Healthier People, Healthier Planet 551 S. Spring Rd. Elmhurst, IL 60126 630.941.TREE www.chirotree.com Case History Patient Information Name: DATE Gender: Male Female Date of Birth: (Age: ) Who may we thank for referring you to office? Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Email address: Occupation: Employer: Marital Status: S M D W Spouse s Name and Occupation: Number of Children and Ages: Have you ever received Chiropractic Care? YES NO If so, where? Reason for those visits Approximate Date of last visit [ ] YES [ ] NO Get Well & Stay Well website membership enrollment Your subscription is granting us permission to send you periodic information including: natural health emails, updates about our practice as well as special offers. Naturally you may opt out at any time. We keep your information private review complete policy on website. About Your Health The human body is designed to be healthy. Throughout life, events occur which damage your health. This case history will uncover the layers of damage, especially to your nerve system, that resulted in poor health. Following your exam, your chiropractor will outline a course of care to begin to correct these layers of damage and recover your innate health potential. Were you aware that Doctors of Chiropractic work with the nervous system? YES NO The nervous system controls all bodily functions and systems? YES NO Chiropractic is the largest natural healing profession in the world? YES NO If Chiropractic care starts at birth, you can achieve a higher level of health throughout life? YES NO 1
Pediatric Patients Only Loss of Wellness Let s begin at birth when you first damaged your nerve system, lost your wellness and began your journey to ill health. NO YES PATIENT COMMENT CHIROPRACTOR S If answer is YES Comments 1. BIRTH PROCESS Did your mother experience any falls, injuries or abuse during pregnancy? Was the delivery long? Was the delivery difficult? Forceps? Cesarean? Breach? Home birth? Hospital birth? Mother given drugs during delivery? Was labor induced? 2. GROWTH AND DEVELOPMENT (BIRTH THROUGH TEENAGE YEARS) Were you taught how to care for your spine? Did you fall out of bed? Fall from crib? Fall from high chair? Fall from changing table? Fall while learning to walk? Fall off skateboard or skates? Fall off bicycle? Fall off swing/slide? Fall off monkey bars? Fall down stairs? Did you have childhood sickness? Chair pulled out when sat down? Did you have accidents/auto? Did you have surgery? Did you take medication/drugs? Were you picked on by siblings? Did you experience child abuse? Did you experience severe spanking? Did you have your ear/chin pulled? Were you yanked by your arm? Did you have an injury playing Organized sports? List all Immunizations you have had: Have you ever been treated at the emergency room? If yes; please explain 2
Loss of Whole Body Health All patients As layers of damage due to physical, chemical, and mental stresses increased, you probably began to experience symptoms and random bouts of sickness. 3. HEALTH HABITS AND STRESSES (CHILDHOOD TO PRESENT) NO YES PATIENT COMMENT CHIROPRACTOR S If answer is YES Comments Did/ do you smoke? Did/ do you drink any alcohol? Diet (Do you eat healthy foods?) Have you been in accidents/falls? Have you had surgery & organs removed/ replaced? Did/ do you take drugs prescriptive or non-prescriptive? Did/ do you have occupational stress? Did/ do you have physical stress? Did/ do you have mental stress? Did/ do you have sports injuries? Primary Reason for Consulting this Office All Patients Finally, the years of continuing damage showed up as acute or chronic symptoms. Purpose of this visit: Wellness Check-up Pain/Discomfort/Injury Present complaint When did this health challenge begin? What were you doing? Pains are: SHARP DULL CONSTANT INTERMITTENT Is this condition getting progressively worse? YES NO Frequency: DAILY 2-3 TIMES WEEKLY SPORADIC Is this condition worse at certain times of the day? Morning Afternoon Evening During sleep Does this condition interfering with: Work Sleep Routine Other Other doctors seen for this Are you using any home remedies? Has anything made it feel better? OTHER SYMPTOMS Please check each of symptoms if you have them now or have had them in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis and care plan. HEADACHES FEVER FAINTING TENSION FOR WOMEN: NECK PAIN FACE FLUSHED SLEEPING PROBLEMS IRRITABILITY NECK STIFF DIZZINESS SHORTNESS OF BREATH FATIGUE PREGNANT UPPER BACK PAIN LOSS OF BALANCE CHEST PAINS DEPRESSION NURSING MID-BACK PAIN LIGHTS BOTHER EYES LOSS OF MEMORY ANXIETY BIRTH CONTROL LOW BACK PAIN SINUS PROBLEMS LOSS OF SMELL STOMACH UPSET PAINFUL PERIODS NUMBNESS OR PAIN IN BUZZING OR RINGING LOSS OF TASTE DIARRHEA IRREGULAR CYCLE ARMS/HANDS/FINGERS IN EARS COLD SWEATS CONSTIPATION NUMBNESS OR PAIN IN COLD FEET/HANDS ASTHMA ALLERGIES LEGS/FEET/TOES Have you been under medical care recently or for this problem? Have you been taking prescriptive or non-prescriptive drugs? Have you had surgery? YES NO Any side effects from drugs or surgery? 3
HEALTH HISTORY OF FAMILY MEMBERS The reason for this form is to assist the doctor by providing past health history information for their review. Condition Self Father Mother Spouse Brothers Sisters Children Arthritis Asthma Back Trouble Cancer Constipation Diabetes Difficulty Sleeping Disc Problems Ear Problems Emphysema Epilepsy/Seizures Fatigue Headaches Heart Trouble High Blood Pressure Kidney Trouble Migraine Nervousness Neck Pain Numbness Pinched Nerve Scoliosis Sinus & Allergies Stomach Troubles I understand that I am directly and fully responsible to Tree of Life Chiropractic Center for all chiropractic care myself or my child, if minor, receives. I hereby certify that the statements and answers given on this form are accurate to the best of my recollection and knowledge. I agree to allow this office to examine me or my child, if minor, for further evaluation and I am responsible for payment of healthcare services. Patient Signature Date Tree of Life Chiropractic Center 551 S. Spring Road Elmhurst, Il 60126 630.941.8733 4
