CONFIDENTIAL PATIENT INFORMATION



CONFIDENTIAL PATIENT INFORMATIONPersonal Information Full name: Date:Address: Street City State ZipHome phone: Work phone:Cell phone:Email address: *e-mail monthly newsletters are sent out to patientsDate of birth:Age:No. of children:Pregnant? Yes □ No □Marital status: M S W DSpouse/guardian name:Occupation:Employer’s name:Name of person responsible for account:Emergency Contact person: Phone #:Relationship:Name of Primary Insurance Company:___________________________________________________________Name of Secondary Insurance Company (if any):___________________________________________________Who may we thank for referring you? _________________________________________________________________________(Relative, friend, yellow-book, Dex, screening event)Have you had previous Chiropractic Care? Y N Approximate date of last visit? ____________________________________Addressing What Brought You Into This Office: If you have no symptoms or complaints and are here for Chiropractic Wellness Services, please skip to the “General Health History”.Health ConcernsPlease list your health concerns according to their severityRate of severity1 = mild10 = worst imaginableWhen did this episode start?Days, weeks, months or years ago?If you had this condition before, when?Did the problem begin slowly, immediately or with an injury?% of the time pain is present1.2.3.-Is your pain Dull □ Sharp □? Does it radiate anywhere? If so, where?______________________________________-Since the problem started is it: About the same? □ Getting better? □ Getting worse? □-What have you done to help condition: Ice □ Heat □ Pain Relievers □ Massage □ Stretching □ -What activities are aggravated by your condition: Sitting □ Standing □ Working □ Bending □ Carrying □ Climbing □ Concentrating □ Dancing □ Doing Chores □ Dressing □ Driving□ Pushing □ Running □ Shoveling □ Sleeping □ Walking□ Lifting □ *Other doctors you have seen for this condition (Chiropractor, Family Practitioner, MD, etc.) Yes NoGeneral Health HistoryHave you EVER had any of the following diseases or conditions? Chiropractic is concerned with how your nervous system is functioning. If it is not functioning at 100%, a multitude of problems can occur. Please take some time to fill out the following:CERVICAL SPINE (Neck): Do you experience…?? Neck pain ? Headaches ? Sinusitis-Allergies? Pain into your shoulders/arms/hands ? Dizziness ? Numbness/tingling in arms/hands ? Visual disturbances ? Coldness in hands ? TMJ/Pain/ClickingTHORACIC SPINE (Upper back): Do you experience…?? Heart Palpitations/murmurs ? recurrent lung infections/bronchitis? Asthma/wheezing? Heart attacks/Angina? Pain into your ribs/chest? Pain on deep inspiration/expiration? Ulcers/Gastritis? Mid back pain ? Indigestion/Heartburn/refluxLUMBAR SPINE (Low back): Do you experience…?? Pain into your hips/legs/feet ? recurrent bladder infections ? Low Back Pain? Numbness/tingling in your legs/feet ? Frequent/difficulty urinating ? Coldness in your legs/feet ? Muscle cramps in your legs/feet ? Constipation/Diarrhea? Menstrual irregularities/cramping (females) Accumulation of life’s stress can lead to health problems and influence our ability to heal. The following three areas of stress can contribute to your loss of health. It also affects your body’s ability to heal and repair. 1. Physical Stress *Please circle:Slips/FallsPoor PostureSleeping PositionComputer WorkRepetitive Heavy LiftingContinuous Sitting/Standing2. Emotional Stress *Please circle:Relationships Career Loss of Loved One3. Chemical Stress *Please circle:SmokerPoor DietPrescription/OTC DrugsCircle Current Medications you are takingTylenolBlood Pressure MedicationAnti-AnxietyAdvil/IbuprofenAspirinThyroid MedicationCholesterol MedicationAnti-DepressantsOther? _________________________Please List any Nutritional supplements, vitamins, homeopathic remedies you presently take:__________________________________________________________________________________________________________________________________________________________________________________________________________**Please list any other Hospitalizations, Accidents and/or Surgeries not mentioned and Date: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________AUTHORIZATION FOR CAREI hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. If the Doctor does accept my case, it does not guarantee nor does it imply a guarantee of being able to cure or prevent any condition illness or injury.I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I have been advised that this office offers all patients and 3rd party payers a discount for services when the services are paid in full at the time of service or pre-paid in advance of services. I also understand that if I suspend or terminate my care, any fees for professional services rendered me will become immediately due and payable.X_________________________ ____________ ___________________________ _______Patient Signature Date Parent/Guardian Authorizing Care DatePatient Acknowledgement for Receipt of HIPAA Compliance InformationPlease complete the information below. Whether you are a new patient and recently provided us with this information or if there have been no changes since you started care we are required to have this acknowledgment on file in your hand. **I acknowledge receipt of a copy of the office “Notice of Patient Privacy Policy”- Yes□X_________________________ ____________ ___________________________ _______Patient Signature Date Parent/Guardian Authorizing Care DateINSURANCE INFORMATION*If you do not have your card with you at the time of your visit we may require payment up front and reimburse you if your insurance company pays.*We directly bill the insurance company for services covered per your policy with the following understanding:*Health and accident insurance policies are an arrangement between the insurance carrier and the insured. Benefits quoted by an insurance company over the phone are not a guarantee of payment. The insured is responsible for all deductibles, co-payments and unpaid services rendered. Subscribers Name (If other than patients):_________________________________________D.O.B. of subscriber: _________________________________________________________X_________________________ ____________ ___________________________ _______Patient Signature Date Parent/Guardian Authorizing Care Date*Missed Appointments will be billed a cash charge of $50. Please give at least an hour notice if you can’t keep your appointment.*Balances that are not paid within 30 days of receipt of statement will incur a $5 monthly service charge.*Balances that are not paid within 4 months of the service date will be turned over to our collection rmed Consent for Chiropractic CareWhen a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective. 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. You have the right, as a patient, to be informed about the condition of your health and the recommended care and treatment to be provided so that you may make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks and alternatives.Chiropractic is a science and art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may affect the restoration and preservation of health. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24 vertebrae in the spinal column become misaligned and/or do not move properly. This causes alteration of nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic.Subluxations are corrected and/or reduced by an adjustment. An adjustment is the specific application of forces to correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Adjustments are usually done by hand but may be performed by handheld instruments. In addition, ancillary procedures such as physiotherapy and/or rehabilitative procedures may be included.If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider.All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction. The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis.*I also understand that this office uses open adjusting rooms for my treatments. If I have a question or condition that I would like to discuss in private or be adjusted in a private room I will inform the front desk staff or doctor.X_________________________ ____________ ___________________________ _______Patient Signature Date Parent/Guardian Authorizing Care DateAcknowledgement for Consent to Use and Disclosure of Protected Health InformationUse and Disclosure of your Protected Health InformationYour Protected Health Information will be used by Pathways Chiropractic & Wellness or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.Notice of Privacy PracticesYou should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. I have received a copy of the Notice of Patient Privacy Policy. ______Patient InitialsRequesting a Restriction on the Use or Disclosure of Your InformationYou may request a restriction on the use or disclosure of your Protected Health Information.This office may or may not agree to restrict the use or disclosure of your Protected Health Information.If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.Notice of Treatment in Open or Common AreasDescribe and Notify private areas available upon requestRevocation of ConsentYou may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.By my signature below I give my permission to use and disclose my health information.X_________________________ ____________ ___________________________ _______Patient Signature Date Parent/Guardian Authorizing Care Date ................
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