CONFIDENTIAL PATIENT INFORMATION



CONFIDENTIAL PATIENT INFORMATIONFull Name: Date:Address: Home Phone: Work Phone:Cell Phone:Email Address:Date of Birth:Age:# of Children:Pregnant? □ Yes □ NoMarital Status: M S W DSpouse/Guardian Name:Occupation:Employer’s Name:Phone Number:Emergency Contact Person: Relationship:Phone Number:Primary Insurance Company:___________________________________________________________Secondary Insurance Company (if any):___________________________________________________Who may we thank for referring you? __________________________________________________(Relative, Friend, Yellow-Book, Online Search)Have you had previous Chiropractic Care? ? Yes ? NoApproximate date of your last visit? ____________________________________________________Addressing What Brought You Into This Office:Health Concerns:(Please list by severity)Rate of Severity1 = Mild10 = Worst ImaginableWhen did this episode start?(Days, weeks, months or years ago?)Have you had this condition before? When?Did it begin slowly, immediately, or with an injury?% of the time your pain is present1.2.3.4.5.In General, What Symptoms Do You Experience: ? Pain ? Muscle Spasm? Stiffness? Numbness ? Headache ? Tingling? Swelling? Tightness ? WeaknessQuality of Your Symptoms: ? Sharp ? Throbbing? Burning? Dull ? Local? Tension? Aching? Radiating Since Your Symptoms Started, Are They: ? About the Same? Getting Better? Getting Worse What Have You Done to Help Your Condition? ? Ice ? Heat ? Pain Relievers? Massage ? Stretching What Activities Aggravate Your Condition?? Sitting ? Concentrating? Running? Standing ? Dancing? Shoveling? Working? Chores ? Sleeping? Bending ? Dressing? Walking? Carrying? Driving? Lifting? Climbing? PushingHave You Seen Anyone Else 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. CERVICAL SPINE (Neck): Do you experience…?? Neck Pain ? Headaches ? Sinusitis/Allergies? Pain into Shoulders/Arms/Hands ? Dizziness ? Numbness/Tingling in Arms/Hands ? Visual Disturbances ? Coldness in Hands ? TMJ/Pain/Clicking THORACIC SPINE (Upper back): Do you experience…?? Heart Palpitations/Murmurs ? Recurrent Lung infections/Bronchitis? Asthma/wheezing? Heart Attacks/Angina? Pain into Ribs/Chest? Mid-Back Pain ? Pain on Deep Inspiration/Expiration? Ulcers/Gastritis? Indigestion/Heartburn/RefluxLUMBAR SPINE (Lower back): Do you experience…?? Pain into Hips/Legs/Feet ? Recurrent Bladder Infections ? Low Back Pain? Numbness/Tingling in Legs/Feet ? Frequent/Difficulty Urinating ? Constipation/Diarrhea? Coldness in Legs/Feet ? Muscle Cramps in Legs/Feet ? Menstrual Irregularities/Cramping Accumulations of Stress The following areas of stress can contribute to your loss of health and influence our body’s ability to heal and repair. PHYSICAL STRESS? Slips/Falls ? Sleeping Position ? Repetitive Heavy Lifting? Continuous Sitting/Standing EMOTIONAL STRESS ? Relationships ? Career ? Loss of Loved OneCHEMICAL STRESS? Tobacco Use ? Prescription/Over the Counter Drug Use? Poor Diet Please List All Medications, Supplements, Vitamins, and Homeopathic Remedies You Presently Use or Take:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please List Hospitalizations, Accidents, or Surgeries Not Mentioned with Dates:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Informed 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.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 future 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.Insurance InformationWe 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. -We accept most insurance plans and will file claims on your behalf with your insurance carrier. We are NOT, however, in-network with all insurance companies. I fully accept responsibility for knowing if Pathways Chiropractic & Wellness is in-network with my insurance provider and I accept all responsibility for non-covered services rendered to me. I also understand that Pathways Chiropractic & Wellness will not quote me an exact amount that I will be responsible to pay.-If you are not using a form of insurance, Pathways Chiropractic and Wellness will require payment prior to treatment. ______InitialGuarantee of PaymentI clearly understand and agree that all services rendered me are charged directly to me at the prevailing rates and that I am personally responsible for payment. I have been advised that this office offers all patients and third 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 to me will become immediately due and payable. ______InitialAcknowledgement for Consent to Use and Disclosure of Protected Health InformationYour protected health Information will be used by Pathways Chiropractic & Wellness and 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. ______InitialRequesting 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.Revocation 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.Appointments are reservations made exclusively for you. Missed appointments will be billed a charge of $50. Please give at least a 4 hour notice if you cannot keep your appointment.Balances that are not paid within 30 days of receipt of statement will incur a $5 late fee.Balances that are not paid within 4 months of the date of service will be turned over to our collection agency.Insurance policies are an arrangement between the insurance carrier and the insured. Your insurance is your responsibility.If you are not using a form of insurance, payment is due PRIOR to treatment.This office uses open adjusting rooms for treatments. If you have a question or condition that you would like to discuss in private or would prefer to be adjusted in a private room, please inform front desk staff or doctor.By signing below I am agreeing to paragraphs I-XI.X_________________________ ____________ ___________________________ _ _______ Patient Signature Date Parent/Guardian Authorizing Care Date ................
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