Chiropractic Chiropractic Step 1 of 9 11% Personal InformationTitleMr.Mrs.Ms.Dr.Rev.Other First Name Middle Name Last Name SuffixSelectJrSr|||||MDPhDSOEsqPARNBSNBirth Date AgeSexSelectMaleFemalePrimary LanguageSelectEnglishFrenchGermanSpanishOtherDriver's License #Blood TypeSelect optionA PositiveA NegativeB PositiveB NegativeAB PositiveAB NegativeO PositiveO NegativeRaceSelect optionAfrican AmericanAsianCaucasianHispanicMultiracialNative AmericanOtherMarital StatusSelect optionSingleMarriedWidowedDivorcedSeparatedHair ColorSelect optionBlackBrownGrayBlondeRedWhiteOtherEye ColorSelect optionBlueBrownGreenGrayHezelOtherAddress Street Address Apt #CityStateZipCountrySelect CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweHome PhoneExtWork PhoneExtCell PhoneFaxEmail Address* Name Spouse Name Emergency ContactTitleMr.Mrs.Ms.Dr.Rev.Other First Name Middle Name Last Name SuffixSelectJrSr|||||MDPhDSOEsqPARNBSNBirth Date SexSelectMaleFemaleAddress Street Address Apt #CityStateZipCountrySelect CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweRelationshipSelect OptionSpouseRelativeFriendOtherEmail Address Home PhoneExtCell PhoneWork PhoneExtFaxExtCONFIDENTIAL PATIENT HEALTH RECORDUnwanted Condition (Why you are here today?)When did this condition BEGIN?Has this condition ever occurredSelect OptionYesNoIndicate the type and location of your sensations right now Head Neck Shoulders Arms Hands Chest Stomach Hips Upper-back Lower-Back Front-Thighs Back-Thighs Knees Calves Front-Feet Back-Feet Is the condition: Auto Related Job Related Home Injury Slip or Fall Lifting Slept Wrong Unknown Cause OtherDate of Accident Time of Accident : HH MM AM PM Pain STARTED on what date Do you SUFFER with ANY other condition than which you are now consulting us?How did you hear about us?*SelectFamily/FriendCo WorkerYellow PagesDrive ByHospitalDoctorInsurance PlanClose to Home/Work Employment InformationAddress Street Address Apt #Business NameCityStateZipCountrySelect CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweHome PhoneFaxEmployer Email Address Occupation/Job TitleJob DescriptionREVIEW OF SYSTEM: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Below is a list of symptoms that may seem unrelated to the purpose of your appointment. However,the question must be answered carefully as the problems can affect your overall course of care.Constitutional: Chills Fatigue Night Sweats Weight Loss Daytime Drowsiness Fever Weight Gain EYES VISION: I DENY having or have had of the symptoms or problems Below is a list of symptoms that may seem unrelated to the purpose of your appointment. However the questions must be answered carefully as they effect your overall. Blindness Change in Vision Field Cuts Photophobia Blurred Vision Double Vision Tearing Glaucoma Cataracts Eye Pain Itching Wear Glasses/contacts Ears,Nose,Throat: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Below is a list of symptoms that may seem unrelated to the purpose of your appointment. Bleedings Ear Drainage Hearing Loss Nosebleed Sore Throat Dentures Ear Pain History Of Head Injury Postnasal Drip Tinnitus Fainting Difficulty Swallowing Frequent Sore Throat Hoarseness Rhinorrhea TMJ Problem Discharge Loss Of Sense Of Smell Sinus Infection Dizziness Headaches Snoring Nasal Congestion Respiration: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Asthma Coughing Up Blood Sputum Production Cough Shortness Of Breath Wheezing Cardiovascular: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Angina(Chest pain or discomfort) Chest Pain Heart Problems Heart Murmur Claudication High Blood Pressure Low Blood Pressure Palpitations Paroxysmal Nocturnal Dyspnea Short Of Breath With Exertion Swelling Of Legs Ulcers Gastrointestinal: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Abdominal Pain Belching Black Tarry Stools Constipation Diarrhea Difficulty Swallowing Heart Burn Hemorrhoids Indigestion Jaundice Nausea Rectal Bleeding Abnormal Stool Abnormal Stool Color Abnormal Stool Consistency Vomiting Blood Vomiting Female: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Birth Control Breast Pain Burning Urination Frequent Urination Hormone Therapy Irregular Menstruation Pregnancy Urine Retention Vaginal Bleeding Vaginal Discharge Male: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Burning Urination Erectile Dysfunction Frequent Urination Hesitancy/Dribbling Prostate Problems Urine Retention Endocrine: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Cold Intolerance Diabetes Excessive Appetite Excessive Hunger Excessive Thirst Urine Retention Abnormal Urination Goiter Hair Loss Heat Intolerance Voice Change Unusual Hair Growth Skin: I DENY having or had any of the symptoms or problems listed below. Select all that apply. Change In Nail Texture Change In Skin Color Hair Growth Hair Loss Hives History Of Disorders Skin Lesions Varicose Veins Itching Goiter Rash Nervous System: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Dizziness Facial Weakness Headache Limb Weakness Loss Of Consciousness Loss Of Memory Numbness Paresthesia Seizures Sleep Disturbance Slurred Speach Stress Strokes