Michael Dardano D.C., M.S.N. Holistic Healthcare

Transcription

1 Michael Dardan D.C., M.S.N. Hlistic Healthcare 609 S. Vulcan Ave. Ste 201 Encinitas, CA Vic (760) West 27 th Street New Yrk, NY Vic (917) Website: Cancellatin Plicy: We require 24 hurs ntice when cancelling/rescheduling r "n-shw" appintments. Otherwise a $100 fee will be charged befre yu can schedule yur next appintment. The same applies fr "n-shw" appintments. Please scheduledrmike@gmail.cm r leave a message at Please nte that text message reminders f yur appintment are a curtesy, but yu are respnsible fr nting the date and time f yur appintment, as the texts may nt always wrk crrectly. Please DO NOT respnd t text message reminders t cancel appintments. New Patient Intake Frm Full Name Gender Age f Birth / / Address City State Zip Cde Marital Status M S D Wrk Status F/t P/t Retired Phne ( ) - Cell ( ) - Females: Pregnant Y N Last menstrual Cycle / Nursing Y N Name f Spuse Wh may we thank fr referring yu? We want yu t knw hw yur Patient Health Infrmatin will be used in this ffice and yur rights cncerning thse recrds. Befre we will begin any health care peratins we must require yu t read and sign this cnsent frm stating that yu understand and agree with hw yur recrds will be used. If yu wuld like t have a mre detailed accunt f ur plicies and prcedures cncerning the privacy f yur PHI we encurage yu t read the HIPAA NOTICE that is available t yu at the frnt desk befre signing this cnsent. 1. The patient understands and agrees t allw Dr. Dardan t use their PHI fr the purpse f treatment, payment, health care peratins and crdinatin f care. 2. The patient has the right t examine and btain a cpy f his/her wn health recrds at any time and request crrectins. The patient may request t knw what disclsures have been made and submit in writing any further restrictins n the use f their PHI. Our ffice is nt bligated t agree t thse restrictins. A patient s written cnsent need nly be btained ne time fr all subsequent care given the patient in this ffice. 3. The patient may prvide a written request t revke cnsent at any time during care. This wuld nt effect the use f thse recrds fr the cared given prir t the written request t revke cnsent but wuld apply t any care given after the request has been presented. 4. Fr yur security and right t privacy, all staff has been trained in the area f patient recrd privacy and a privacy fficial has been designated t enfrce thse prcedures in ur ffice. We have taken all precautins that are knwn by Dardan Chirpractic t assure that yur recrds are nt readily available t thse wh d nt need them.

2 5. Patients have the right t file a frmal cmplaint with ur privacy fficial abut any pssible vilatins f these plicies and prcedures. 6. If the patient refuses t sign this cnsent fr the purpse f treatment, payment and health care peratins, the chirpractic physician has the right t refuse t give care. I have read and understand hw my Patient Health Infrmatin will be used and I agree t these plicies and prcedures. Patient Signature Health Cncerns: Please list yur tp health cncerns in rder f pririty Treatment: what type f treatment are yu lking fr? I am lking fr the mst minimal amunt f care t patch up the symptms f my prblem. I am lking t reslve my symptms and then g n t fix the cause f my prblem. I am lking t take care f my prblem and then g n t achieve ptimal health and wellness. Cmplaint /Prblem: In relatin t yur PRIMARY cmplaint: When did yu first seek treatment fr this prblem: Has anther dctr treated yu fr this cnditin? Whm? MD DC DO PT LMT Other Name f Primary Dctr Treatments Previusly Tried: Medicatin Surgery Lifestyle Change Chirpractic Massage Physical Therapy Other Have yu had an intlerance t any f these treatments? Y N When did this prblem start? Hw did it ccur? Has it becme wrse recently? Y N Remained cnstant? Y N Hw lng des it last? Is this cnditin interfering with: wrk sleep daily rutine recreatin sexual activities Des anything relieve the symptms? Des anything aggravate the symptms? Hw lng has it been since yu have felt really gd? Days weeks mnths years can t remember Describe the Pain: Sharp Dull Numbness Tingling Aching Burning Stabbing Shting What d yu believe is the cause f yur prblem? Are there any ther cnditins r symptms that may be related t yur majr symptm? Y N If Yes, please explain

3 Please check all the symptms that apply: past r present. Headache Feel Lss f Cntrl Insmnia Walking prblems Swallwing Hemrrhids Nausea/Vmiting Pr Circulatin Excessive Thirst Earache Slw Heart Rate Fatigue Sweating Tingling in Feet Clammy Hands Cnstipatin Abdminal Pains Unsteady Vice Dry Muth Dizziness Swllen Jints Imptence Shakiness Rapid Heart Rate Tingling in Hands/Feet Frequent Urinatin Lw Bld Pressure Lw Back Pain Teeth Grinding Blurred Visin Shulder Pain Irritability Paralysis Jint Stiffness Elbw/Hand Pain Urinatin Difficulty High Bld Pressure Sre Thrat Sinusitis Eye Pain Hip Pain Cnvulsins Weak Muscles Persistent Cughing Menstrual Irregularities Fullness f Bladder Swllen Ankles Neck pain Cnfusin Facial Pain Lump in Thrat Fainting Sre Muscles Knee Pain Decreased Sex Drive Pr Appetite Chest Pressure Unpleasant Taste Frgetfulness Ankle/Ft Pain Allergies and Sensitivities: Fd: Dairy Wheat Crn Sy Seafd Gluten Peanuts Fruit ther Medicatins: Penicillin Sulfa Drugs Idine Insulin Antibitics Other Seasnal: Pllen Dust Hay Mld Chemical Smke Animals Insects Feathers ther Medicatins: Please list individually all medicatins yu are currently taking including nutritinal supplements: Scars and surgical prcedures: Please list lcatin and reasn fr all scars n the bdy: Apprx hw many hurs f sleep d yu get every night? Hw many meals d yu eat a day?

