SHEPHERD CHIROPRACTIC

Transcription

1 SHEPHERD CHIROPRACTIC Patient Information Name First M.I. Last Street Address City State Zip Home # ( ) Cell # ( ) Work # ( ) May we include you in our online newsletter? Yes No Social Security # - - Sex M F Birthdate / / Age Single Married Widowed Separated Divorced Occupation Emergency Contact Employer Relationship Parent's name (if a minor) Spouse's Name Home #( ) Alt ( ) Number of children To whom may we thank for referring you? Injury Information Is your condition due to an accident? Yes No Date: Type of accident? Automobile Work Home Other To whom have you reported the accident? Insurance Worker s Comp Employer Other Attorney Name (If applicable) Information About Your Condition Reason for visit When did your symptoms begin? Is this condition getting progressively worse? How does it feel? Burning Sharp Shooting Dull Aching Stiff Tingling Throbbing Swelling Other How often do you have this pain? What makes your condition better? What makes your condition worse? Does it interfere with Work Sleep Daily Routine Recreation Activities or movements that are painful to perform Sitting Standing Walking Bending Lying down Health History Have you ever seen a Chiropractor before? Yes No Previous Chiropractor What treatment (if any) have you already received for your condition? Medications Surgery Physical Therapy Chiropractic services Other How often do you exercise? Daily Moderate Heavy None Work activity includes Sitting Standing Light Labor Heavy Labor Smoking Alcohol Packs/Day Drinks/Week Coffee/Caffeine Cups/Day Are you pregnant? Yes No

2 Injuries and Surgeries Spinal taps/injection Accident/falls Head injuries Description: Date: Description: Date: Description: Date: Broken bones Description: Date: Dislocations Surgeries Medications Description: Date: Description: Date: Taking for: Taking for: Taking for: Vitamins/Supplements: Review of Symptoms: (Circle current problems, Check significant past problems) Constitutional Breathing and Lungs Blood System Decreased sleep Shortness of breath Lymph gland swelling Irregular sleep Wheezing or asthma Easy bruising Excessive sleep Repeated colds and flus Hormones and Metabolism Poor appetite Cough dry or irritating Thyroid trouble Fevers Cough up mucous or blood Weight and diet trouble Chills Digestion and Intestines Fluid retention Fatigue Indigestion Moods, Thought, Emotions Food cravings Belching Manic episodes Weight loss Difficulty swallowing Energy problems Weight gain Heartburn Spiritual needs Immune System Diarrhea Depression Too many infections Liver trouble Anxiety Allergies to food or environment Hemorrhoids, piles Anger problems Other concerns Vomiting Panic or fear attacks Eyes Nausea Muscles, Bones, Joints Eye pain Rectal pain or itching Neck pain Blurred vision Abdominal pain Back pain Poor vision Cramping bowels Muscle pain Corrective lenses Gassy gut Muscle weakness Near-sighted Constipation Muscle cramps Far-sighted Foods that upset system: Joint swelling Other: Painful joints Skin, Hair,Breasts Nerves, Movement, Brain Elbow? Shoulder? Breast lumps or pain Seizures Hip? Knee? Rashes Poor balance Ankle? Foot? Menopause Poor coordination Toes? Fingers? Hair loss Tremors or shaking Wrist? Hands? Dry skin Numbness Ears, Nose, Mouth, Throat Dizziness Ringing ears Poor memory Nose bleeds Trouble sleeping Postnasal drip Heart and Circulation Sinus problems Chest pain Trouble with taste/smell Lightheadedness Poor hearing Palpitations Earaches Fainting Bad breath Cold hands/feet Headaches Swelling feet Facial pain Varicose veins Jaw clicks Urine, Kidneys, Bladder Teeth problems Decreased urine flow Grinding teeth Painful urination Trouble chewing Frequent urination Sore throat Sudden urges to urinate Mouth sores Blood or pus in urine

3 Name Date Pain Drawing Be sure to fill this out extremely accurately. On the diagram below mark the area on your body where you feel the described sensation(s). Use the appropriate abbreviation(s), mark areas of radiating pain, and include all affected areas. Dull/Achy Pain = D Numbness = N Stiffness = F Sharp Pain = S Tingling = T Throbbing = B Visual Analogue Scale Please mark on the line the pain level that most accurately represents your pain. If there is more than one area write the area (example: neck, mid-back, low back, etc.) beside your mark. Right Now: No Pain Unbearable At Worse: No Pain Unbearable

