APPLICATION FOR TREATMENT



APPLICATION FOR TREATMENT

Name________________________________________________________________Today’s Date

Address:

Birthdate:______________________________ Are you pregnant? ( Yes ( No

Employer’s Name & Address:

Occupation:_________________________________Work Phone____________________Home Phone

Email Address Cell Phone________________________________________________

What type of care do you desire? ( Temporary Relief ( Lasting Correction ( Best Care Possible

Describe any accidents, falls, injuries, sudden movements, etc., that may have caused your problem:

Have you had any similar health problems or injuries before? ( Yes ( No If yes, please explain:

Diagnosis and type of treatment you received (please include where and when you received treatment, and the results):

Has your health problem been: ( Improving ( Worsening ( Staying the same

Please describe anything you do that improves or worsens your condition:

Please check off and describe how this problem interferes with your work and/or personal life:

( Home activities affected:

( Work activities affected:

Have you missed any work days? How Many?

( Recreational activities affected:

( Rest or sleep affected:

Have you been treated by a doctor within the last year?

If yes, please explain:

Name, Address, and Phone Number of Medical Doctor:______________________________________________________________

___________________________________________________________________________________________________________

Have you ever received Chiropractic care?____________________ If yes, please list the doctor’s name, address and what your problem was at the time:

Please check off the drugs you are now taking: ( Pain Killers ( Muscle Relaxers ( Anti-inflammatory

( Blood Pressure Medication ( Insulin ( Tranquilizers ( Diet Pills ( Birth Control

( Nerve Medication ( Anti-Depressants ( Other (please list):

List the approximate dates of any accidents, operations or serious injuries (including broken bones) you have had:

If you have been in an auto accident, when? ( This Year ( Last Year ( Past 5 Years ( Over 5 Years

Please check off the following that apply to you within the past 2 years: ( Went to a Health Spa

( Purchased Vitamins ( Purchased Health Foods ( Received a Massage

Please explain why you choose to do any of the above:

Who is responsible for your bill? ( I am ( Spouse ( My Employer ( Insurance

Type of Insurance: ( Worker’s Comp. ( Health ( Automobile

Insurance Company’s name and address:

If you are responsible for your health care fees, payment will be made by: ( Cash ( Check ( Credit Card

Your fees are due and payable at the time examination, X-rays, and treatments are received, unless other arrangements have been made in advance. X-rays remain property of this clinic.

I, the undersigned, hereby give permission for treatment.

Patient’s Social

Signature____________________________________ Security No:_______________________________ Date________________

Basic Nutrition Questionnaire

Have you ever been told you have High Cholesterol or Triglycerides? YES / NO

Have you ever been diagnosed with High Blood Pressure? YES / NO

Have your been Diagnosed as Diabetic? YES / NO

Have you been diagnosed as Pre-Diabetic or Metabolic Syndrome? YES / NO

How many days a week do you skip a meal? (3/meals/day) __________

How many “fast food’, “refined food”, or “pre-prepared” meals to you eat per week?

(0) (1-3) (4-6) (7+)

How many servings of fruit do you eat per day?

(0-1) (2-3) (4-5)

How many servings of vegetables to you eat per day?

(0-1) (2-3) (4-5)

Do you regularly drink 1 or more per day of the following: (circle all that apply)

Soda Diet Soda Coffee Juice Milk Alcohol

How many servings of refined sugar do you eat per day? (Candy, Cookies, Cake, etc)

(0-1) (2-3) (4-5)

Please list all nutritional supplements/vitamins you take regularly:

(Staff can photocopy a list if you have one)

Supplement Name/Type Frequency Brand or Where Purchased

___________________________________ __________________ ______________________________________

___________________________________ __________________ ______________________________________

___________________________________ __________________ ______________________________________

___________________________________ __________________ ______________________________________

___________________________________ __________________ ______________________________________

Confidential Patient Case History

Dear Patient: Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept you case. THANK YOU.

Name ___________________________________________________ Date _____________________

Please check the appropriate box for any of the following symptoms which you now have or have had previously. We want all the facts about your health before we accept your case. THIS IS A CONFIDENTIAL HEALTH REPORT.

