Healing Touch Chiropractic- New Patient Intake

Informed Consent
Please answer the following questions to help us determine possible risk factors
In general, have you ever had an adverse (i.e. bad) reaction to or following chiropractic care?

Yes No
Please explain
BONE WEAKNESS

Toggle to "Yes" if the corresponding question applies to you.
Have you been diagnosed with osteoporosis?
Do you take corticosteroids (e.g. prednisone)?
Have you been diagnosed with a compression fracture(s) of the spine?
Have you ever been diagnosed with cancer?
Do you have any metal implants?
VASCULAR WEAKNESS

Toggle to "Yes" if the corresponding question applies to you.
Do you take aspirin or other pain medication on a regular basis?
Do you take warfarin (Coumadin), heparin, or Other similar “blood thinners”?
Have you ever become dizzy or lost consciousness when turning your head?
Ever been diagnosed with any of the following disorders or diseases
SPINAL COMPROMISE OR INSTABILITY

Toggle to "Yes" if the corresponding question applies to you.
Have you had spinal surgery?
Please Describe
Have you been diagnosed with spinal stenosis?
Have you ever experienced sudden weakness in the arms or legs?
Have you ever experienced numbness in the genital area?
Have you ever had the inability to urinate or lack of control when urinating?
Please describe any "yes" answers above.

Acknowledgements
Assignment of Benefits & Release of Health Information: I Authorize Healing Touch Chiropractic to use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, replying to requests from my insurance company, evaluating the quality of services provide, communicating with my referring physician, and any other administrative operations related to treatment or payment as noted in HTC’s Notice of Privacy Practices. I understand that benefits quoted from my insurance carrier to Healing Touch Chiropractic are only an estimate and not a guarantee of payment. I assign HTC all benefits payable to me under my insurance policies and health benefit plans. I shall be personally responsible for any unpaid balances. Initial Below *
Agreement in financial responsibility: I understand that I am directly and fully responsible to for all medical charges resulting from any no show fees, consultation, examination and/or treatment which I will receive. I am aware that this agreement is made solely for the doctor's protection and in consideration of any awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover. Initial Below *
No Show Fees: I understand that if I do not cancel or reschedule my appointment with at least 24-hour notice, we may assess a $50 “no-show” service charge to your account. Initial Below *
Signature

Clear
SUMMARY ( FOR OFFICE USE ONLY)

General:

The patient, a {age} year old {gender} presents to the clinic complaining of {whereDo}. Symptoms began on {whenDid}. The pain is described as {howWould} and is {howOften}. The patient explains that symptims are{progressOf} since onset.

Patients Description of injury: {pleaseBriefly}

Activities of daily living that are affected include: {activitiesOf}

Prior Treatments: {whatTypes}

Auto Injury (If Applicable):

The patient, a {age} year old {gender} presents to the clinic complaining of {whereDo} as a result of an {whatBrings}. Symptoms began on {whenDid}. The pain is described as {howWould} and is {howOften}. The patient explains that symptims are{progressOf} since onset.

The patient, a restrained {positionIn} of a {typeOf78} was {mechanismOf} by a {otherVehicle}. The patients vehicle was driving at approximately {howFast} while the opposing vehicle was traveling at approximately {howFast85}. The patient explains that the road conditions during the time of the accident was {whatWere} and occurred during {whatWere76}.

At the time of the accident, the patient exhibited feelings of {whatWere87}.

Activities of daily living that are affected include: {activitiesOf}

Prior Treatments: {whatTypes}

After the accident the patient went {whereDid} via {howWere}.

The patient description of the accident: "{brieflyDescribe}"

Transported to Hospital/ER: {wereYou95}

If so, which Hospital: {whichHospital}

Imaging taken: {anyImaging}. Findings: {whatWere93}

Did you lose consciousness? {didYou}

Did you hit your head?{didYou132} If so, Where: {whereDid130}

Did you have any cuts/bruises? {didYou133}; If so where: {whereDo134} Stitches: {didYou135}

Did you miss any days from school or work: {missAny}; if so How many? {howMany}
Should be Empty:

Healing Touch Chiropractic

Demographics

Insurance Information

Pain/Injury Details

Auto Injury Information

Health History

Review of System

Informed Consent

Please answer the following questions to help us determine possible risk factors

BONE WEAKNESS

VASCULAR WEAKNESS

SPINAL COMPROMISE OR INSTABILITY

Acknowledgements