4 Hw many bwel mvements d yu have n average in a day? What is the mst cmmn activity perfrmed at wrk? Habits: Heavy Md Light Nne Alchl Cffee Sda/Diet Tbacc Drugs Stress Exercise Family Histry: Identify any cnditins yu r any f yur family members have nw r have had in the past: Mark S fr Self and F fr family members. Alchlism Emphysema Allergies Anemia Epilepsy Pneumnia Cancer Giter/Thyrid Disease AutImmune Disease Cld Sres Gut Irritable Bwel Syndrme Deep Vein Thrmbsis Heart Disease Strke Psriasis HIV/AIDS Tumr Diabetes Miscarriage Ulcer Eczema Mumps Other: Patient s Printed Name Signature Patient Billing Infrmatin I understand that all payments are due t Dr. Michael Dardan at the time that services are rendered, except when prir arrangements are made. All bills are due and payable in full. All fees are based upn individual services rendered, and may vary frm visit t visit depending upn the dctr s specific recmmendatins. A cmplete list is available at the frnt desk. Initial Cnsultatin: $ This cnsultatin des nt include diagnstic imaging which may be referred ut t an imaging center if deemed necessary. All fees are subject t change withut ntice. Fllw up Visits: $ The fllw up visit fee des nt include the cst f herbs, vitamins, and hmepathic remedies.

5 Cancellatin Plicy: We require 24 hurs ntice when cancelling/rescheduling r "n-shw" appintments. Otherwise a $100 fee will be charged befre yu can schedule yur next appintment. The same applies fr "n-shw" appintments. Please scheduledrmike@gmail.cm r leave a message at Please nte that text message reminders f yur appintment are a curtesy, but yu are respnsible fr nting the date and time f yur appintment, as the texts may nt always wrk crrectly. Please DO NOT respnd t text message reminders t cancel appintments. If yu r yur insurance cmpany request cpies f yur medical recrds, a $30.00 cpy charge as well as a $0.10 per page will be billed t yu. Yu may try t recver this charge frm yur insurance cmpany. Any Financial Arrangements are t be determined prir t services rendered. I agree t the terms abve, and acknwledge that in the event that there is an utstanding balance, which fails t be cured within sixty days, my accunt with Dardan Chirpractic will be turned ver t cllectin. I understand that shuld this happen, I will remain respnsible fr any and all additinal cllectin fees and/r attrney and curt csts. Signature Cnsent fr Purpse f Treatment, Payment and Health Care Operatins I, (the patient), cnsent t Dr. Dardan (the practice), use and disclsure f my Prtected health infrmatin fr the purpse f prviding treatment t me, fr purpse relating t the payment f services rendered t me, and fr the practice s general health care peratins purpses. Health care peratins purpses shall include, but nt be limited t, quality assessment activities, credentialing, business management and ther general peratin activities. I understand that the practice s diagnsis r treatment f my may be cnditined upn my cnsent as evidence by my signature n this dcument. Fr purpses f this Cnsent, prtected health infrmatin: means any infrmatin, including my demgraphic infrmatin, created r received by the Practice, that relates t my past, present, r future physical r mental health r cnditin; the prvisin f health care t me; r the past, present, r future payment f the prvisin f health care services t me; and that either identifies me r frm which there is a reasnable basis t believe the infrmatin can be used t identify me. I understand that I have the right t request a restrictin n the use and disclsure f my Prtected Health Infrmatin fr the purpses f treatment, payment r health care peratins f the Practice, but the Practice is nt required t agree t these restrictins. Hwever, if the Practice agrees t a restrictin that I request, tile restrictin is biding n the practice. I understand I have a right t review the Practices s Ntice f Privacy Practices prir t signing this dcument. The Ntice f Privacy Practices describes my rights and the Practices duties regarding the types f uses and disclsures f my Prtected Health Infrmatin. I have the right t revke this cnsent, in writing, at any time, except t the extent that the Physician r the Practice has acted in reliance n this cnsent. Signature f patient Name f patient Printed

6 Infrmed Cnsent fr Chirpractic Care Chirpractic care, like all frms f health care, while ffering cnsiderable benefit, may als prvide sme level f risk. This level f risk is mst ften very minimal, yet in rare cases injury has been assciated with chirpractic care. The types f cmplicatins that have been reprted secndary t chirpractic care include sprain/strain injuries, irritatin f a disc cnditin, and rarely, fractures. One f the rarest cmplicatins assciated with chirpractic care, ccurring at a rate between ne instances per ne millin t ne per tw millin cervical spine adjustments may be a vertebral artery injury that culd lead t strke. Prir t receiving chirpractic care at this ffice, a health histry and physical examinatin will be cmpleted. These prcedures are perfrmed t assess yur specific cnditin, yur verall health and, in particular, yur spine health. These prcedures will assist us in determining if chirpractic care is needed, r if any further examinatins r studies are needed. In additin, they will help us determine if there is any reasn t mdify yur care r prvide yu with a referral t anther health care prvider. All relevant findings will be reprted t yu alng with a care plan prir t beginning care. I understand and accept the risks assciated with chirpractic care and give my cnsent t the examinatins that the dctr deems necessary, and t the chirpractic care including spinal adjustments, as reprted fllwing my assessment. Printed Name Signature