O – OCCASIONAL

F – FREQUENT

C – CONSTANT

O F C

GENERAL

( ( ( Allergy

( ( ( Chills

( ( ( Convulsions

( ( ( Dizziness

( ( ( Fainting

( ( ( Fatigue

( ( ( Fever

( ( ( Headache

( ( ( Loss of sleep

( ( ( Loss of weight

( ( ( Nervousness/depression

( ( ( Neuralgia

( ( ( Numbness

( ( ( Sweats

( ( ( Tremors

MUSCLE & JOINT

( ( ( Arthritis

( ( ( Bursitis

( ( ( Foot trouble

( ( ( Hernia

( ( ( Low back pain

( ( ( Lumbago

( ( ( Neck pain or stiffness

( ( ( Pain between shoulders

Pain or numbness in:

( ( ( Shoulders

( ( ( Arms

( ( ( Elbows

( ( ( Hands

( ( ( Hips

( ( ( Legs

( ( ( Knees

( ( ( Feet

( ( ( Painful tail bone

( ( ( Poor posture

( ( ( Sciatica

( ( ( Spinal Curvature

( ( ( Swollen joints

O F C

GASTRO-INTESTINAL

( ( ( Belching or gas

( ( ( Colitis

( ( ( Colon trouble

( ( ( Constipation

( ( ( Diarrhea

( ( ( Difficult digestion

( ( ( Distension of abdomen

( ( ( Excessive hunger

( ( ( Gall bladder trouble

( ( ( Hemorrhoids

( ( ( Intestinal worms

( ( ( Jaundice

( ( ( Liver trouble

( ( ( Nausea

( ( ( Pain over stomach

( ( ( Poor appetite

( ( ( Vomiting

( ( ( Vomiting of blood

EYES, EARS, NOSE &THROAT

( ( ( Asthma

( ( ( Colds

( ( ( Crossed eyes

( ( ( Deafness

( ( ( Dental Decay

( ( ( Earache

( ( ( Ear discharge

( ( ( Ear noises

( ( ( Enlarged glands

( ( ( Enlarged thyroid

( ( ( Eye pain

( ( ( Failing vision

( ( ( Far sightedness

( ( ( Gum trouble

( ( ( Hay fever

( ( ( Hoarseness

( ( ( Nasal obstruction

( ( ( Near sightedness

( ( ( Nosebleeds

( ( ( Sinus infection

( ( ( Sore throat

( ( ( Tonsillitis

O F C

CARDIO-VASCULAR

( ( ( Hardening of arteries

( ( ( High blood pressure

( ( ( Low blood pressure

( ( ( Pain over heart

( ( ( Poor circulation

( ( ( Rapid heart beat

( ( ( Slow heart beat

( ( ( Swelling of ankles

RESPIRATORY

( ( ( Chest pain

( ( ( Chronic cough

( ( ( Difficult breathing

( ( ( Spitting up blood

( ( ( Spitting up phlegm

( ( ( Wheezing

SKIN

( ( ( Boils

( ( ( Bruise easily

( ( ( Dryness

( ( ( Hives or allergy

( ( ( Itching

( ( ( Skin eruptions (rash)

( ( ( Varicose veins

GENITO-UNRINARY

( ( ( Bed-wetting

( ( ( Blood in urine

( ( ( Frequent urination

( ( ( Inability to control kidneys

( ( ( Kidney infection or stones

( ( ( Painful urination

( ( ( Prostate trouble

( ( ( Pus in urine

FOR WOMEN ONLY

( ( ( Congested breasts

( ( ( Cramps or backache

( ( ( Excessive menstrual flow

( ( ( Hot flashes

( ( ( Irregular cycle

( ( ( Menopausal symptoms

( ( ( Painful menstruation

( ( ( Vaginal discharge

( Yes ( No Are you pregnant?

