Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address City State Zip Code Home Phone ( ) - Work Phone ( ) - Cell Phone ( ) - Email Date of Birth / / Sex: Male Female Social Security Number: - - Marital Status: Single Married Other Employment Status: Employed Unemployed FT Student PT Student Other Occupation if Employed: Emergency Contact Contact Name Relationship to Patient Contact Home Phone ( ) - Cell Phone ( ) - How did you hear about our office? Have you ever had chiropractic care before? Yes No For what problem? Were the results satisfactory? Yes No N/A Have you seen anyone else for this problem? 1
Patient Name Date Medical Conditions: (Check all that apply to you) Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Other Surgeries: (Check all that apply to you) Appendectomy Cardio-vascular procedure Cervical spine Hysterectomy Joint Replacement Prostate Lumbar spine Gall Bladder Brain Shoulder Thoracic spine Knee Carpal Tunnel Gastro-intestinal Uro-genital Hernia Shoulder Other Allergies: (List any allergies) Please list ALL current medications, vitamins and/or supplements being taken: Social History: (Check all that apply to you) Caffeine use: occasional often never Drink Alcohol: occasional often never Exercise: occasional often never Tobacco Use: occasional often never Sleep: Hours per night = Stress Level: High Moderate Low None Family History: (Check all that apply) Arthritis: Parent Sibling Mental Illness: Parent Sibling Cancer: Parent Sibling Kidney Dis.: Parent Sibling Diabetes: Parent Sibling Ulcer: Parent Sibling Heart Disease: Parent Sibling Asthma: Parent Sibling Hypertension: Parent Sibling Stroke: Parent Sibling Thyroid: Parent Sibling Other 2
Patient Name Date Review of Systems (Check if you have had trouble with any of the following within the last 3 months) General: Skin: Cardio: Weight change Rash Murmur Fever Hair Changes Palpitations Chills Nail Changes Cough Night Sweats Itching Chest Pain Fatigue Difficulty Breathing Weakness Blue Extremities Neurologic: Swollen Extremities Eyes: Headache Wheezing Vision Dizziness Pain Convulsions Breasts: Discharge Fainting Mass Discharge G-I: Pain Ears: Appetite Self-exam Hearing Abdominal Pain Ringing Vomiting Pain Diarrhea Psychologic: Discharge Constipation Depression Moods Nose: G-U: Anxiety Pain Frequent Urination Memory Bleeding Painful Urination Taste Musculoskeletal Incontinence Neck Upper Extremities Mouth/Throat: Lower Back Sores Upper Back Bleeding Lower Extremities Taste Additional Info: If you selected headache, please answer the following questions: My headache is located: My headache typically lasts: I experience sensitivity to light when I get my headache: Yes No Sometimes I experience sensitivity to sound when I get my headache: Yes No Sometimes I experience nausea or vomiting before, during or after my headache: Yes No Sometimes I experience headaches: Everyday 1-2 days/week 3-5 days/week Other 3
Patient Name Date Are you pregnant? Yes No N/A Major complaints please be specific in describing what brings you in today: When did you first notice this problem/pain? How do you believe this problem/pain began? During the course of the day how often do you experience your symptoms? Intermittently 0-25% Occasionally 26-50% Frequently 51-75% Constantly 76-100% By using the key below, indicate on the body diagram where you are experiencing pain: On average rating, from 0-10, how much pain are you experiencing? (0 = no pain and 10 = the worst pain imaginable) Please circle the pain level over the last 24 hours: 0 1 2 3 4 5 6 7 8 9 10 Please circle the pain avg. level over the last week: 0 1 2 3 4 5 6 7 8 9 10 Describe your symptoms in order of severity, with worse symptom being #1: Are your symptoms a result of: Motor Vehicle Accident Work related Accident Other How much have your symptoms changed? Getting Better Getting Worse Not Changing In general, my overall health is Excellent Very good Good Fair Poor 4
Patient Name Date Activities of Daily Living - Please check if you have pain or difficulty performing the following: Carrying Groceries Change of Position Sit-to-Stand Driving Extended Computer Use Lifting Children Climbing Stairs Bending Feeding Household Chores Kneeling Walking Lifting Reading Self Care Bathing Sleep Sexual Activities Static Sitting Self Care Dressing Pet Care Static Standing Running Yard Work Other Please list all imaging studies (XRAY/MRI/etc.) taken in the last 6 months: My pain/symptoms have previously been made better by: (Check all that apply) Chiropractic Physical Therapy Massage NSAIDS Heat Ice Nothing Pain Medication Movement Exercise Stretching Rest Other: My pain is: (Check all that apply) Worse in the morning Worse during the day Worse at night Worse while sleeping Does not change during the course of the day Intermittent Other: What type of treatment are you looking for? I am looking for