New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Email Address Occupatin Emplyer s Name Single / Married / Divrced / Widwed Spuse s Name Number f Children Names, Ages, & Gender Wh may we thank fr referring yu? List the health cncerns that brught yu int this ffice Health Cncern: Rate f Severity When did Have yu had the Did the Are symptms List accrding 0 = n pain this prblem prblem befre? prblem begin cnstant (C) r t severity. 10 = unbearable start? If s, when? with an injury? intermittent (I)? A: B: C: D: Have yu ever seen ther dctrs fr these cnditins? Yes N If Yes: Chirpractr Medical dctr Other Wh? When? Results? Please Mark P Fr In The Past OR Mark C Fr Currently Have: Headaches Ear Infectins Sinus Issues Kidney Prblems Sexual Dysfunctin Migraines Hearing Lss Frequent Clds Bladder Prblems Sleep Prblems Jaw/TMJ Pain Ringing in the Ears Thyrid Issues Menstrual Prblems Tight/Sre Muscles Neck Pain Dizziness Asthma Prstate Prblems Sprts Injury Shulder Pain Lss f Energy Chest Pain Infertility Sciatica Arm Pain Nervusness Heart Prblems Fibrmyalgia Arthritis/Jint Pain Upper Back Pain Duble/Blurry Visin Nausea Epilepsy/Cnvulsins GERD/Gastric Reflux Mid Back Pain Anxiety Ulcers Tremrs Numb/Tingling in Arms/Hands Lwer Back Pain ADD/ADHD Digestive Issues Disc Prblems Numb/Tingling in Legs/Feet Hip/Leg Pain Lss f Balance Diarrhea Sclisis Stmach Prblems Knee Pain Depressin Cnstipatin Pr Psture High/Lw Bld Pressure Ft Pain Allergies Bed Wetting Skin Prblems Difficulty Breathing Other: Page 1
Please Mark P Fr In The Past OR C Fr Currently Have: Strke Cancer Heart attack Spinal Surgery Spinal Bne Fracture Sclisis Diabetes Arthritis Seizures Other Cnditins List all surgical peratins & years: List any ther injuries t yur spine, minr r majr, that the dctr shuld knw abut: List all ver the cunter & prescriptin medicatins yu are n, & the reasn fr each: Have yu ever been in an aut accident? List all: Have yu ever been kncked uncnscius? Yes N Explain Fractured A Bne? Yes N Explain: Other trauma: Scial Histry 1. Smking: Hw ften? Daily Weekends Occasinally Never 2. Alchl: Hw ften? Daily Weekends Occasinally Never 3. Exercise: Hw ften? Daily Weekends Occasinally Never 4. Have yu cnsumed any caffeine r prducts with caffeine in the past 48 hurs? Yes N Quadruple Visual Analgue Scale Please circle the number that best describes the questin asked. If yu have mre than ne cmplaint, please answer each questin fr each individual cmplaint listed n page ne and indicate the crrespnding letter abve EXAMPLE: N pain A B Wrst pssible pain 1. Hw wuld yu rate yur pain RIGHT NOW? 2. What is yur typical r AVERAGE pain? 3. What is yur pain level at its BEST? (Hw clse t 0 des yur pain ever get?) 4. What is yur pain level at its WORST? (Hw clse t 10 des yur pain get at its best?) Health Gals Please list yur tw main health gals that yu wuld like t achieve while under care in this ffice: 1. 2. Page 2
Family Health Histry This frm is t assist the dctrs by prviding past health histry infrmatin fr their review. CONDITION SPOUSE MOTHER FATHER SON DAUGHTER Headaches Neck Pain Jaw/TMJ Pain Shulder Pain Back Pain Hip/Leg Pain Arthritis/Jint Pain Ear Infectins Hearing Lss Dizziness Lss Of Energy Nervusness Blurred/Duble Visin Anxiety ADD/ADHD Depressin Allergies Sinus Issues Thyrid Prblems Asthma Breathing Prblems Heart Prblems High/Lw Bld Pressure Stmach Prblems Infertility Bed Wetting Sciatica Sleep Prblems Strke Fibrmyalgia Pr Psture Alzheimer s Diabetes Heart Disease Cancer Page 3
ACTIVITIES OF LIFE Please identify hw yur current cnditin is affecting yur ability t carry ut activities that are rutinely part f yur life: CIRCLE 3 activities that affect yu the mst n a day t day basis. Climb Stairs Walk Run Sleep Dress Carry Grceries Pet Care Drive Lift Extended Cmputer Use Husehld Chres Read/Cncentrate Shaving Sweep Vacuum Dishes Laundry Yard Wrk Static Standing Static Sitting Page 4
Practice Member Infrmatin (Must be Cmpleted Befre Services Can Be Rendered) NAME OF PRIMARY INSURANCE CARRIER: Name f Insured Insured Date f Birth Insured Scial Security Number NAME OF SECONDARY INSURANCE CARRIER: Name f Insured Insured Date f Birth Insured Scial Security Number: SOCIAL SECURITY NUMBER: CONTACT IN CASE OF EMERGENCY: Phne #: Insurance Plicies and Fee Schedule Cnsultatin- includes practice member histry. This service is cmplimentary Assessment (new r established practice member)- includes ne r mre f the fllwing: thermgraphy, surface electrmygraphy, range f mtin, mtin and/r static palpatin, leg check $20-$80. Chirpractic Adjustment- The actual re-alignment f the vertebra dne by hand. Often a sund will be heard, but if there is n auditry result, it des nt mean that the adjustment has nt taken place. $10-$50. X-rays- Specific x-ray