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5 Informed Consent to Chiropractic Treatment The practice of chiropractic is the application of chiropractic science in the adjustment of the spinal column, skeletal articulations, and adjacent tissue. This includes diagnosis and analysis to determine the existence of spinal subluxation and associated nerve energy expression. The doctor will establish a chiropractic program which includes, but is not limited to, chiropractic adjustments, exercise, lifestyle changes, nutrition, and other wellness oriented activities. The risks of complications due to chiropractic care have been described as rare. As in any health care procedure, there are possible risks. Muscle and ligament strain is the most common complaint following chiropractic care. In patients who are elderly and exhibit bone mineral loss, an occasional rib fracture may occur. The least common occurring complication is stroke. It is estimated the risk for this problem to be 1 in 3 million per chiropractic adjustment, which statistically is less frequent that that of spontaneous stroke occurring in the general public. You can be comforted by the fact that serious injury is so infrequent that the average malpractice premium for chiropractors is less than $3,000 annually, compared to tens of thousands of dollars for traditional medical specialists. Financial Policy for Major Medical Patients Thank you for trusting us with your health. We will do everything we can to assist you in getting and staying well. The following policies are established so that we can provide you with the best possible service. Our office hours are Mondays, Wednesdays, and Fridays from 8am -12pm and 2pm - 6pm and Tuesdays and Saturdays from 8am 10am. Emergency care is available by calling our office. Please make every effort to maintain your appointments and your schedule of care. Our staff will try to reschedule you as soon as possible to make up any missed treatment so that you can stay on your schedule of care. Please call if you are going to miss your appointment time so we can make this time available to others. We want you to be an informed partner in your health care. Please ask any questions that you may have. We loan out educational books and videos and also offer informational classes (watch for times and dates to be posted in our office). Our office is built on referrals from our patients and our friends. Your referrals are always welcome. With each new patient referral, our office will thank you with a complimentary adjustment. Please look for your card in the mail. Most major medical policies are covered here in our office. As a courtesy, we will verify your insurance benefits. This will be done after your first visit. You will be given a quotation of your anticipated insurance benefits, but this is not a guarantee. All co-pays are due at the time services are rendered. Patient balances may be subject to change due to the unpredictability of insurance payments. You will be 100% responsible for any unpaid balances by your insurance company. I have read the explanation above of chiropractic treatment and the financial policy. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment for myself (or my child), and hereby give my full consent to treatment. Printed Name Patient/Guardian Signature Date

6 Lien and Assignment of Insurance Benefits I(we), the undersigned patient and/or legal representative(s) of that patient, in consideration of the services rendered or to be rendered by you, Shepherd Chiropractic, hereby understand and agree to the following: I am personally responsible for all bills incurred by me for services rendered by Shepherd Chiropractic. I understand that you may make claims to insurance companies and other third parties for reimbursement to changes on my behalf as a result of professional services rendered by you. I agree, however, that I remain personally liable for all amounts due to you, which are not paid by such insurance companies or other third parties. In the event that any insurance company or third party is obligated by contractual agreement to make benefit payments to me or you, I hereby authorize and direct that such insurance companies or other third parties make direct payments to you for any amounts owed to the extent allowable under such contractual terms. In the event that any insurance company or third party under contractual obligation to make benefit payments to me or you refuses to make such payments after demand is duly made, I hereby assign, transfer, and set over to you, free and clear of any other encumbrances, the right to bring demands, claims, and other causes of actions which exist in my favor, against any such insurance companies or third parties for the total amounts owed to you. I authorize you to prosecute such actions and to compromise, settle, or otherwise resolve such claims as you determine appropriate. In the event that the treatment provided by you was necessitated as a result of the potential negligence of any entity, I hereby give a lien to you against the proceeds of any settlement, judgments, or verdicts which may be acquired against such entity or any other third party providing indemnification or compensation to such entity. I hereby authorize and direct that any attorney who may now or hereafter represent me make direct payments to you for services rendered out of the proceeds of any such settlement, judgments, or verdicts. You are authorized to release information concerning my condition and treatment to my insurance company and attorney for the purposes of processing claims for benefits and payment of services rendered to me. I hereby state that a photocopy of this document shall be as valid and binding on all parties as the original and applies to all past and future records. Consent for Use or Disclosure of Health Information There are several circumstances in which we may have to use or disclose your health information. We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services. We may need to use your health information within our practice for quality control or other operational purposes such as reminder cards, messages on your answering machine or voic , or newsletters. You have the right to request that we do no disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. You may revoke any of your authorizations at any time; however, your revocation must be made in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have the right to your health information if they decide to contest any of your claims. By signing below, I have read and agree to the terms of the information above. Printed Name Patient/Guardian Signature Date:

7 Notice of Privacy Practices Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the Federal privacy rules. Your Right to Complain You may complain to us or to the Secretary of Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. While you may make an oral complaint at any time, written comments should be sent to us at the address listed below. To Contact Us If you would like further information about our privacy policies and practices please contact: Shepherd Chiropractic 2343 West Silvernail Road Pewaukee, WI This notice is effective as of. This notice will expire seven years after the date upon which the record was created. By signing below, I acknowledge that I have received a copy of this notice. Patient Name Printed Date Patient Signature Authorized Provider Representative Personal Representative Printed Personal Representative Signature Description of Personal Representative's authority to act for the patient