the most minimal amount of care to patch up the symptoms of my problem I am looking to resolve my symptoms and then go on to fix the cause of my problem I am looking to take care of my problem and then go on to achieve optimal health and wellness Cancellation Policy We are very pleased to participate in your healthcare, and have set aside time for your appointment. We understand that sometimes it is necessary to cancel or change an appointment. In consideration of the others who need care, we ask that if you are unable to keep an appointment with our office, that you please observe our cancellation policy which follows: Our office requires at least 24 hour notice for all appointment cancelations. If you are unable to provide 24 hour notice, you will be billed a $50.00 charge. Please sign stating you agree to the terms and conditions. Signature Date 5
Patient Name Date Payment/Insurance Information: Who is responsible for your bill? Self Health Insurance Spouse Worker s Comp Auto Insurance Medicare Medicaid Other Personal Health Insurance Carrier: Insur. Card ID # Policy Holder s Name: Group # Policy Holder s Date of Birth / / Primary Care Physician Worker s Compensation Injury / Auto / Personal Injury: Have you filed an injury report with your employer? Yes No Date: / / Time: am / pm If Work is responsible, Please fill out the following: Employer Data Name Your Occupation Your Job Description Address City State Zip Code Notice of Privacy Policy for Protected Health Information THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW THIS FORM CAREFULLY AND LET US KNOW IF YOU HAVE ANY QUESTIONS. A COPY OF THIS FORM WILL BE GIVEN TO YOU UPON YOUR REQUEST. Our Duties We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information. Privacy Pledge We respect our patients right to privacy and value your trust. We will never provide your contact or health information to any outside organization for marketing or solicitation. In general, we will not disclose your protected health information without your prior written consent. Some exceptions are listed below. 6
Uses and Disclosures for Which Your Consent is Requested 1) Disclosure to another health care provider for referrals for treatment (initial) 2) Disclosure to third party billing, insurance carrier for payment of services (initial) 3) Disclosure to contact you for appointment reminders (initial) May we leave a message on your voicemail? Yes / No I consent to the above listed disclosures which I have initialed and I understand that I have the right to revoke this consent, in writing, at any time. Signature: Date: Permitted Uses and Disclosures Without Your Consent Under federal law, we are permitted to use or disclose your health information without your consent in the following circumstances: 1) If we provide health care services to you based on the orders of another health care provider 2) If we provide health care services to you as an inmate 3) If we provide health care services to you in an emergency 4) If we are required by law to treat you and we are unable to obtain your consent prior to doing so 5) If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care 6) If we have reasonable cause to suspect that a child has been abused 7) If you disclose to us your intent to harm another person Your Right to Inspect and Copy Your Health Information You have the right to inspect and/or copy our health information for seven years from the date that the record was created or as long as the information remains in our files. We require that your request to inspect and/or copy your record be made in writing. Your Right to Amend Your Health Information You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require that your request to amend your health information be made in writing and that you give us a reason to support the change that you are requesting us to make. 7
Your Right to Receive an accounting of the Disclosures We Have Made of Your Record You have a right to request that we give you an accounting of the disclosures we have made of your record for the last seven years before the date of your request. Re-Disclosure Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. Your Right to Complain You may complain to us or to the Secretary of Health and Human Services is you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take action against you if you do so. HIPAA Privacy Practices I acknowledge that I have received and /or have been given the opportunity to review this Chiropractic Office s Notice of HIPAA Privacy Practices for protected health information. Print Patient s Name Patient s Signature Date Consent to Treat a Minor: (Minor s Printed Name) Guardian / Spouse s Signature Authorizing Care Date SIGNATURE OF PHYSICIAN: Date: Consent to Treatment and Payment Agreement 1. Treatment Consent and Authorization: I consent and authorize