Thank you for choosing Be Well Chiropractic. Please fill out this form as completely and accurately as possible. If answer is “N/A” or “None”, please indicate. Today’s Date PERSONAL DATA First MI Last Suffix Age Date of Birth Parent’s names (if you are under 18) Home Address City State Zip Home phone () Business Phone () Cell Phone () E-mail address Occupation Employer Business Address City State Zip SS# (opt’l) Emergency contact Marital Status S M D W L/W Spouse/Partner Names and Ages of Children Whom may we thank for referring you to our office? REASONS FOR SEEKING CHIROPRACTIC CARE What concerns do you feel Be Well Chiropractic can address for you? (Please list on line below.) Are these concerns affecting your quality of life? (Please select only those applicable to you) Work: Y N Driving: Y N Sleep: Y N School: Y N Walking: Y N Sitting: Y N Exercise/sports: Y N Eating: Y N Love life: Y N HEALTH CARE PRACTITIONER HISTORY Have you had X-rays taken in the last 6 months? Y N Name of Doctor Date of last X-ray: Reason for X-ray Have you ever received Chiropractic care? Y N Name of D.C. How long under care? days weeks months years Date of last visit: Why did you stop? Have you ever received Wellness care? Y N Name of Doctor How long under care? days weeks months years Date of last visit: Why did you stop? Have you consulted or do you regularly consult any of the following providers? (check all that apply) Medical Physician Naturopath Acupuncturist Homeopath Massage Therapist Psychotherapist Energy Healer Dentist Reason why: FOR WOMAN Are you pregnant? Y N Date of last menstrual period: If x-rays are recommended, you are required to type your name (below) to indicate that you are not pregnant. Signature: Date: If pregnant, Due Date: Name of OBGYN or Midwife Where will you be birthing your baby? Hospital Home Birthing Center Other HEALTH, WELLNESS AND CHIROPRACTIC CARE The primary system in the body which coordinates health is the CENTRAL NERVE SYSTEM. The vertebrae, (bones of the spinal column) surround and protect the delicate NERVE SYSTEM. Chiropractors are specialists trained in “early detection” of injury to the SPINE & NERVE SYSTEM. The information below will help us to see the types of PHYSICAL, EMOTIONAL & CHEMICAL stresses you have been subjected to and how they may relate to your present spinal, nerve and health status. PHYSICAL STRESS: BIRTH AND INFANCY The birth process can traumatize a baby’s spine and cause damage to the spine & nerve system. Please indicate where and how you were birthed. (If you do not know, please skip to next question) Home Natural Hospital Caesarian section Forceps Breech Cord around neck Prolonged labor Drug induced labor Suction PHYSICAL STRESS: CHILDHOOD THROUGH ADULT The minor & often ignored repetitive physical traumas that we have endured are often too numerous to list. Please list the major traumas that you remember from your childhood up to the present. Have you had any accidents or injuries in your life related to any of the following? (check all that apply) Automobile Motorcycle Bicycle Sports Playground Abuse If yes, state type of injury and date: Have you ever hurt/injured your spine, head, neck, ribs, chest, upper or lower back, pelvis or hips? Y N If yes, state type of injury and date: Have you ever hurt, broken, fractured or sprained any bones or joints? Y N If yes, list body parts injured and dates: Have you ever been hospitalized? Y N If yes, state reason and dates: EMOTIONAL STRESS It is difficult to separate the emotional stress in our life from the physical response that often occurs. Please indicate if you have experienced any of the emotional stresses below: Childhood Trauma Y N Loss of loved one Y N Abuse Y N Work or School Y N Divorce/separation Y N Financial Y N Lifestyle change Y N Parents divorce Y N Illness Y N CHEMICAL STRESS Chemical stress can occur when a substance, that is toxic to the body, is breathed, injected, taken by mouth, or placed on the skin (e.g.: food allergies, drug reactions, exposure to chemicals in the air, etc.) The following will reveal exposures you may have had. Were you vaccinated? Y N If yes, did you have a reaction? Y N Toxic chemicals Radiation Second hand smoke Chemotherapy Drug therapy Other If yes, please list: Do you have allergies to any foods? Y N If yes, please list: Do you consume any of the following presently? Coffee/caffeine Alcohol Tobacco Over the counter drugs Prescribed drugs Please list all medications (prescribed and over the counter) below: Note: It is imperative that you list all medications as they may have an influence on your care. QUALITY OF LIFE How do you grade your physical health? Good Fair Poor How do you grade your emotional/mental health? Good Fair Poor How do you rate your overall “quality of life“? Good Fair Poor How do you grade your diet/eating habits? Good Fair Poor Do you exercise regularly? If yes, how often & what type? How many hours per day do you watch TV? How many hours per day do you use a computer? How many hours per day do you spend sitting down? Do you meditate, attend worship service or engage in any form of positive mental thinking? How well do you sleep? If not well, why? How many hours of uninterrupted sleep do you get each night? How many ounces of water do you consume daily? Is the water filtered? Do you follow a special dietary regime? If yes, what? How many softdrinks do you consume on a typical day? How much fast food do you consume per week? How many servings of vegetables do you eat in a typical day? How many servings of fruit do you eat in a typical day? Are any of these fruits and vegetables organic? Are you happy with your present overall wellbeing and health status? Chiropractic care has shown to be effective for many different symptoms, please mark all the health concerns below that you have experienced. (Please mark with a check) Circulatory/Vascular Asthma Infertility Digestive Problems Back Pain Heart Condition Dizziness Bladder Problems Menstrual Cramps Headaches Urinary Difficulty Cancer Heartburn/Reflux Depression Neck Pain Mood Swings Diarrhea Numbness/Tingling Arthritis Immune System Disorder Osteoporosis Allergies Sinus Trouble Vertigo Skin