PATIENT INFORMATION Name Date Address City State Zip Home Phone Work Phone Cell Phone Is it okay to contact you at work? Yes No Carrier: E-mail @ SSN - - DOB Age Occupation: Employer: Marital Status: S M D W L/W Spouse/Partner Name: Names and Ages of Children: Whom may we thank for referring you to our office? REASON FOR SEEKING CHIROPRACTIC CARE What concerns do you feel The Wellness Path can address for you? When did the symptoms first begin? Are these concerns affecting your quality of life? (please circle all that apply) Work: Y N Driving: Y N Sleep: Y N School: Y N Walking: Y N Sitting: Y N Exercise/Sports: Y N Eating: Y N Love Life: Y N HEALTH CARE PRACTITIONER HISTORY Have you ever received Chiropractic Care? Y N Name of D.C.: How long under Chiropractic Care? Days Weeks Months Years (please circle one) Date of last visit: Why did you stop care? Have you consulted or do you regularly consult any of the following providers? (check all that apply) Medical Physician Naturopath Acupuncturist Homeopath Massage Therapist Psychotherapist Energy Healer Dentist Reason: FOR WOMEN ONLY Are you pregnant? Y N Date of last menstrual period: If x-rays are recommended, your signature is required below to verify that you are NOT PREGNANT Signature: Date: Where will you be birthing your baby? Hospital Home Birthing Center Other:
HEALTH, WELLNESS AND CHIROPRACTIC CARE The primary system in the body that coordinates all function is the NERVOUS SYSTEM. The NERVOUS SYSTEM consist of your brain, spinal cord and the network of nerves that communicate to every cell, tissue and organ. When your body cannot adapt properly to the stresses of our lives, it causes something called, SUBLUXATION. SUBLUXATION is an interference of communication in your NERVOUS SYSTEM that impairs function and makes your body work harder than it should. SUBLUXATION can have a physical, chemical and mental/emotional causes and effects on your body. This information below will help us to see the types of PHYSICAL, CHEMICAL and MENTAL/ EMOTIONAL stresses you have been subjected to in our life and how they may have related to your present spinal, nerve and health status whether they may have caused Subluxations to occur. PHYSICAL STRESS: BIRTH AND INFANCY The birth process can traumatize a baby s spine and cause damage to the spine and nervous system. Please CHECK where and how you were birthed. (if you do not know, please skip to next question). Home Natural Hospital Caesarian section Forceps Breech Cord around Neck Prolonged Labor Drug Induced Suction/Vacuum Assisted PHYSICAL STRESS: CHILDHOOD THROUGH ADULT The minor and often ignored repetitive physical traumas that we have endured are often too numerous to list. Please list the major traumas that you remember from your childhood up to the present. Have you had any accidents due to any of the following? (check all that apply) Automobile Motorcycle Bicycle Sports Playground Abuse If yes, please state type of injury and date: Have you ever hurt, broken, fractured, sprained, injured or felt pain in any bones or joints (spine, head, neck, ribs, chest, upper or lower back, pelvis or hips, legs or arms)? YES NO If yes, please list body parts injured and dates of injuries: Have you ever been hospitalized or had surgery? YES NO If yes, please state reason and dates: EMOTIONAL STRESS: CHILDHOOD THROUGH ADULT It is difficult to separate the emotional stress in our life from the physical response that often occurs. Please indicate if you have ever or are experiencing any of the emotional stresses below: Childhood Trauma Y N Loss of Loved One Y N Abuse Y N Work or School Y N Divorce/Separation Y N Financial Y N Lifestyle Change Y N Parents Divorce Y N Illness Y N
CHEMICAL STRESS: CHILDHOOD THROUGH ADULT Chemical stress can occur when a substance that is toxic to the body, is breathed, injected, taken by mouth, or placed on the skin (e.g. food allergies, drug reactions, exposure to chemicals in the air, etc.) The following will reveal exposures you may have had. Were you vaccinated? Y N If yes, did you have a reaction? Y N Unsure Have you been exposed to any of the following on a regular basis (either in the past or presently)? Toxic Chemicals Second hand smoke Drug Therapy Radiation Chemotherapy Other If yes, please list and explain: Do you have any allergies or sensitivities to foods? Y N If yes, please list below: Do you presently consume any of the following? Coffee/Caffeine Alcohol Tobacco Over the Counter Drugs Prescribed Drugs Please list all medications (prescribed AND over the counter): QUALITY OF LIFE (presently) How do you grade your physical health? Good Fair Poor How do you grade your emotional/mental health? Good Fair Poor How do you rate your overall quality of life? Good Fair Poor Do you exercise regularly? If yes, how often: Do you take supplements? If yes, please list: EXPECTATIONS FROM CHIROPRACTIC CARE I would like to experience the following benefits from Chiropractic Care (check all that apply): Relief of symptom or problem Relief and Prevention of symptom or problem Healthier spine and Nervous System Optimal Health on All Levels OTHER:
