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Park County Chiropractic Nutrition Questionnaire

Park County Chiropractic Nutrition Questionnaire

Our  Mission is to help you to Better Health and Better Function so you can have more Possibilities

HIPAA

Compliance

  • 1

    HIPAA Notification - Please Read and Sign Below
    Park County Chiropractic believes in protecting your private health information and we are in accordance with the Health Insurance Portability and Accountability act of 1996 (HIPAA). If you would like to have the full privacy policy, it is available for review.
    Treatment, Payment, Health Care Operations: You should be aware that during the course of our relationship, we could use and disclose heath information about you for treatment, payment, and healthcare operations.
    Examples of these activities are as follows:

    • Treatments: We may use or disclose your health information to other health care providers providing treatment to you.
    • Payment: We may use and disclose your health information to obtain payment for services we provide to you.
    • Health care operations: We may use and disclose your health information in connection with our health care operations. Health care operations include clinical education, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and employee performance and other business operations.
    • Contacting You: We may contact you by phone, text, email, or postal service for health related matters and thank you notices. Messages may be left on an answering machine, voice mail, or with a person answering your specific phone number(s).

    Authorization: You may specifically authorize us to use your health information for any purpose or to disclose your health information to anyone by submitting such an authorization in writing. Upon receiving an authorization in writing from you, we may use or disclose your health information in accordance with that authorization. You may revoke an authorization at any time by notifying us in writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those permitted by this Notice or Law.

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  • 2

    Please read this entire page prior to signing it. It is important that you understand the information contained in this document.

    The Nature of the Nutritional/Lifestyle Care

    As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

    Analysis and Examination Procedures:

    Vital signs (Temp, BP, etc) Postural analysis testing
    Palpation (feeling muscles/joints) Neurological examination
    Range of motion testing Order blood labs
    Muscle strength testing Order of Imaging
    Orthopedic testing Urine analysis
    Body composition analysis  

    Treatments:

    Nutritional Support
    Herbal Supplements
    Functional Movement Training
    Recommendations for other types of care to support goals
     

    The material risks inherent in treatments: As with any healthcare procedure, there are certain complications which may arise. These complications include but are not limited to: allergic reactions, toxicity, medication interaction, upset stomach, loose stools, conspitation, or muscle soreness. Some people will experience unpleasent symptoms with nutritional/herbal care while the body balances or is healing. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition or are taking medication or other supplements that would otherwise not come to my attention, it is your responsibility to inform me.

    The probability of those risks occurring is extermely low and are generally described as rare.

    The availability and nature of other treatment options: Other treatment options for your condition will vary and depend on your health status and the severity and may include:

    • Self-administered, over-the-counter medications or supplements
    • Other types of health care like Chiropractic care, massage, dry needling, or medical care.
    • Medical prescription drugs
    • 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 the treating health care provider.

    The risks and dangers attendant to remaining untreated:  Remaining untreated may allow the formation of a more substainal health problem. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. More extensive interventions may become required or necessary.

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  • 3

    I * have read the above explanation of the chiropractic adjustment and related treatment(s). I will discuss any questions I have with Dr Dobelbower.
    By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided it is in my best interest to undergo the treatment. Having been informed of the risk, I hereby give my consent to treatment.
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  • 4
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  • 5
    If different from Legal Name
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  • 6
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  • 7
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  • 8
    This is private information. It will only be used to help provide appropriate health care to you.
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  • 9
    We will not sell or give anyone this phone number!
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  • 10
    We will not sell your number to anyone. This is part of your private health information.
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  • 11
    We will not sell your number to anyone. This is part of your private health information.
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  • 12
    We will not sell this address to anyone. This is part of your private health information
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 13
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  • 14
    Please Select
    • Please Select
    • Spouse
    • Parent
    • Legal Guardian
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  • 15
    Describe what you do, not where you work.
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  • 16
    Please select from the drop down list
    • Friend or Family Member
    • Local Gym
    • Medical Doctor
    • Massage or Physical Therapist
    • Website
    • Google Search
    • Facebook
    • Other Social Media
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  • 17

    * recommended Park County Chiropractic to you . May we thank them for referring you?    *         

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  • 18

    * recommended Park County Chiropractic to you .  May we contact them to coordinate care?           
    *

