LANDMARK CHIROPRACTIC

LANDMARK CHIROPRACTIC

NPM ADOLESCENT (8 - 17 Years Old)
PATIENT DEMOGRAPHICS
Name
Birth Date

MonthDayYear
Date
Age
Gender

MaleFemale
Address

Address

Street Address Line 2

CityState

Zip
E mail Address
example@example.com
Home Phone
Mobile Phone
Parent/Guardian's Name
Phone
Parent/Guardian's Name
Phone
Name & Number of Emergency Contact
Relationship
How did you find out about Landmark Chiropractic?
What is your main goal for coming here today
HISTORY OF CURRENT HEALTH CONCERNS

Current Health Concerns

	List Concerns According to Severity	Rate of Severity 0=NoPain 10=Unbearable	When did this problem start?	Have you had this problem before?	Did the problem begin with an injury?	Are symptoms constant (C) or intermittent (l)?
Primary
Second
Third
Fourth

Have you seen other doctors for these conditions?

YesNo
If yes

ChiropractorMedical DoctorOther
Name of Previous Chiropractor
If none, select:

N/A
Name of MD
If none, select:

N/A
When?
Results?
When is the problem at its worst?

AMPMmid-daylate PM
List PERSCRIPTION & NON PRESCRIPTION DRUGS you take, and provide a REASON for taking each one
Health Concerns

Mark "C" for Current Health Concern or Mark "P" for Past Health Concern

	Health Concern (C / P)
Acid Reflux
ADD/ADHD
Allergies
Anxiety
Arthritis/Joint Pain
Asthma
Bed Wetting
Bladder lssues
Chronic Colds
Constipation
Depression
Diarrhea
Difficulty Ereathing
Digestive lssues
Disc lssues
Dizziness
Double/Blurry vision
Ear lnfections
Epilepsy/Convulsions
Fatigue
Fibromyalgia
Food Sensltivity
GERD/Gastric Reflux
Headaches
Hearing Loss
High/Low Blood Pressure
lrritability
Kidney lssues
Loss of Balance
Loss of Energy
Memory Loss

Mark "C" for Current Health Concern or Mark "P" for Past Health Concern

	Health Concern (C / P)
Menstrual lssues
Migraines
Muscle Spasms
Muscle Weakness
Nausea
Nervousness
Numb/Tingling in Arms/Hands
Numb/Tingling in Legs/Feet
Plantar Fasciitis
Poor Circulation
Poor Posture
Ringing in the Ears
Sciatica
Shortness of Breath
Sinus lssues
Skin Problems
Sleep lssues
Sports lnjury
Stiffness
Stroke
Thyroid lssues
Tight/Sore Muscles
Tremors
Ulcers
Weight Loss/Gain
Vertigo
Stroke
Cancer
Heart Disease
Spinal Surgery
Seizures
Spinal Bone Fracture
Spinal Surgery
Scoliosis
Diabetes

Pain Concerns

Mark "C" for Current PAIN Concern or Mark "P" for Past PAIN Concern

	PAIN Concern (C / P)
Arm
Chest
Foot
Hip/Leg
Jaw/TMJ
Knee
Lower Back
Mid Back
Neck
Shoulder
Stomach
Upper Back

Pacemaker?

YesNo
Other Health Concerns?

VISUAL ANALOGUE SCALE (VAS)
Please circle the number that best describes the question asked. If you have more than one complaint, please answer each question for each individual complaint and indicate the score of each complaint. Use a different symbol for each of your own complaints.
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?)
Key: Use your own complaints
◯ Headache
▲ Neck Pain
□ Low Back Pain
What daily activities are being restricted by your current health problems?(i.e.; 2 activities of daily living that are limited by your health conditions)

Daily Activity

1.

2.
Patient Name
Date

MonthDayYear
Date

	Daily Activity
1.
2.

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 YOUR X-RAYS IN OUR FILES. THE FEE FOR COPYING YOUR X-RAYS IS $60.00. THIS FEE MUST BE PAID IN ADVANCE.

DIGITAL X-RAYS ON CD WILL BE AVAILABLE WITHIN 72 HOURS OF PREPAYMENT ON ANY REGULAR PRACTICE HOURS DAY.

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 LANDMARK CHIROPRACTIC 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.
PRINT YOUR NAME HERE
DATE

MonthDayYear
Date
SIGNATURE

Clear
YOUR AGE
FEMALE PATENTS ONLY

TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT LANDMARK CHIROPRACTIC.
SIGNATURE

Clear
DATE

MonthDayYear
Date

Practice Member Information (Must be Completed Before Services Can Be Rendered)
NAME

First NameMiddle NameLast Name
PHONE: Home
PHONE: Cell
PHONE: Work
SOCIAL SECURITY NUMBER
MARITIAL STATUS
DATE OF BIRTH

MonthDayYear
Date
CONTACT IN CASE OF EMERGENCY
Phone #
NAME OF PRIMARY INSURANCE CARRIER
Name of Insured
Insured Date of Birth

MonthDayYear
Date
Insured Social Security Number
NAME OF SECONDARY INSURANCE CARRIER
Name of Insured
Insured Date of Birth

