Welcome To Health First Chiropractic Dear Patient: Please complete this questionnaire. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU. Name (First) (MI) (Last) Social Security # Address City State Zip Home Phone Work Phone Marital Status M S W D Cell Phone E-mail Occupation Age Birth Date Referred by # of Children Spouse s Name Spouse s Phone HEALTH INFORMATION: Have you had previous chiropractic care? Y N What is your major complaint? Other Complaints: How long have you had this condition? Have you had this or similar condition in the past? What activities aggravate your condition? Is this condition getting progressively worse? Yes No Constant Comes and goes Is this condition interfering with your: Work Sleep Daily routine Other How long has it been since you really felt good? Other doctors who treated this condition List surgical operations and years: Drugs you now take: Nerve pills Pain killers Muscle relaxers Pep pills Birth control pills Insulin Tranquilizers Other Age of mattress Yrs. Comfortable Uncomfortable Are you wearing: Heel lifts Sole lifts Inner Soles Arch supports Involved in an auto accident: Past year Past 5 years Over 5 years Never Describe: Have you had any other personal injury or accident? Past year Past 5 years Over 5 years None Describe:
Date of Last Physical Examination Please mark your areas of pain on the figures below Have You Ever Suffered From: Dizziness Backaches Heart Trouble Diabetes Arthritis Headaches Asthma Neuritis Digestive Disorders Nervousness Sinus Trouble Neck Pain If Yes, Please Explain FAMILY HEALTH INFORMATION. Many health problems are the result of hereditary spinal weakness; thus information about your family members will give us a better picture of your total health picture. NAME RELATION PAST AND PRESENT HEALTH PROBLEMS Health is the most valuable asset in the world YOU and YOUR FAMILY S. Healing includes taking responsibility for that health. Aspects of this responsibility are following your care plan, attending a spinal wellness information session and meeting your financial obligations. We operate on a fee for service basis. We will supply you with a copy of each day s services and charges that you may submit to your insurance company for your own personal reimbursement. Nutrition consultations and supplements are not a covered service by Medicare or most insurance companies. I clearly understand that ALL services rendered to me are charged directly to me and that I am personally responsible for payment. I further understand and am informed that, as in all health care, there are some slight risks to treatment and do not expect the doctor to be able to anticipate or explain all risks and combinations; and wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. I have read this consent and intend this consent form to cover the entire course of my care and any care in the future rendered by Health First Chiropractic, LLC, its doctors and staff. Patient s Signature: Guardian or Spouse s Signature: Doctor s Signature:
401 Headquarters Drive, Suite 201 Millersville, MD 21108 Health History Questionnaire Patient Name Date Part 1: Review of Systems Do you currently have any of the following symptoms listed below? General Fatigue Weakness Fever/ Chills Anemia Loss of Sleep Weight Change (unplanned) Night Sweats Headaches Dizziness Fainting Convulsions Nervousness/ Anxiety Depression (prolonged) Phobias (excessive fears) Memory Loss or Impairment Mood Swings (excessive) Ear / Hearing Trouble Eye/ Vision Trouble Nose/ Sinus Trouble Nose Bleeds None of the symptoms listed above. Part 2: Medical History Absence of Smell Mouth Sores Bleeding Gums Enlarged Glands Abnormal Taste Sensation Tonsillitis / Infected Tonsils Difficulty Swallowing Heat / Cold Intolerance Sugar in Urine Goiter (enlarged thyroid gland) Tremor (shaking) Skin Trouble (rash) Eczema (red, inflamed skin) Hair/ Nail Changes (unplanned) Bruise Easily Chronic Cough Chronic Wheezing Difficulty Breathing Swollen Extremities Blue Fingers/Toes Chest Pain Rapid Heart Beat Heart Palpitations Heart Murmur Abdominal Pain Intestinal Problems Hemorrhoids Excess Gas Excessive Vomiting Abnormal Bowel Habits Heartburn/Indigestion Difficult Urination Bed-Wetting Irregular Menstruation Abnormal Vaginal Bleeding Redness/Itching of Breast Dimpling of Breast(s) Discharge from Breast(s) Breast Pain/ Lump Perimenopausal /Menopausal 1. Have you been hospitalized in the past? If yes, date and reason. 2. Have you ever had surgery? If yes, date and reason. 3. Have you ever had a serious accident/ injury? If yes, date and describe injury. 4. Have you ever been the victim of abuse? Yes No 5. List any current vitamins, minerals, or herbs. 6. List any current medications and reason for medication. 7. Are you allergic to any medications or supplements? If yes, please list.