CHECK THE FOLLOWING CONDITION YOU HAVE HAD:

( Alcoholism

( Anemia

( Appendicitis

( Arteriosclerosis

( Arthritis

( Cancer

( Chorea

( Cold sores

( Diabetes

( Diphtheria

( Eczema

( Emphysema

( Epilepsy

( Fever blisters

( Goiter

( Gout

( Heart disease

( Influenza

( Lumbago

( Malaria

( Measles

( Miscarriage

( Multiple sclerosis

( Mumps

( Pleurisy

( Pneumonia

( Polio

( Rheumatic fever

( Scarlet fever

( Stroke

( Tuberculosis

( Typhoid fever

( Ulcers

( Venereal disease

( Whooping cough

PLEASE PRINT

What’s your major complaint? __________________________________________________________________________

___________________________________________________________________________________________________

List surgical operation and years: _______________________________________________________________________

___________________________________________________________________________________________________

Drugs you now take: ( Nerve pills ( Pain killers ( Muscle relaxers

( “Pep” pills ( Tranquilizers ( Birth control pills

Others: _____________________________________________________________________________________

Age of mattress: ___________________ ( Comfortable ( Uncomfortable ( Do you use a bed board? _________

Are you wearing: ( Heal lifts ( Sole lifts ( Inner soles ( Arch supports

Have you been in an auto accident: ( Past year ( Past five years ( Over five years ( Never

Describe: ___________________________________________________________________________________

Have you ever had any mental or emotional disorders? ( Yes ( No When? ____________________________

Have others in your family had such disorders? ( Yes ( No When? _____________________________

HAVE YOU EVER:

Been knocked unconscious?

Used a cane, crutch, or other support?

Been treated for a spine or nerve disorder?

Had a fractured bone?

Been hospitalized for anything other than surgery

Yes No

( (

( (

( (

( (

( (

DESCRIBE BRIEFLY

___________________________________________________________________________________________________________________________________________________________________________________________________

DO YOU:

Now take vitamins or minerals?

Think you may need vitamins or minerals?

Have an allergy to any drug?

( (

( (

( (

_____________________________________________________________________________________________________________________

DATE OF LAST:

Spinal examination

Physical examination

Blood test

Chest X- ray

Spinal X-ray

Dental X-ray

Urine test

Less than 6 months

(

(

(

(

(

(

(

6-18 months

(

(

(

(

(

(

(

Over 18 months

(

(

(

(

(

(

(

Never

(

(

(

(

(

(

(

HABITS

Alcohol

Coffee

Tobacco

Drugs

Exercise

Sleep

Appetite

Heavy

(

(

(

(

(

(

(

Moderate

(

(

(

(

(

(

(

Light

(

(

(

(

(

(

(

None

(

(

(

(

(

(

(

IN CASE OF EMERGENCY: (Name of relative or close friend not living in your home):

NAME ___________________________________________________________________________________________

ADDRESS: _______________________________________________________ PHONE: ________________________

Informed Consent Document

PATIENT NAME:__________________________________________

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

The nature of the chiropractic adjustment.

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click”, much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis / Examination / Treatment

As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

*spinal manipulative therapy *palpation *vital signs

*range of motion testing *orthopedic testing *basic neurological

*muscle strength testing *postural analysis testing

*ultrasound *hot/cold therapy *Electric Muscle Stimulation

*radiographic studies *Inter Segmental Traction

The material risks inherent in chiropractic adjustment.

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination and x-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The availability and nature of other treatment options.

Other treatment options for your condition may include:

• Self-administered, over-the-counter analgesics and rest

• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers

• Hospitalization

• Surgery

If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

The risks and dangers attendant to remaining untreated.

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW.

I have read [ ] or have had read to me [ ] the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.

Dated:____________ Dated:____________

_____________________________ Dr. Lyndsy Johnston

Patient’s Name Doctor’s Name

_____________________________ ______________________________

Signature Dr. Signature

___________________________

Signature of Parent or Guardian

(if a minor)

OFFICE FINANCIAL POLICY

Cash or Major Medical

1. All patients are on a cash basis until their insurance coverage and deductible may be verified by our staff. Coverage verified by phone is not a guarantee of benefits and can only be verified by a copy of the E.O.B. (explanation of benefits)

2. This office may make payment plan arrangements on an individual basis. Any such plan or arrangement will be discussed during your report of findings.