MonthDayYear
Date
Insured Social Security Number
Insurance Policies and Fee Schedule
- Consultation- includes practice member history. This service is complimentary
- Assessment (new or established practice member)- includes one or more of the following: thermography, surface electromyography, range of motion, motion and/or static palpation, leg check $50-$75.
- Chiropractic Adjustment- The actual re-alignment of the vertebra done by hand. Often a sound will be heard, but if there is no auditory result, it does not mean that the adjustment has not taken place. $40-$60.
- X-rays- Specific x-ray views taken of your spine to determine a misalignment/subluxation of your vertebrae. These can also be used to indicate progress after period of care. $40 per view.
Release of Authorization /Assignment of Benefits
I authorize and request payment of insurance benefits directly to Andrew Oestreich DC. 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
Signed

Clear
Date

MonthDayYear
Date

Terms of Acceptance
In order to provide for the most effective healing environment, most effective application of chiropractic procedures, and the strongest possible doctor-patient relationship, it is our wish to provide each patient with a set of parameters and declarations that will facilitate the goal of optimum health through chiropractic.

To that end, we ask that you acknowledge the following point regarding chiropractic care and the services that are offered through
1. Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. Chiropractic is a separate and distinct science, art and practice. It is not the practice of medicine.
2. Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functions through the adjustment of spinal subluxation(s Subluxations are deviations from normal spinal structures and configurations that interfere with normal nerve processes.
3. The chiropractic adjustment process, as defined in the law of this jurisdiction, involves the application of a specific directional thrust to a region or regions of the spine with the specific intent of re-positioning misaligned spinal segments. This is a safe, effective procedure applied over one million times each day doctors of chiropractic in the United States alone.
4. A thorough chiropractic examination and evaluation is part of the standard chiropractic procedure. The goal of this process is to identify any spinal health problems and chiropractic needs. If during this process, any condition or question outside the scope of chiropractic is identified, you will receive a prompt referral to an appropriate provider or specialist, according to the initial indications of the need.
5. Chiropractic does not seek to replace or compete with your medical, dental or other type(s) of health professionals. They retain responsibility for care and management of medical conditions. We do not offer advice regarding treatment prescribed by
6. Your compliance with care plans, home and self-care, etc., is essential to maximum healing and optimal health though chiropractic
7. We invite you to speak frankly to the doctor on any matter related to your care at this facility, its nature, duration, or cost, in what we work to maintain as a supporting, open environment.
By my signature below, I 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 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 physicians certifications.
I acknowledge that I may request your NOTICE OF PRIVACY PRATICES 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 agree, then you are bound to abide by such restrictions.
(Signature)

Clear
(Date)

MonthDayYear
Date

INFORMED CONSENT FOR CHIROPRACTIC CARE
CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE

INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.

PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.
I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATEO WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT.
PRACTICE MEMBER'S NAME
PRACTICE MEMBER'S SIGNATURE

Clear
DATE

MonthDayYear
Date
IF PRACTICE MEMBER IS A MINOR/CHILD, PARENT OR GUARDIAN MUST SIGN BELOW.
SIGNATURE OF PRACTICE MEMBER OR GUARDIAN

Clear
DATE

MonthDayYear
Date
RELATIONSHIP TO MINOR/CHILD
WITNESS SIGNATURE (OFFICE STAFF)

Clear
DATE

MonthDayYear
Date

	SPOUSE	SON	DAUGHTER	MOTHER	FATHER
ARM PAIN
ARTHRITIS
ASTHMA
ADD/ADHD
ALLERGIES
BACK TROUBLE
BED WETTING
CANCER
CARPAL TUNNEL
DECEASED
DIABETES
DIGESTIVE PROBLEMS
DISC PROBLEMS

	SPOUSE	SON	DAUGHTER	MOTHER	FATHER
EAR INFECTIONS
FIBROMYALGIA
HEADACHES
HEARTBURN
HIGH BLOOD PRESSURE
HIP PAIN
LEG PAIN
MENSTRUAL DISORDER
MIGRAINES
NECK PAIN
SCOLIOSIS
SHOULDER PAIN
SINUS TROUBLE
TMJ

PATIENT DEMOGRAPHICS

HISTORY OF CURRENT HEALTH CONCERNS

Health Concerns

Pain Concerns

PAST HISTORY

Females Only

BIRTH EXPERIENCE

PHYSICAL TRAUMAS

What would success look like for your child?

VISUAL ANALOGUE SCALE (VAS)

X-RAY AUTHORIZATION

FEMALE PATENTS ONLY

Practice Member Information (Must be Completed Before Services Can Be Rendered)

Insurance Policies and Fee Schedule

Release of Authorization /Assignment of Benefits

Terms of Acceptance

Notice of Privacy Practices Acknowledgement

INFORMED CONSENT FOR CHIROPRACTIC CARE

IF PRACTICE MEMBER IS A MINOR/CHILD, PARENT OR GUARDIAN MUST SIGN BELOW.

FAMILY HEALTH HISTORY