Psychologic: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Anhedonia Behavioral Change Convulsions Memory Loss Anxiety Loss or change in appetite Bi-polar disorder confusion Depression Insomnia Mood Change Allergy: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Anaphylaxis Food Intolerance Itching Acute Nasal Congestion Chronic Nasal Congestion Rash Hematologic: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Anemia Bleeding Blood Clotting Blood Transfusion Bruising Easily Fatigue Lymph Node Swelling PAST HEALTH HISTORY:Fill out carefully as these problems can affect your overall course of care. Previous Care for This Same Condition: I have not previously seen a doctor for this condition OR Fill in the information BELOW.Have you seen other doctors for THIS CONDITION:Select OptionYesNoWho(Name)TYPE OF TREATMENTExplainPrevious Chiropractic Care:I have not previously seen a chiropractic OR fill out the information below Doctor NameLocationDate Of Last Visit Were you satisfied with your care?Select OptionYesNoWhyDo you wear any of the following? Heel Lift Inner soles Arch Supports OtherFor how long?Where they prescribed by a doctor?Select OptionYesNoCurrent Medication(s):List Any/All medications you are currently taking. Be specific.Medication:Dosage:For What Conditions:How long have you been taking this? Current Vitamins, herbs, etc:List Any/All medications you are currently taking. Be specific.Medication:Dosage:For What Conditions:How long have you been taking this?Childhood Illness(es): I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. ADD Atopic dermatitis(eczema) Allergies/Hayfever Chicken pox Crohn's/Colitis Depression Seizure disorder Sickle cell anemia Headaches Hepatitis HIV Scoliosis Anemia Asthma Bedwetting Cerebral palsy Diabetes Ear infections Fetal drug exposure Food allergies(list below) Measles Mumps Psoriasis Rash Spinal bifida Other Do you believe that the adult illnesses listed below are contributory to your CURRENT conditons?Select optionYesNoAdult Illness: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. ADD Alzheimers Anemia Arthritis Asthma Cancer Cerebral palsy Chicken pos Crohn's/colitis CRPS(RSD) CVA(stroke) Cystic kidney disease Depression Diabetes (insulin dep) Diabetes(non insulin) Eczema Emphysema Eye problems HIV Hypertension Influenza pneumonia Liver disease Lung disease Lupus (discoid) Lupus systemic) Multiple sclerosis Parkinson's disease Unspecified pleural effusion Pneumonia Psoriasis Psychiatric problems Scoliosis Seizures Shingles Past history of similar symptoms STD's (unspecified) Suicide attempts(s) Thyroid problems Lymphadema Other Surgery: I DENY having or had any of the symptoms or problems listed below. Select any or all that apply. Angioplasty Appendectomy Caesarian section Cardiac catheterization Carpal tunnel repair Coronary artery bypass Cosmetic D & C Dental surgery Gall bladder Hemorrhoidectomy Hernia repair Hysterectomy Joint reconstruction Joint replacement Knee repair Laminectomy Mastectomy Pacemaker insertion Tonsillectomy Other Full or Partial (Hysterectomy)Which joint? (Joint reconstruction)Which joint? (Joint replacement)Location (Laminectomy)Females Only:O\b/Select all that apply below. If you have been pregnant in the past, please fill in the appropriate information below.Number of complicated pregnanciesNumber of uncomplicated pregnanciesNumber of C-sectionsNumber of vaginal deliveriesNumber of miscarriagesNumber of terminated pregnanciesMenstrual HistoryI am currently pregnantSelect an optionYesNoI am NOT currently pregnantSelect an optionYesNoMy menses ARE regularSelect an optionYesNoAre NOT regularSelect an optionYesNoAge of first mensesAge when menopause beganDate of last mensesInjury: I DENY having or had any of the symptoms or problems listed below. Select Injuries if applicable Back injury Broken Bones Disability(ies) Fall(severe) Fracture Head injury (loss of consciousness) Head injury (no loss of consciousness) Industrial accident Joint injury Laceration(severe) Motor vehicle accident Bi-polar disorder confusion Soft tissue injury (mild) Soft tissue injury (moderate) Other Immunizations: I DENY having or had any of the symptoms or problems listed below. Please list the date(s) next to the immunization, if known. Adenovirus Anthrax Influenza Pneumococcal Tuberculosis Botulism Diphtheria DTP / DTap HIB Hepatitis A Hepatitis B Hepatitis C IPV (polio) Japanese encephalitis Lyme disease Measles Meningococcal MMR Mumps Pneumovax PPD (mantoux test- TB) Rabies Rotavirus Rubella Smallpox Tetanus Typhoid Varivax(chicken pox) Whooping cough (pertussis) Yellow fever Other Non-Drug Allergies: I DENY having or had any of the symptoms or problems listed below. Select all that apply below. Adhesive tape Animals Bee sting Chocolate Dairy Eggs Feathers Food coloring Latex Mold Newsprint Nuts Peanuts Perfumes Pollen Shellfish Smoke Soap Soy Wheat Other I DENY having or had any of the symptoms or problems listed below. Adhesive tape allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Animals allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Bee sting allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Chocolate allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Dairy allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Eggs allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Feathers allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Food coloring allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Latex allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Mold allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Newsprint allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Nuts allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Peanuts allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Perfumes allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Pollen allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Shellfish allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Smoke allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Soap allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Soy allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Wheat allergy reactions Anaphylaxis GI disturbance Headache Joint pain Rash Shortness of breath Unspecified reaction Provide information about allergyFamily History:Select all that apply below. List any specific condtions past or present after has/had:has/hadFather Alive Deceased No significant disease has/hadMother Alive Deceased No significant disease has/hadPaternal Grandfather Alive Deceased No significant disease has/hadPaternal Grandmother Alive Deceased No significant disease has/hadMaternal Grandfather Alive Deceased No significant disease has/hadMaternal Grandmother Alive Deceased No significant disease has/hadSon(s) Alive Deceased No significant disease has/hadDaughter(s) Alive Deceased No significant disease has/hadBrother(s) Alive Deceased No significant disease has/hadSister(s) Alive Deceased No significant disease has/hadSocial History:Select all that apply below.Alcohol: Rarely Occasionally Socially Frequent Never Drink the following regularly (mark below) Beer Wine QuantityQuantity in oz / glassesPer Day Week Month My Dietary Intake: I DENY having or have had of the symptoms or problems Consists mainly of the following: (select all that apply). High fat High salt Low fiber High fiber Low calorie Low salt High protein Low carbohydrate Low sugar Mark the highest level of education completed:Consists mainly of the following: (Select all that apply). Pre-school High school College Doctorate Elementary school High school graduate College graduate Graduate school Middle school GED Associates degree Graduate degree Vocational school High school - incomplete Bachelors degree OtherSubstance:Consists mainly of the following: (Select all that apply). I have never used illegal drugs Used illegal drugs Used IV drugs Has not used illegal drugs sinceUsed illegal drugs for (how long?)Tobacco Don't use tobacco. Don't smoke cigars or pipe. Live with a smoker Quit smoking Smoking #PerSelect an optionDayWeekMonthChew FrequencyCans perSelect an optionDayWeekMonth Insurance InformationWho is responsible for your billSelect an optionMyself OnlySpouseWorker's CompAuto InsuranceMedicareOtherPersonal Health Insurance carrierPolicy Holder NameHealth Id CardGroupPolicy Holder Social SecurityPolicy Holder BirthdatePatient's BirthdatePrimary Care PhysicianWorker Compensation Injury / Auto / Personal Injury:Have you filed an injury report with your employer?Select an optionYesNoDate Time : HH MM AM PM CarrierPolicy #Carriers Phone #AdjusterClaim # I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that the Chiropractic Clinic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Chiropractic Clinic will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care or treatment, any fees for professional services rendered me will be immediately due and payable. I hereby authorize the Doctor to treat my condition was here or she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only and the x-ray negative will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office. Patient Signature PATIENT CONSENT AUTHORIZATION:CONSENT FOR TREATMENT: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physicians. RELEASE OF INFORMATION: By signing the form, you are granting consent to BODY BALANCE CHIROPRACTIC & WELLNESS CENTER to use and disclose your protected health information for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review OUR Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full. Our notice of Privacy Practices is subject to change. If we change our notice you may obtain a copy of the revised notice by telephoning our office at 281-890-5599. You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement. You have the right to revoke this consent in writing, except Jo the extent we already have used or disclosed your protected health information in reliance on your consent. MEDICARE AND MEDICAID CONSENT TO RELEASE INFORMATION: I certify that the information given by me in applying for payment under Title XVIII and/or Title XI of the Social Security Act is correct, I authorize my holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. INFORMED CONSENT TO PARTICIPATE IN ACTIVE REHABILITATION THE GOALS OF THE