3. If you have insurance, we will gladly accept assignment with the following exceptions and regulation provided that we have prior certification from your insurance company.

I authorize Heartland Chiropractic to release any pertinent information regarding my treatment to my insurance company. As such I herby authorize and direct my Insurance Company, liability insurance adjuster and/or my attorney, to pay directly to Heartland Clinic of Chiropractic. LLC such sums as may be due and owing this office for services rendered me, both by reason of accident or illness, and by reason of any other bills that are due this office, and to withhold such sums from any disability benefits, medical payment benefits, No Fault benefits, health and accident benefits, workmen’s compensation benefits, or any other insurance benefits obligated to reimburse me or from any settlement, judgment or verdict on my behalf as may be necessary to adequately protect said office. I hereby further give a lien to said office against any and all insurance benefits named herein, and any and all proceeds of any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by said office.

4. We accept assignment as a courtesy to you; you are ultimately responsible for your entire bill should your insurance company not pay any of the anticipated charges for any reason. We are not a mediator between you and your insurance company and will not enter into any dispute with the same, as your contract is between you and your insurance company.

5. Any services not covered or coverage reductions by your insurance will be the patient’s responsibility.

6. This office will resubmit a claim ONE TIME. We will not enter into any dispute with your insurance company. If coverage problems arise, you will be expected to assist directly in dealing with your insurance company, adjuster, or agent. Any denied or disputed claims will be treated as uncovered services and you will be expected to pay such charges on a timely basis.

7. If the patient is referred to another specialist or discontinues care for any reason other than discharge by the doctor, the bill is due and payment in full expected immediately regardless of any claims submitted.

8. If you have questions concerning this or any other matter, please speak with the front desk or our insurance department prior to seeing the doctor.

I authorize and instruct ClearGage, LLC (my Provider’s billing administrator) to obtain and review my RiskView(TM) Report from LexisNexis, which Report draws upon public records and proprietary data sources of LexisNexis. I understand that this RiskView(TM) Report will assist in the evaluation of my credit worthiness, may be used to obtain credit and payment history, and may be used to verify my past credit or payment history information. I understand, agree, and hereby give my consent that: (1) my provider will provide information about me, including my name, address, phone and cell phone numbers, age, birthday,sex, and Driver’s License number to ClearGage, LLc, which will provide said information to LexisNexis, (2) information derived from this RiskView(TM) Report will be shared with ClearGage, LLc, my Provider, and third party lenders; (3) information derived from this RiskView(TM) Report will be used in the determination of whether my Provider will offer me a payment plan; (4) my authorization for the RiskView(TM) Report is not an offer of a payment plan and is not a guarantee of any such offer. Likewise, my consent does not constitute my agreement to any payment plan or payment terms; and (5) if I am offered a payment plan, at that time, the terms will be disclosed to me and I can choose whether to accept or reject it.

I understand that I may request a copy of my RiskView(TM) Report by writing LexisNexis at:

LexisNexis Risk Solutions Bureau LLC

RiskView Consumer inquiry Department

P.O.Box 105108

Atlanta, Ga 30348-5108

866-897-8126

Thank You,

I have read and understand the Financial Office Policy and agree to abide by these terms.

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Patient’s Signature Date

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Please circle the exact location of any pain you are experiencing. Then describe the type of pain, i.e. dull, sharp, constant, on & off, etc.

[pic]

In order of importance, list the health problems you are most interested in correcting:

1.________________________________________________________

2.________________________________________________________________

3.________________________________________________________________

In order of severity, list those body functions that you are unable to perform, or that produce pain upon performance, i.e. walking, sitting, bending, etc.:

1.________________________________________________________

2.________________________________________________________

3.________________________________________________________________

When was the first time you noticed this problem?_________________

Marital Status: ( Married ( Single ( Widowed ( Divorced ( Separated

Names and Ages of Children__________________________________________________________________________________

Name of Spouse____________________________________________________________________________________________

Spouse’s Employer________________________________________________________Work Phone________________________

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