Foundation Chiropractic - Adult History Form

HISTORY FORM

Personal Information
Name*

First NameLast Name
Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Date
Gender*
Marital Status*
How did you hear about us?*
Email Address*
example@example.com
Work Email
example@example.com
Have you ever been in the military?*

Insurance Information

Please give your insurance card and driver's license to the front desk for a complimentary benefits evaluation.
Primary Insurance Carrier
Subscriber's Name
Occupation
Employer
Subscriber's SSN
Birth Date

MonthDayYear
Date
Chiropractic Services Provided
• Consultation-includes practice member history. This service is complimentary.
• Examination (new patient or established patient)-includes one or more of the following: thermography, surface electromyography, range of motion, motion and/or static palpation, leg check.
• Chiropractic Adjustment – The actual re-alignment of the vertebra. A specific instrument is used to make the spinal adjustment. 1 to 3 specific adjustments will be made per visit, re-aligning the vertebra.
• X-rays – Specific x-ray views taken of your spine to determine a misalignment/subluxations of your vertebrae. These can also be used to indicate progress after period of care.
**All charges will be reviewed and authorized by practice member before any charges are rendered

Release of Authorization/Assignment of Benefits
I authorize the release of any information necessary to process my insurance claims. I authorize and request payment of insurance benefits directly to the doctors. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.
Signature

Clear
Date

MonthDayYear
Date

Confidential Practice Member Information

This information is confidential. If we do not sincerely believe your problem will respond favorably, we will not be able to accept your case. We will refer you to a health professional we believe will help you. In order for us to understand your health problems properly, please complete this form neatly, accurately, and completely.
Who can we thank for referring you here today?*
Have you ever been to a Chiropractor before?*
If yes, when was your last visit?
On a scale of 1 to 10, with 10 being the highest, rate your commitment in helping us solve this problem:*
Health Concerns

List each concern along with the following information: severity (1 = Mild | 10 = Unbearable), how long you have had this, did this start with an injury, have you had this before and is this constant or comes/goes?
In order of importance:*
How do your health concerns affect your daily life (brushing teeth, getting dressed, etc.)?*
Do you have a history of cancer, spinal surgeries or any heart conditions? Briefly explain.*
Initials*
Date

MonthDayYear
Date

WRITTEN CONSENT FOR A CHILD/MINOR
IF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOW
Name Of Patient Who Is A Minor/Child

First NameLast Name
I AUTHORIZE DRS. MATTHEW AND/OR TAYLOR FILTZ AND ALL FOUNDATION CHIROPRACTIC INC. STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.

AS OF THIS DATE, I HAVE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY FOUNDATION CHIROPRACTIC.
Guardian Signature

Clear
Date

MonthDayYear
Date
Guardian's Relationship to Minor/Child
Witness Signature (Office Staff) _______________________________________

Please select any of the conditions below that you (or your family) have or have had in the past:

	Yourself	Spouse	Children	Mother	Father
Acid Refulx
Arthritis
Asthma
Cardiac Condition
Cancer
Disc Problems
Dizziness
Ear Infections
Epilepsy
Fatigue
Headaches
Irritable Bowel
Kidney Condition
Liver Disease
Lupus
Menstrual Irregularity
Migraines
Nausea
Nervousness
Numbness
Sciatica
Sinus
Stiffness
Stomach Condition
TMJ
Ulcers
Vertigo

TERMS OF ACCEPTANCE
When a patient seeks chiropractic health care and we accept a patient 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 patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

In the event that you do not move forward with recommendations any credits not utilized within 30 days of your last visit to Foundation Chiropractic will entirely become the property Foundation Chiropractic. Funds will not be able to be refunded back to you if a refund is not requested within those 30 days. You may request an itemized receipt of your account if needed.

ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxations. Our chiropractic method of correction is by specific adjustments to 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 its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxations. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual finding, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.

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, First Name* Last Name* have read and fully understand the above statements.

All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.

I therefore accept chiropractic care on this basis.
Signature*

Clear
Date

MonthDayYear
Date

Notice of Privacy Practices Acknowledgement

I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

1. Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

2. Obtain payment from third-party payers.

3. Conduct normal healthcare operations, such as quality assessments and physician’s certifications.

I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my private information is used to disclosed to carry out treatment, payment, or healthcare operation. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
Signature*

Clear
Date

MonthDayYear
Date

I,   First Name*   Last Name*hereby request and authorize Foundation Chiropractic to disclose information.

Medical / Financial/ All to:
First Name*   Last Name*
Relationship*
Street Address*      City*   State*   Zip*   Area Code*   Phone Number*
This authorization will be effective until I discontinue care, unless cancelled in writing. I understand that the cancellation will have no effect on information released prior to receiving the cancellation. A copy of this authorization is as valid as the original. This will remain in effect until the (adult) child cancels in writing.
Signature of Patient*

Clear
Date

MonthDayYear
Date
Signature of Legal Representative/Relationship

Clear
Date

MonthDayYear
Date

X-RAY AUTHORIZATION
AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF THE X-RAYS IN OUR FILES.

PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF FOUNDATION CHIROPRACTIC INC. DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.

BY SIGNING BELOW, YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS
Name*

First NameLast Name
Signature*

Clear
Your Age*
FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT FOUNDATION CHIROPRACTIC INC
Signature

Clear
Date

MonthDayYear
Date

QUADRUPLE VISUAL ANALOGUE SCALE (QVAS)
Please select the number that best describes the question asked. If you have more than one complaint, please answer each question for each individuation complaint and indicate the score of each complaint.

EXAMPLE: 0 = No Pain | 10 = Worst Possible Pain
How would you rate your pain RIGHT NOW?*
What is your TYPICAL or AVERAGE pain?*
What is your pain level at its WORST? (How close to 10 does your pain get at its worst?)*
What percentage of your awake hours is your pain its worst?*
Name*

First NameLast Name
Date

MonthDayYear
Date
Score: Q1 _____+Q2_____+Q3_____=_____/3x10=_____

(Low Intensity = 50)
Should be Empty:

HISTORY FORM

Insurance Information

Confidential Practice Member Information

Health Concerns

Main Complaint History

QUADRUPLE VISUAL ANALOGUE SCALE (QVAS)