Welcome! Please allow our staff to make a copy of your driver’s license and insurance cards. Please Print
Full Name______Phone______
Address______City______State______Zip______
Please List Email if would like reminded of appointments______
Date of Birth______Emergency Contact______
Gender M F SSN______
How did you hear about our office?______
Reason for your visit today?(Please list areas of pain)______
Is your condition due to an accident? YES NO Date of your accident______
Have you ever had any previous Chiropractic experience? ______
Have you seen any other health care provider for the above complaint? ______
Informed Consent Chiropractic Care
I hereby consent to the performance of examination and treatment on myself or on ______, by Dr. Lindsey Rovenstine. I further understand there can be risk associated with chiropractic care, which includes but not limited to fractures, sprain/strains, strokes, disc injuries and am therefore willing to accept and consent to the risk associated with care currently and in the future. Furthermore any risk involved with chiropractic care, will be explained upon request.
NOTICE: Our office often utilizes an open area for treatments, adjustments, and physical therapy. This may result in some of your care or discussions with the doctor being overheard by other patients and staff. All necessary actions will be taken to prevent or limit this during the history and review of the patient’s confidential information. If you have any concerns about your privacy please bring it to the doctor’s attention immediately. This notice of privacy and open bay notice is effective as of February 17th 2014. This notice, and any alterations or amendments made hereto, will expire seven years after the date upon which the record was created. My signature below acknowledges that I had the opportunity to read this notice and here by agree to its terms. I (we) hereby authorize the doctor and the staff to release any information deemed appropriate concerning my physical condition to any insurance company, claims adjuster, case nurse, claims reviewer, employer, healthcare provider, or attorney in order to process any consequences thereof. I agree that a photo static copy of this agreement shall serve as the original.
Patients Signature ______Date______
Guardians Signature______Date______
When did this your pain start? ______
HOW DID IT HAPPEN? ______
Where is the pain located? ______
What does this prevent you from doing or enjoying? ______
How frequent is this condition? ______
How long does it last? ______
On a scale of 0-10 Zero is no pain 10 needs to go to the ER. What is your pain currently? ______
What your pain is at its worst? ______What is your pain at its best? ______
Describe the pain:Sharp Dull Numbness Tingling Aching Throbbing Burning Stiff/Tightness Stabbing
Does your pain travel? If so where? Down into your arms and hands or legs and toes?______
What makes the problem worse? Standing Sitting Lying Bending Lifting Twisting Other______
Do you have any pain when coughing, sneezing, laughing, or going to the bathroom? ______
Do you have any weakness in your arms, hands, fingers, in your legs, feet or toes? ______
Do you have any difficulty controlling bowl or bladder? ______
Does your pain wake you up at night? YES NOIn what position do you sleep and how well? ______
What makes your pain better?______
Have you had any recent weight gain or losses? YES NOHow is your diet? Good Fair Poor
Do you exercise? YES NO Have you had a fever recently? YES NO
Do you have shortness of breath? YES NO
List any broken bones, dislocations, or sprains: ______List any accidents, injuries, falls and Dates:
______
Have you ever had x-rays, MRI, or CAT of your body? YES NO When? ______
(FEMALE) is there any possibility you are pregnant? YES NO MAYBE
(MALES) Have you ever had any prostate problems? YES NO
Please list all the different doctors and their specialties you have seen in the last 3 years.
Is there any family history of serious illnesses? Cancer, Heart disease, ect If yes please describe______
Do you have any of the following: Stroke, Aneurysm, Heart Disease, Kidney Disease, Liver Disease,or Lung Disease?
Please list all medications (prescription, non prescription, and vitamins) ______
Do you have a history of cancer, high blood pressure, shingles, diabetes or any other serious illness? ______
Have you ever been diagnosed with a spondylolisthesis, compression fracture, spinal fracture, or osteoporosis?
______
Please list any surgeries or operations and dates
______
I attest to the information above to be correct. Patient denies any other past illnesses, hospitalizations, or surgeries. I further understand that any charges incurred in the office are my sole responsibility, despite any insurance plan, legal involvement, or settlement.
Patients Signature: ______Date______
Patient Health Information Consent Form
We want you to know your Patient 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 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 your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing the consent.
The patient understands and agrees to allow this chiropractic office to use their
Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow 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 needed to what the insurance companies require for payment.
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.
A patients’ written consent need only be obtained one time for all subsequent care given the patient in the office.
The patient may provide a written request to revoke consent at any time during care. This would not affect 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.
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.
Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
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 care.
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
Identification of Persons with Authorization of Access to Patient Health Information
Those individuals or parties that could have access to Patient Health Information at Crossroads Chiropractic include but may not be limited to:
The staff of Crossroads Chiropractic, This includes: Dr. Lindsey Rovenstine and All Chiropractic Assistants
______
Patients Signature Date