GOALS FOR MY CHIROPRACTIC CARE Are you healthier now than you were a year ago? YES NO If yes, what did you do to accomplish this? Is it your goal to be healthier a year from now than you are today? YES NO Do you have a plan on improving your health? YES NO If yes, please explain If there is a need for dietary changes, would you like to know? If there is a need for specific exercises, would you like to know? If there is a need for support in the mental/emotional/body/stress dimensions of health, would you like assistance? At our office, we concern ourselves with YOUR health and YOUR wellness goals. Please list your goals for your health/wellness below Physical Goals Nutritional/Chemical Goals Psychological Goals AUTHORIZATION FORM Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, and public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view changes to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician s certifications. I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and or disclosed. Print Name Signature Date: Relationship to Patient (if minor)
AUTHORIZARION FOR CHIROPRACTIC CARE RESPONSIBILITY OF BILL The undersigned hereby accepts full financial responsibility for charges and services rendered to the patient. The undersigned understands that services are rendered and charged to the patient and not to the insurance company. The Chiropractic Care Center cannot accept total responsibility for collecting an insurance claim or negotiating a disputed settlement. The undersigned also agrees that this obligation shall exist regardless of private contractual agreement between the patient and any insurance carrier, attorney, or third party not signing this agreement. Financial responsibility will also include charges and services not covered by insurance for which payment is denied through may utilization review or precertification procedures. Signature AUTHORIZATION FOR PAYMENT OF INSURANCE BENEFITS TO PROVIDER I hereby irrevocably authorize payment of the medical benefits otherwise payable to me to be made payable and mailed directly to The Chiropractic Care Center for professional services rendered. NO OTHER THIRD PARTY, including my attorney, should receive payment of my bills except this office for the remainder of this claim. It will be assumed and relied upon that the insurance carrier has agreed to and acknowledges medical coverage and will send payments directly to this office. This payment will not exceed my indebtedness to the doctor/ clinic. I agree that a photostatic copy of this agreement shall serve as the original. Signature PATIENT AUTHORIZATION FOR CHIROPRACTIC CARE IN AN OPEN ADJUSTING AREA: It is the practice of this office to provide chiropractic care in an open adjusting environment. 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. 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 and health information. 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 effects on your care from Dr. Manzo or your relationship with our staff. Your signature indicates your authorization of this activity. Print Name Signature Date 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 Witness Date
AUTHORIZATION FORM When a patient seeks chiropractic care and we accept such a patient for 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 able to attain it. This will prevent any confusion or disappointment. 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 to the spine. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease/symptoms. Vertebral Subluxation is a misalignment of one or more of the joints of the body. This may or may not cause pain. This also will result in alteration of nerve function and interference of the transmission of nerve impulses, lessening the body s innate ability to heal and achieve optimal health. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic evaluation, 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 a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. One method is specific adjusting to the correct vertebral subluxation. I, have read and fully understand the above statement. Any questions regarding the Doctor s objectives pertaining to care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. Signature Date
INFORMED CONSENT I hereby request and consent to the performance of chiropractic procedures, including various modes of physio therapy, diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand and I am informed that, as is with all Healthcare treatments, results are not guaranteed and there is no promise to cure. I further understand and I am informed that, as is with all Healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. I further understand that Chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations allowing the body to return to improved health. It can also alleviate certain symptoms through a conservative approach with hopes to avoid more invasive procedures. However, like all other health modalities, results are not guaranteed and there is no promise to cure. Accordingly, I understand that all payment(s) for treatment(s) are final and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment. I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited self-administered, over the counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Print Patient Name Signature of Patient Date Printed Name of Chiropractor Signature of Chiropractor Date