly causing interference and/or irritation to the nervous system. The primary goal in chiropractic care is the removal and/or reduction of nerve interference cause by vertebral subluxation. A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, specialized instrumentation, radiological examination, and laboratory testing. The chiropractic adjustment is the application of a precise movement and/or force into the spine or extremity in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. In addition, physiotherapy or rehabilitative procedures may be included in the management protocol. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life. In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them. Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. Risks associate with physiotherapy may include the preceding as well as allergic reaction and muscle and/or joint pain. In addition there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate the patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment. I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been
explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to concerning the results of the care and treatment. I have read the above paragraph. I understand the information provided. All questions I have about this information have been answered to my satisfaction. Having this knowledge, I knowingly authorize Dynamic Essence chiropractic Center to proceed with chiropractic care and treatment. Patient Signature Date Social Media Consent I DO authorize Dynamic Essence Chiropractic Center to display testimonials, photographs, and videos of me in the office or on social media outlets. I understand that the purpose of sharing this information is to provide other s with chiropractic education. My consent remains in effect until revoked by me in writing. I DO NOT authorize Dynamic Essence Chiropractic Center to display testimonials, photographs, or videos of me in the office or on social media outlets at this time. Appointment Policy There is a fee charged for all appointments that are not canceled within 24-hour notice prior to scheduled visit. If you find yourself running late, please call our office and notify the front desk and we will get you in for your visit as soon as possible. When you fail to notify us, this leaves a slot open that could otherwise be used to help someone else. Please help us help others. Thank you. Payment Policy The first day s charges are expected on your initial visit. We accept cash, check, or credit card. Insurance: Please present your insurance card today. We will call your insurance company for you to verify your coverage. If you have coverage for your chiropractic care, our office will submit claims for you. After your insurance company has been reached for benefit information a financial payment plan will be presented on your following visit. Until we have the completed necessary insurance information, you will be required to pay for your care on a cash basis.* Cash: Fees are to be paid at the time services are rendered, unless special arrangements have been made in advance. Work Injury: You need to report your accident to your employer, bring in necessary insurance information. Complete and sign a required Accident Report in our office. Until the necessary information is provided OR if the claim is denied you will be required to pay for your care on a cash basis. Approved worker s compensation claims are not required to pay for care as it is rendered. Transfer of Care claims will be verified with the claims manager. Reopening of claims closed past 90 days will require patient to make personal arrangements and will be reimbursed if claim is allowed.* Personal Injury: You need to provide us with the accident report, your auto insurance, health insurance, and attorney if applicable. If the claim is a possible third party liability, please provide us with the other parties insurance carrier information. Until necessary insurance information is gathered and verified for chiropractic care, you will be required to pay for your care on a cash basis. Patients with approved personal injury claims are not required to pay for care as it is rendered. Patients who are covered by third party insurance only will need to check with the insurance department to make payment arrangements.*
*I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Dynamic Essence Chiropractic Center will prepare all necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Dynamic Essence Chiropractic Center will be to my account on the 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 for professional services rendered to me will be immediately due and payable. Open adjusting environment It is the desire of this office to provide chiropractic care in an open adjusting environment. An open adjusting area involves several patients being seen in the same adjusting room at the same time. Patients are within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting. We are requesting this authorization of you due to various interpretations under federal law with respect to what is known as an incidental disclosures of health information. It is our view that the kinds of matters related in an open adjusting environment are incidental matters, in the event you or someone else would not agree with us we are providing this disclosure and requesting your authorization. The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care. If you choose not to be adjusted in an open adjusting environment, other arrangements will be made for you. Your decision will have no adverse effect on your care from the doctor(s) at Dynamic Essence Chiropractic Center or on your relationship with our staff. This authorization may be revoked by you at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our procedures to be completed. Parental Consent for Minor Patient Patient Name: Patient age: DOB: Printed name of person legally authorized to sign Signature Relationship to patient Notice of Privacy Practices This notice describes how health information about you may be used and disclosed and how you can get access to your health information and records. Dynamic Essence Chiropractic Center understands the importance of privacy and we are committed to maintaining the confidentiality of your protected health information (PHI) in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We have developed office policies and procedures that protect your personal and health information when used within our office and any devices used to copy or transfer this data. We assure you that your information will only be shared as required and only for the purpose of administering your case and obtaining payment for services. Be assured that without your permission, your health information will not be used for any other purpose.
The following ways are how your PHI may be used within our office to provide you the best care and services possible: To provide treatment, obtain payment, and conduct health care operations. To schedule appointments and send reminders. To communicate with your family, friends, and/or caregivers with your authorization. As permitted or required by the law. For certain activities when the law requires it. The following describes your rights regarding your PHI. You may: Request to inspect any copy of your records. Request to amend incomplete or inaccurate information in your records. Receive an accounting of certain disclosures of your health information. Ask for additional privacy protections (although your request may be declined). Ask for confidential communications in a particular manner. Receive a paper copy of this Notice. File a complaint without penalty Dynamic Essence Chiropractic Center reserves the right to change this privacy policy as allowed by law and to make the new notice apply to health information already received as well as any information received in the future. A copy of our current notice is available upon request. The notice will contain the effective date in the top right-hand corner. If you believe that we have not properly respected the privacy of your PHI, you may file a complaint with our center by calling (989) 573-1170, sending a letter to our office address: 746 Wealthy St SE, Grand Rapids, MI 49503, or by emailing info@grandrapidschirocenter.com Acknowledgement I have read and fully understand the above statements. I have reviewed the notice of privacy practices (HIPAA) and have been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy. I have reviewed and understand the informed consent, social media consent, appointment policy, payment policy, and open adjusting environment. Print Name Signature Date I consent the release of my protected health information over the telephone, email or via mail to the following individuals (please include your spouse): Name of Person: Relationship: Phone number: I understand that the information used or disclosed pursuant to the consent may be subject to re-disclosure by the recipient and no longer be protected by HIPPA. I also understand that this consent will remain in effect until revoked in writing.
Print Name Sign Name Date