Healing Touch Chiropractic- New Patient Intake

Informed Consent
The Doctor of Chiropractic evaluates the patient using standard examination and testing procedures. A chiropractic adjustment involves the application of a quick, precise force directed over a very short distance to a specific vertebra or bone. There are a number of different techniques that may be used to deliver the adjustment, some of which utilize specially designed equipment. Adjustments are usually performed by hand but may also be performed by hand-guided instruments. In addition to adjustments, other treatments used by chiropractors include physical therapy modalities (heat, ice, ultrasound, and soft-tissue manipulation), nutritional recommendations and rehabilitative procedures.

Chiropractic treatments are one of the safest interventions available to the public demonstrated through various clinical trials and indirectly reflected by the low malpractice insurance paid by chiropractors. While there are risks involved with treatment, theses are seldom great enough to contraindicate care. Referral for further diagnosis or management to a medical physician or other health care provider will be suggested based on history and examination findings.

Listed below are summaries of both common and rare side-effects/complications associated with chiropractic care:
Common
Reactions most commonly reported are local soreness/discomfort (53%), headaches (12%), tiredness (11%), radiating discomfort (10%), dizziness, the vast majority of which resolve within 48 hours

Rare
• Fractures or joint injuries in isolated cases with underlying physical defects, deformities, or pathologies
• Physiotherapy burns due to some therapies
• Disc herniations
• Cauda Equina Syndrome (1 case per 100 million adjustments)
• Compromise of the vertebrobasilar artery (i.e. stroke) (range: 1 case per 400,000 to 1 million cervical spine adjustments [manipulations]). This associated risk is also found with consulting a medical doctor for patients under the age of 45 and is higher for those older than 45 when seeing a medical doctor. Please indicate to your doctor if you have headache or neck pain that is the worst you have ever felt.

I understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. I also understand that my condition may worsen and referral may be necessary if a course of chiropractic care does not help improve my condition. The patient examination process includes important tests that require movement, exertion, balance control and may result in worsening of symptoms, muscle spasm, and falling. I accept these risks and agree that I will provide correct answers to information and will notify Healing Touch Chiropractic if there has been any change in any of my answers and information.

Reasonable alternatives to these procedures have been explained to me including prescription medications, over-the-counter medications, possible surgery, and non-treatment. Listed below are summaries of concern with the associated alternative procedures.

• Long-term use or overuse of medication carries some risk of dependency with the use of pain medication the risk of gastrointestinal bleeding among other risks.

• Surgical risks may include unsuccessful outcome, complications such as infection, pain, reactions to anesthesia, and prolonged recovery.

• Potential risks if refusing or neglecting care may result in increased pain, restricted motion, increased inflammation, and worsening of my condition.

Neck and back pain generally improve in time; however, reoccurrence is common. Remaining active and positive improve your chances of recovery.
Please answer the following questions to help us determine possible risk factors
In general, have you ever had an adverse (i.e. bad) reaction to or following chiropractic care?

YesNo
Please explain
BONE WEAKNESS

Toggle to "Yes" if the corresponding question applies to you.
Have you been diagnosed with osteoporosis?
Do you take corticosteroids (e.g. prednisone)?
Have you been diagnosed with a compression fracture(s) of the spine?
Have you ever been diagnosed with cancer?
Do you have any metal implants?
VASCULAR WEAKNESS

Toggle to "Yes" if the corresponding question applies to you.
Do you take aspirin or other pain medication on a regular basis?
Do you take warfarin (Coumadin), heparin, or Other similar “blood thinners”?
Have you ever become dizzy or lost consciousness when turning your head?
Ever been diagnosed with any of the following disorders or diseases
SPINAL COMPROMISE OR INSTABILITY

Toggle to "Yes" if the corresponding question applies to you.
Have you had spinal surgery?
Please Describe
Have you been diagnosed with spinal stenosis?
Have you ever experienced sudden weakness in the arms or legs?
Have you ever experienced numbness in the genital area?
Have you ever had the inability to urinate or lack of control when urinating?
Please describe any "yes" answers above.

Acknowledgements
Assignment of Benefits & Release of Health Information: I Authorize Healing Touch Chiropractic to use or disclose my personal health information for the purposes of carrying out treatment, obtaining payment, replying to requests from my insurance company, evaluating the quality of services provide, communicating with my referring physician, and any other administrative operations related to treatment or payment as noted in HTC’s Notice of Privacy Practices. I understand that benefits quoted from my insurance carrier to Healing Touch Chiropractic are only an estimate and not a guarantee of payment. I assign HTC all benefits payable to me under my insurance policies and health benefit plans. I shall be personally responsible for any unpaid balances. Initial Below*
Agreement in financial responsibility: I understand that I am directly and fully responsible to for all medical charges resulting from any no show fees, consultation, examination and/or treatment which I will receive. I am aware that this agreement is made solely for the doctor's protection and in consideration of any awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover. Initial Below*
Signature

Clear
SUMMARY ( FOR OFFICE USE ONLY)

General:

The patient, a {age} year old {gender} presents to the clinic complaining of {whereDo}. Symptoms began on {whenDid}. The pain is described as {howWould} and is {howOften}. The patient explains that symptims are{progressOf} since onset.

Patients Description of injury: {pleaseBriefly}

Activities of daily living that are affected include: {activitiesOf}

Prior Treatments: {whatTypes}

Auto Injury (If Applicable):

The patient, a {age} year old {gender} presents to the clinic complaining of {whereDo} as a result of an {whatBrings}. Symptoms began on {whenDid}. The pain is described as {howWould} and is {howOften}. The patient explains that symptims are{progressOf} since onset.

The patient, a restrained {positionIn} of a {typeOf78} was {mechanismOf} by a {otherVehicle}. The patients vehicle was driving at approximately {howFast} while the opposing vehicle was traveling at approximately {howFast85}. The patient explains that the road conditions during the time of the accident was {whatWere} and occurred during {whatWere76}.

At the time of the accident, the patient exhibited feelings of {whatWere87}.

Activities of daily living that are affected include: {activitiesOf}

Prior Treatments: {whatTypes}

After the accident the patient went {whereDid} via {howWere}.

The patient description of the accident: "{brieflyDescribe}"

Transported to Hospital/ER: {wereYou95}

If so, which Hospital: {whichHospital}

Imaging taken: {anyImaging}. Findings: {whatWere93}

Did you lose consciousness? {didYou}

Did you hit your head?{didYou132} If so, Where: {whereDid130}

Did you have any cuts/bruises? {didYou133}; If so where: {whereDo134} Stitches: {didYou135}

Did you miss any days from school or work: {missAny}; if so How many? {howMany}
Should be Empty:

Healing Touch Chiropractic

Demographics

Pain/Injury Details

Health History

Review of System

Informed Consent

Please answer the following questions to help us determine possible risk factors

BONE WEAKNESS

VASCULAR WEAKNESS

SPINAL COMPROMISE OR INSTABILITY

Acknowledgements