Dr. Garett Rosati to examine me and perform all treatments for this and following visits, including, without limitation, performance of diagnostic procedures, examination and all treatment deemed necessary to include but not be limited to; chiropractic manipulation/adjustments, adjunct procedures such as physiotherapy, exercise, therapeutic ultrasound, cold laser, interferential current, Graston Technique, Active Release Technique, Myofascial Release Technique, Kinesio-Tape, Activator or any other treatment by Dr. Garett Rosati. This consent and authorization is given in advance of any specific diagnosis or treatment and is continuing until revoked in writing. I have disclosed all of my past medical history to Dr. Garett Rosati so that an appropriate treatment plan can be developed. I am aware of the risks associated with my treatment, the most common of which is soreness in the treated area, and full and freely accept those risks. I will report any soreness or discomfort that I feel, from the treatment or otherwise, promptly to Dr. Garett Rosati. Any questions I have regarding these treatment procedures, treatment results or treatment alternatives have been answered to my satisfaction prior to my signing this consent form. I have made my decision voluntarily and freely. 8
One treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible pop or click, much as you have experienced when you crack your knuckles. You may feel a sense of movement. The material risks inherent in chiropractic treatment As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me. The probability of those risks occurring. Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare. The availability and nature of other treatment options Other treatment options for your condition may include: Self-administered, over-the-counter analgesics and rest Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers Hospitalization Surgery If you chose to use one of the above noted other treatment options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician. 2. Insurance Plan Benefits: Dr. Garett Rosati participates with multiple insurance plans. Each insurance plan has different benefit packages and regulations. I understand, acknowledge, and agree that it is my responsibility to be familiar with my insurance benefits and to advise Dr. Rosati s staff regarding my insurance coverage. I understand that Medicare does not reimburse for examinations or re-examinations and agree to pay the fee of $120 on the initial examination date. I understand, acknowledge, and agree that I am fully responsible for all charges, including, without limitation, chiropractic and physiotherapy procedure codes that are not covered by my insurance policy. 3. Payment Agreement and Financial Patient Policies: Dr. Garett Rosati will file the insurance claim(s) with my insurance carrier for services provided to me. I understand, acknowledge, and agree that Dr. Garett Rosati must collect my co-payments and deductibles at the time the service is rendered. If the deductible is not met the patient is responsible for paying a $50 time of service fee for treatment or $100 new patient time of service fee or a combination of the both depending on the services provided on the scheduled visit Upon receiving the patients explanation of benefits the patient will either be credited or billed the difference from what they have already paid at the time of service. The patient is required to present his or her insurance card at the time of visit. Without a current insurance card, Dr. Garett Rosati 9
will not be able to file the patient s claims appropriately and the patient will be responsible for the payment of all charges. If my insurance coverage changes, I agree to notify Dr. Garett Rosati at the time of my visit. Dr. Garett Rosati may not be able to re-file claims, and I would be responsible for full payment. Failure to make a payment of a past due invoice after the third notice will result in the claim being handed over to a collections agency. 4. Returned Checks: Dr. Garett Rosati accepts personal checks, cash, Mastercard, Visa, Amex and Discover cards. I understand, acknowledge, and agree that if my check is returned for any reason, a $30 service charge will be charged to my account. Dr. Garett Rosati will require me to pay for all future visits by cash or credit card. PATIENT NAME: DATE: PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW By signing below, I acknowledge that I have read [ ] or have had read to me [ ] and understood all pages, 1 through 10, which include; the Chiropractic Case History, Patient Information, Presenting Problem, Triple (VAS), Review of Systems, Privacy Policy and Consent to Treatment and Payment Agreement of Rosati Family Chiropractic. Dated: Dated: Patient s Name Garett Rosati, D.C. Signature Signature Signature of Parent or Guardian (if a minor) 10