TERMS OF ACCEPTANCE When a practice member seeks chiropractic health care and we accept a practice member for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each practice member understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of force to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express it s maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter a non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations: I have read and fully understand the above statements. All questions regarding the doctor s objective pertaining to my care in this office have been answered to my complete satisfaction. I, therefore, accept chiropractic care on this basis. Signature: Date: Consent to evaluate and adjust a minor child I, being the parent or legal guardian of have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-rays can be hazardous to an unborn child. Date of last menstrual period. Signature: Date: Tree of Life Chiropractic Center 551 S. Spring Rd. Elmhurst, IL 60126 630.941.8733 5
Tree of Life Chiropractic Center Kelly Synowiec-Moroney, D.C. Office Policies 1. Family Exams: We recommend that everyone in a family be checked for subluxations within 14 days. It is not a requirement for them to start care, but it is offered, and strongly encouraged, that everyone be checked 2. Missed Appointments: In the event that you need to miss an appointment, we ask that you make that appointment up within 24 hours. If you miss your appointment and do not call to reschedule no-show - there is a missed appointment fee of $25.00, which is your personal responsibility. 3. Appointment Make-up: In the event you must reschedule an appointment, please reschedule it within the same week so that we can keep your spinal correction program on track. 4. No Cell Phones: To create a healthier healing environment, we ask that you not use cell phones at any time while in the office. If you need to make/take a call/text, please step outside. 5. Therapy Charges it is expected that you follow the doctor s recommendations and perform all the proper therapies on every visit unless instructed to do otherwise. If for some reason you do not perform the therapy, notify the front desk. You will be billed for all therapies unless you inform the front desk. CHIROPRACTIC FEE-FOR-SERVICE AGREEMENT 1. PAYMENT payment for all services are due in full at the time services are rendered. 2. PATIENT COOPERATION in order to get the best results; please follow the visit frequency laid out in your care plan. 3. TERMINATION - should you need to discontinue care at any time, kindly provide written notice to our office so that we may close out your file. Our office will then make a refund of any and all fees pre-paid for services not rendered. 4. REFUNDS IN THE EVENT of DISCONTINUATION the refund shall equal the amount prepaid less any and all sums due for the services actually performed. Refunds will be pro-rated at non-discounted fees. All Care Credit refunds will incur a 15% service charge reduction. Refunds will be paid to the patient within 30 days of discontinuing care. 5. SUBSEQUENT INJURIES the care the patient is to receive under this care plan has been determined based upon the patient s present condition. If a new injury or condition arises during the course of treatment provided for in this care plan, the current care will be suspended until such time as the subsequent problem has resolved, or maximum medical improvement has been obtained. 6. NO GUARANTEE OF RESULTS patient recognizes this agreement is not a guarantee of results and deals solely with the services to be rendered and the fees to be paid for the care as provided. The patient s payment obligation is not contingent upon the outcome of care. 7. POSSIBLE ADDITONAL CHARGES additional items needed to support the patient s care such as orthopedic supports, orthotics, cervical pillow, exercise materials, laboratory tests, x-rays and/or analysis, nutritional support and other similar things will be separately charged for and payment for said care shall be due at the time received by the patient. 8. INSURANCE COVERAGE (if applicable) our office has estimated the amount of reimbursement expected from your insurance company based on our experience/contract with your carrier. If for some reason your insurance fails to pay as expected, you are responsible for any services not covered. Signature Witness Date Date 6
Tree of Life Chiropractic Center Patient Consent 551 S. Spring Rd Elmhurst, Illinois 60126 Office (630)941-8733 Fax (630) 941-8731 For use and/or disclosure of Protected Health Information (PHI) To carry out Treatment, Payment and Healthcare Operations (name), hereby states that by signing this Consent, I acknowledge and agree as follows: 1. The Practice s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information ( PHI ) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out it s health care operations. The Practice explained to me that the Privacy Notice would be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. 2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. 3. The Practice s Notice of Privacy Practices is provided at the front desk. I may also request a copy from this office at any time via US Mail. 4. This Notice of Privacy Practices also describes my rights and the duties of this office with respect to my protected health information. 5. I understand that, and consent to, the following appointment reminders and office updates that will be used by the Practice: a) a postcard mailed to me at the address provided by me; b) telephoning my home/cell and leaving a message on my answering machine or with the individual answering the phone; and c) emailed office updates and events. 6. The Practice may use and/or disclose my PHI (which included information about my health or condition and the treatment provided to me) in order for the Practice to provide Chiropractic care for me and obtain payment for that care, and as necessary for the Practice to conduct its specific health care operations. 7. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. IF the Practice agrees to a requested restriction, then the restriction is binging on the Practice. 8. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on the consent. 9. I understand that if I do not sign this consent or revoke consent at any time, the Practice has the right to refuse to provide chiropractic care to me. 10. I understand and consent to the following other types of correspondence from this office: a. A birthday card may be mailed to me at the address I provided b. I may receive periodic mailings of general health information in the form of a newsletter, etc. c. I will be signing in on a daily sign-in sheet when I come in for my appointment. d. I may receive periodic informational emails and text messages. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand. Name of Individual Signature of Individual Date Signed Staff/Witness 7