REHABILITATION PROGRAM INCLUDE: Determining the cause and extent of your problem, Providing a therapeutic exercise program to strengthen you, increase your cardiovascular endurance, range of motion and flexibility, and decrease your pain. Return your to full-duty, non-restricted work status and lifestyle. THE EQUIPMENT USED TO TEST YOU AND THE PROCESS WE WILL BE USING WILL BE EXPLAINED TO YOU: Your participation in the rehabilitation program is voluntary. You can stop at any point in the program. Should you stop your program, we are obligated to notify your doctor, insurance company, attorney, and DVR manager, if it is applicable. If at any point during the evaluation or rehabilitation process you have any questions, we will answer them to the best of our ability or refer you to someone more qualified. Please be advised that there are no guarantees that your personal goals and orthose listed above will be met to your satisfaction. The success of any rehabilitation process lies in the combined effort of you and your provider. The "team" approach has the best chance of attaining your goals, so please ask as many questions as necessary for you to gain the maximum benefit from your rehabilitation program. Since the process of strengthening and conditioning are a form of "controlled strain", there is a chance of aggravation or injury. It is therefore imperative that you communicate to your provider any aggravation or injury that you may observe during the rehabilitation process. For example, the best exercise for you, if performed too early in your condition, may be your worst enemy if performed too soon. Communication with your provider will help put into perspective problems that may occur. Failure to discuss problems may only foster additional problems down the road. Research concerning the rehabilitation program and results may be conducted. Data will be used from the participant's evaluations and exercise program. No names will be used and all information is strictly confidential. Chiropractic as well as all other health profession is associated with potential risks in the delivery of treatment. Therefore, it is necessary to inform the patient of such risks prior to initiating care. While Chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition or disease as a result of treatment in this office. An attempt to provide you with the very best care is OUR goal and if the results are not acceptable, we will refer you to another provider who we feel can further assist you.Chiropractic adjustments and physical therapy procedure are sometimes accompanied by post treatment soreness, disc injury aggravation, minor joint, ligament, tendon, or other soft tissue injury, minor bums to the skin while receiving moist heat as well as rare rib injury or fracture from thoracic spine adjustments. Stroke is the most severe complication of Chiropractic treatment, as well as the least occurring; with the estimated incidence of this type of side effect 1 in 3 million upper cervical adjustment (JMPT 1996; 19; 37). Precautions such as pre-treatment history, examination, and x-ray prior to care minimize such risks, as well as performing all treatment carefully. These are not a normal and acceptable accompanying response to chiropractic care and physical therapy. Please advise your doctor if you experience any soreness, discomfort, dizziness, headache, tiredness, nausea, vomiting, loss of balance, or any other side effects or symptoms.I understand that the physician, medical personnel and other assistants will rely on statements about the patient, the patient's medical history, and other information in determining whether to perform the procedure or the course of treatment for the patient's condition and in recommending the procedure which has been explained. I understand that the practice of medicine is not an exact science and NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO ME concerning the results of any procedure. [consent to diagnostic studies, x-ray examinations, and any other treatment or courses of treatment relating to the diagnosis or procedures describe herein. By signing this form, I acknowledge that I have read or had this form read and or explained to me, that I fully understand its contents that I have been given ample opportunity to ask questions and that any question have been answered satisfactorily. All blanks or statements requiring completion were filled in and all statements I do not approve of were stricken before I signed this form. I also have received additional information including but not limited to the materials listed below, related to the procedure described herein. I hereby voluntarily request and consent to the performance of the procedures describe or referred to herein by Doctor at this facility and any other physicians or other medical personnel who may be involved in the course of my treatment.VERIFICATION OF NON-PREGNANCY (Female Patients Only): By my signature on this form I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular timeDate of last menstrual period SignatureGuardian or Spouse SignatureCAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.