401 Headquarters Drive, Suite 201 Millersville, MD 21108 Part 3: Family History Please indicate which condition correlates with the family member. Cancer Diabetes Heart Trouble High Blood Pressure Stroke Kidney Disease Anemia Mental Illness Headaches Osteoporosis Arthritis Joint Problems Scoliosis Back Problems Disc Problems Congenital Defects Genetic Disease Deceased Father Mother Brothers Sisters Children None Part 4: Conditions of Illness Please indicate if you Now Have or Have Had in the Past any of the following illnesses. Sinus Trouble Hay Fever Allergies Asthma Emphysema Tuberculosis Cancer Diabetes Epilepsy Thyroid Trouble High Blood Pressure Low Blood Pressure Heart Trouble Pacemaker Stroke Aortic Aneurysm Rheumatic Fever Now Illnesses. Past Now Past Polio Multiple Sclerosis Ulcer Liver Trouble Kidney Trouble Prostate Trouble Arthritis Scoliosis Dislocated Joints Spinal Disc Disease Mental/ Emotional Difficulty Sexual Transmitted Diseases HIV AIDS/ARC Bone Fracture (list/dates) Other important information not listed on this form:
Dr. Larry A. Berlin 401 Headquarters Drive, Suite 201 Millersville, MD 21108 Office (410) 846-6454 Fax (443) 458-6767 Informed Consent Document Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. The nature of the chiropractic adjustment The primary 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. Analysis / Examination / Treatment As a part of the analysis, examination and treatment, you are consenting to the following procedures: Spinal manipulative therapy, palpation, vital signs, range of motion testing, orthopedic testing, basic neurological testing, muscle strength testing, postural analysis testing, ultrasound, hot/cold therapy, EMS (electric muscle stimulation), radiographic studies and other treatment modalities and procedures deemed medically necessary by the doctor(s) at Health First Chiropractic, LLC. The material risks inherent in chiropractic adjustment. As with any healthcare procedure, there may be complications that can arise during chiropractic manipulation and therapy. These complications include but not limited to: fractures, disc injuries, dislocation, muscle strain, cervical myelopathy, costovertebral strains, separations, burns or in very rare instances stroke. Some patients will fell 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 and X-ray. 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 and surgery. If you choose 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. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE CHECK THE APPROPRAITE BLOCK AND SIGN BELOW I have read [ ] or have had read to me [ ] the above explanation of the chiropractic adjustment and related treatment. I have discussed it with Dr. Larry Berlin and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. Patient s Name: Signature of Patient or Guardian: Doctor s Name: Doctor s Signature:
401 Headquarters Drive, Suite 201 Millersville, MD 21108 Patient Consent for Use and Disclosure of Protected Health Information We want you to know how your Protected Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Protected Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Protected Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum required for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Patient Name (printed) Patient Signature Date
NOTICE OF PRIVACY FOR: PATIENT S PROTECTED HEALTH INFORMATION This notice describes how health care information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This office abides by the terms described in this policy. This office uses and discloses your protected health care information for the following reasons: To share with other treating health care providers regarding your health care. To submit to insurance companies or Worker s Compensation Claim to verify that treatment has been rendered. To determine patient s benefits in a health care plan. Releasing information required by State or Federal Public Health law. To assist in overcoming a language barrier when caring for a patient. Business associates providing written assurances for your privacy have been attained. Emergency situations. Abuse, neglect, or domestic violence. Appointment reminders to household members or answering machines. Mailings for appointment reminders, birthday cards, bills and other correspondence. Sign-In logs may be disclosed to verify office visits. Any other uses or disclosures will only be made with your specific written prior authorization. You have the right to: Revoke authorization, in writing at any time by specifying what you want restricted and to whom. Speak to our privacy officer who is: Dr. Larry Berlin Inspect, copy and amend your protected health information and amend it as allowed by law. Obtain an accounting of disclosures of your protected health information. To render a complaint to our privacy officer or the Secretary of Health and Human Services. This office reserves the right to change the terms of this notice and to make new notice provisions for all protected by health information that it maintains. Patients may also get an updated copy upon request at any time by asking the staff. I acknowledge that I have received and reviewed this notice with full understanding. Name of Patient (print) Signature of Patient/Legal Representative Date