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  • 19
    Select ALL that apply
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  • 20
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  • 21
    Select All that apply
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  • 22
    Select ALL that apply
    1 of 12
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  • 23
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  • 24
    This includes medical doctors, massage therapists, acupuncturist, other nutritional providers, etc
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  • 25
    Please list all providers
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  • 26
    Please Tell Us Where So If Needed Your Records Can Be Requested
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  • 27
    List Your Goals
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  • 28
    Please type a brief description
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  • 29
    Prescription or Over The Counter
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  • 30
    Please be thorough as possible
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  • 31
    Please be as thorough as possible
    Please Select
    • Please Select
    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
    • Heart Burn/Gerd
    • Thyroid
    • Pain
    • Asthma
    • Diabetes
    • Mental Health
    • Other
    Please Select
    • Please Select
    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
    • Heart Burn/Gerd
    • Thyroid
    • Pain
    • Asthma
    • Diabetes
    • Mental Health
    • Other
    Drop down select
    • Drop down select
    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
    • Heart Burn/Gerd
    • Thyroid
    • Pain
    • Asthma
    • Diabetes
    • Mental Health
    • Other
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  • 32
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  • 33
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  • 34
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  • 35
    Liquids
    1 of 5
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  • 36
    Foods - You can select more than 1 per row
    1 of 3
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  • 37
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  • 38
    Please Select
    • Please Select
    • Less than 1
    • 1-2 Packs/Day
    • 2-3 Packs/Day
    • 3+ Packs/Day
    Please Select
    • Please Select
    • Yes
    • No
    • Maybe
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  • 39
    Select ALL that apply
    1 of 12
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  • 40
    Select ALL that apply
    1 of 11
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  • 41
    Select ALL that apply
    1 of 7
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  • 42
    Select ALL that apply
    1 of 16
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  • 43
    Select ALL that apply
    1 of 10
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  • 44
    Select ALL that apply
    1 of 16
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  • 45
    Select ALL that apply
    1 of 15
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  • 46
    Select ALL that apply
    1 of 14
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  • 47
    Select ALL that apply
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  • 48
    Select ALL that apply
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  • 49
    Please Select
    • Please Select
    • Yes
    • No
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  • 50
    Select ALL that apply
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  • 51
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  • 52
    Select ALL that apply
    1 of 8
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  • 53
    Select ALL that apply
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  • 54
    I eat whole foods
    I avoid processed foods
    I sleep 7-9 hour/night
    I exercise 3+/week
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  • 55
    Move the foods on the right to the left if so
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  • 56
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  • 57
    Please Select
    • Please Select
    • YES
    • NO
    Please Select
    • Please Select
    • YES
    • NO
    Please Select
    • Please Select
    • Excessive
    • Irregular
    • Painful/Cramping
    • Light
    • No Longer Applies
    Please Select
    • Please Select
    • Painful/Swollen Breasts
    • Pain/Bleeding Intercourse
    • Emotional Up/Downs
    • Bloating
    • Brain Fog
    • No Longer Applies
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  • 58
    Select ALL that apply
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  • 59
    Select ALL that apply
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  • 60
    Select ALL that apply
    1 of 6
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  • 61
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  • 62
    Alter Your Eating Habits
    Take Nutritional Supplement Daily
    Modify Sleep Habits
    Modify Exercise Habits
    Practice Meditation/Relaxation
    Have Regular Labs/Testing
    Seek Other Recommended Care
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  • 63

    Payment Agreement
    I understand and agree all services rendered me are charged directly to me and that I am personally responsible for payment.
    I understand Park County Chiropractic and it's doctors do not accept assignment from major medical insurance policies.
    I understand that there is no guarantee that my insurance company or health plan will cover or pay for any charges.
    I understand that all charges for services rendered to me or my dependent are due at the time services are rendered unless other arrangements are made.
    It is my responsibility to pay for services rendered without receiving billings statements.
    Rescheduling Policy
    Our goal is to provide quality individualized health care in a timely manner. Not showing up or late rescheduling inconveniences other people (who might be in pain) needling access to health care in a timely manner. We ask YOU to be respectful of the health care needs of other people and promptly call if you are unable to keep an appointment. If it is necessary to reschedule your appointment, we require AT LEAST 24 HOURS NOTICE. WE RESERVE THE RIGHT TO CHARGE $30 FOR MISSED APPOINTMENTS WITH LESS THAN 24 HOURS NOTICE.

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  • 64

    Patient Consent: By signing below, you are stating the information you have filled in this form is true and correct to be best of your ability. You understand your privacy rights, your payment responsibility, and Park County Chiropractic's Rescheduling policy. You will have the opportunity to ask questions and address concerns with the treating doctor prior to treatment. We look forward to meeting you!
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