views taken f yur spine t determine a misalignment/subluxatin f yur vertebrae. These can als be used t indicate prgress after perid f care. $25 per view. Release f Authrizatin/Assignment f Benefits I authrize and request payment f insurance benefits directly t Juan Munz DC. I agree that this authrizatin will cver all services rendered until I revke the authrizatin. I agree that a phtcpy f this frm may be used in place f the riginal. All prfessinal services rendered are charged t the patient. It is custmary t pay fr services when rendered unless ther arrangements have been made in advance. I understand that I am financially respnsible fr charges nt cvered by this assignment. Signed Date Ntice f Privacy Practices Acknwledgement I understand that I have certain rights f privacy regarding my prtected health infrmatin, under the Health Insurance Prtability & Accuntability Act f 1996 (HIPPA). I understand that this infrmatin can and will be used t: 1. Cnduct, plan and direct my treatment and fllw-up amng the multiple healthcare prviders wh may be invlved in that treatment directly and indirectly. 2. Obtain payment frm third-party payers. 3. Cnduct nrmal healthcare peratins, such as quality assessments and physician s certificatins. I acknwledge that I may request yur NOTICE OF PRIVACY PRACTICES cntaining a mre cmplete descriptin f the uses and disclsures f my health infrmatin. I als understand that I may request, in writing, that yu restrict hw my private infrmatin is used t disclse t carry ut treatment, payment, r healthcare peratin. I als understand yu are nt required t agree t my requested restrictins, but if yu agree, then yu are bund t abide by such restrictins. Signature: Date: Page 5
INFORMED CONSENT Yu have a right, as a patient, t be infrmed abut the cnditin f yur health and the recmmended care and treatment t be prvided t yu s that yu can make the decisin whether r nt t underg such care with full knwledge f the knwn risks. This infrmatin is intended t make yu better infrmed in rder that yu can knwledgeably give r withhld yur cnsent. THE NATURE AND PURPOSE OF CHIROPRACTIC Chirpractic is predicated n the science which cncerns itself with the relatinship between structures (primarily the spine) and functin (primarily f the nerve system) f the bdy and hw this relatinship can affect the restratin and preservatin f health. The fllwing infrmatin is rutinely furnished t all wh cnsider Chirpractic care and treatment in this clinic. Adjustments are made by Chirpractrs in rder t crrect spinal and extremity jint subluxatins. One f the mst cmmn disturbances t the nerve system is the vertebral subluxatin. This cnditin is where ne r mre vertebra in the spine is misaligned sufficiently t cause interference and/r irritatin t the nerve system. The primary gal in Chirpractic health care is the remval f nerve interference caused by subluxatin. A Chirpractic examinatin will be undergne which may include spinal and physical examinatin, rthpedic and neurlgical testing, palpatin, specialized instrumentatin, and radilgical examinatin (x-rays). The Chirpractic adjustment is the applicatin f a precise, high velcity mvement f the spine ver a very shrt distance. There are a number f different methds r techniques by which the Chirpractic adjustment is delivered. Chirpractic adjustments can be delivered by hand, but will be delivered using an instrument r ther specialized equipment at Inside-Out Family Chirpractic. CONSENT FOR CHIROPRACTIC CARE I have been infrmed f the nature and purpse f Chirpractic care, the pssible cnsequences f care, and the risks f care, including the risk that care may nt accmplish the desired bjective. I have been advised f the pssible cnsequences if n care is received. I acknwledge that n guarantees have been made t me cncerning the results f the care and treatment. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE INSIDE-OUT FAMILY CHIROPRACTIC TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT. PRINT NAME HERE SIGNATURE FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT INSIDE-OUT FAMILY CHIROPRACTIC. DATE SIGNATURE WITNESS SIGNATURE (OFFICE STAFF) DATE DATE If this health prfile is fr a minr/child, please fill ut and sign belw: Written Cnsent Fr A Child Name f practice member wh is a minr/child: I authrize Dr. Juan Munz and any and all Inside-Out Family Chirpractic staff t perfrm diagnstic prcedures, radigraphic evaluatins, render chirpractic care and perfrm chirpractic adjustments t my minr/child. As f this date, I have the legal right t select and authrize health care services fr my minr/child. If my authrity t select and authrize care is revked r altered, I will immediately ntify Navigate Chirpractic. Guardian Signature: Date: Relatinship t minr/child: Page 6