Conditions Other (briefly describe): EXPECTATIONS I would like to have the following benefits from Chiropractic Care: (Check all that apply) Relief of a symptom or problem Relief and Prevention of a symptom or problem Healthier spine and nerve system Optimal health on all levels CHIROPRACTIC CLINICAL OBJECTIVE Physical, Emotional and Chemical STRESSES, common to our contemporary lifestyles, can result in misalignment of the spinal column causing damage to the nerve system. The result is a condition called Vertebral Subluxation. The Chiropractic Exam/evaluation is specifically designed to detect Vertebral Subluxations in all phases of their progression. Please read the following carefully, then sign and date. Thank You! My Responsibility My responsibility is to provide you with the best quality Chiropractic Wellness care possible and to educate you to care for your spine and body, so that you may thrive at your full living potential. Your Responsibility Your responsibility is to learn, by participating in our patient education programs, to ask questions, and make informed decisions about the recommendations I make for your Chiropractic Wellness care. We expect you to take a pro-active approach in achieving your health goals. You are also responsible for keeping your schedule of care and for payment for your care. Payment is due at time of services unless you have made specific financial arrangements with our office. Please inform me if you have insurance that covers Chiropractic care, although I do not except assignment, I can provide you with the necessary paperwork for you to send to your provider for reimbursement. If you have a fall or accident, a surgery, any change in health history including change in prescription medication, or change in address, please advise us. Your Care The Chiropractic adjustment is a quick movement of the vertebrae of the spine, for the purpose of specifically realigning the bone(s) of your spine. Most patients say the adjustment is comfortable, others may be sore the day after the adjustment. The risk of injury during an adjustment is very small. These risks include fracture or in extremely rare instances, stroke can occur. Great controversy exists within the scientific community regarding this risk: some authors say Chiropractic care actually reduces the risk, others say that the risk is one million, to one in five million. The risk of having a subluxation and receiving no care includes degeneration of the affected area and nerve compromise, which affects the health of your entire body. Ongoing research suggests that with early intervention, the vertebral subluxation complex can be eliminated. If degeneration occurs, the prognosis for full recovery decreases significantly. Terms of Acceptance When a person seeks Chiropractic care and when a Chiropractor accepts that person as a patient, essential to the success of the relationship is that both parties seek the same goals. My sole intent and goal as your Chiropractor is to find and correct verterbral subluxations and to educate and assist you in attaining Optimum Health and Wellness. I do not treat or cure any physical, mental, o r emotional ailments or diagnose disease, however, your body, when properly maintained and free from the effects of subluxation, can self-heal and self- regulate as it was designed to do. Acknowledgement By typing your name(s) and date(s) below, you affirm: I have read and understand the above and agree to the terms and intent. Patient Signature Date Parent/Guardian Signature (if patient is under 18) Date THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFOR MATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In the course of your care as a patient at Be Well Chiropractic, we may use or disclose personal and health related information about you in the following ways: • Your personal health information, including your clinical records, with your permission, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment. • Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer (if they are responsible for the payment of your services) Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, to provide information about alternatives to your present care, other health related information that may be of interest to you, or a notice of special events or personalized greeting. Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in the following circumstances: If we are providing health care services to you based on the orders of another health care provider. If we provide health care services to you in an emergency. If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so. If there are substantial barriers to communication with you, but in our professional judgment we believe that you intend for us to provide care. If we are ordered by the courts or another appropriate agency. Any use or disclosure of your protected health information, other than as described in the examples outlined above, will only be made upon your written authorization. We normally provide information about your health care to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a different form, please advise us in writing as to your preferences. You have the right to inspect and /or copy your health information for seven years from the date that the record was created or for as long as the information remains in our files. In addition, you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy policy. If changes are made to our privacy policy, we will notify you in writing as soon as possible following the changes. Any change in our privacy policy will apply for all of your health information in our files. Information that we use or disclose based on the privacy policy may be subjected to re-disclosure by the person or persons to whom we proved the information and may no longer be protected by the federal privacy rules. If you have a complaint regarding our privacy policy, our privacy practices or any aspect of our privacy activities, please inform us. Privacy policy effective as of March 1, 2010. My signature acknowledges that I have received a copy of this notice. Patient Signature Date Parent/Guardian or Representative (Printed) Date
