Legacy Chiropractic Pregnancy Form

Pregnancy Form

Legacy Chiropractic & Wellness Center

826 E 12300 S Ste 4, Draper, Utah 84020

www.legacypainandwellness.com

801-523-2233

Law requires us to obtain your informed consent prior to examination and treatment. By signing this document, you are confirming that you have read and/or the doctor has discussed with you the following information, you have had an opportunity to ask questions, and all your questions have been answered fully and satisfactory.

Associates and Assistants- In this office we may use trained staff to assist the doctor with portions of your consultation, examination, and treatment. Occasionally, when your doctor is unavailable, another clinic doctor may treat you.

Treatment- An adjustment is performed by the doctor using her hands or mechanical device on your body in such a way as to move your joints. This procedure may cause an audible “click”, much as you have experienced when you “crack” your knuckles. There are some inherent risks involved in doing this and they are as follows:

·       Pain: Most patients come to this office in pain. Rarely will treatment even temporally increase soreness in the region being treated. However, since it is possible, this is included in this section.

·       Rib Fracture: It is possible to “crack” an arthritic rib with an adjustment. This can happen to anyone. It occurs most often in aging patients who have weakened bones with osteoporosis. These problems occur so rarely, it is difficult to find available statistics to quantify their probability.

·       Disc Herniations: Occasionally, treatment will aggravate or cause a problem if the disc is in a weakened state. These problems occur so rarely, it is difficult to find available statistics to quantify their probability.

·       Physical Therapy: Some of the machines we use generate heat. We also use ice in this office. Burns can possibly come from such treatment. If you have a pacemaker or metal in your body, notify the doctor prior to therapy. These problems occur so rarely, it is difficult to find available statistics to quantify their probability.

·       Stokes: Strokes are not that common, and even less so in a chiropractic office. They are so rare that you have a greater chance of getting hit by lightning-less than one in three million. This office reduces your odds even further through screening tests during your examination.

·       Other Problems: There may be other problems or complications that might arise from treatment such as massage, traction, etc. These problems or complications are so infrequent that it is not plausible to anticipate and/or explain them all in advance.

Non-Treatment- Remaining untreated results in adhesions, pain and reduction in associated joint mobility. The probability that adhesions and pain will interfere with motion, function, and quality of life is almost certain.

I hereby state that I have read or have had read to me this consent form. I authorize and direct the above-named physician, associates and/or assistants to provide such additional services as they may deem reasonable and necessary.
Patients Printed Name
Patients Signature

Clear
Date

MonthDayYear
Date
CONSENT TO TREAT A MINOR- I hereby authorize Dr. Shannon Nelson to administer treatment as she SO deems necessary to my Date: son / daughter, Minor's NameSigned:
Minor's Name:

First NameLast Name
Signed

Clear
RELEASE OF INFORMATION: You are authorized to release and permit the examination or copying of any of my medical records, x-rays, laboratory reports, and the results of all tests of any type or character as needed for treatment, payment, and health care operations.

I acknowledge that I have been informed and given the opportunity to review the Notice of Privacy Practices for Legacy Chiropractic & Wellness Center.

RELEASE OF INFORMATION: You are authorized to release and permit the examination or copying of any of my medical records, x-rays, laboratory reports, and the results of all tests of any type or character as needed for treatment, payment, and health care operations. I acknowledge that I have been informed and given the opportunity to review the Notice of Privacy Practices for Legacy Chiropractic & Wellness Center.

HIPPA: Information to be Used or Disclosed- The information covered by this authorization includes-Appointments, Account Billing Information, Personal Health Information, and Treatment Recommendations.
Persons Authorized to Use or Disclose Information shall include:
SIGNATURE

Clear
PATIENT INFORMATION
Sex

MaleFemale
Age
Marital Status

SingleMarriedWidowedDivorced
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

Zip
Email
example@example.com
Phone #
Work #
Please enter a valid phone number.
Ext
Best time and place to reach you
Occupation
Employer
Address

Employer Address

Street Address Line 2

CityState

Zip
May we send cards, promotions, etc. to you?

YesNo
IN CASE OF EMERGENCY CONTACT Name
Relationship
Phone #
Whom may we thank for referring you
HEALTH HISTORY
Chief Complaint
Pain scale 1-10 (10 is worst)
Previous treatment for this complaint
Other health complaints or problems
Surgeries or Injuries
Current Medications
Other Physicians or health providers
Nutritional Supplements
Sleep (# of hours, common position, sleep issues, etc)
Exercise (# of steps per day, days per week, type of exercise, etc)
ACCIDENT INFORMATION
Is condition due to an accident?

YESNO
Type of Accident

AutoHomeWorkOther
To whom have you reported your accident?

Auto InsuranceEmployerPolice officer or Police Report
Date of Accident

MonthDayYear
Date
Claim #
Claim Contact Person Name
Claim Contact Person Phone or Email
Attorney Name if applicable
MISSED APPOINTMENT POLICY
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Dr. Nelson cannot bill your health insurance. Payment is due at the time of service. The office has a 24 hour cancellation policy and fee of $50. Parents or their guardians need to notify me at least 24 hours in advance if they are unable to keep an appointment. No insurance company will pay for your no-show fee. Not health insurance or PIP. Any no show fees incurred will be due and payable immediately by the patient or guardian.

I hereby authorize Legacy Chiropractic to charge my credit card. Credit card details will be taken in the office or over the phone.
Signature

Clear
Name of Obstetric Care Provider/Midwife
Pregnancy Questionaire
How many weeks pregnant?
Due Date

MonthDayYear
Date
Have you had any problems with pregnancy?

YesNo
Have you had any vaginal bleeding or leaking of fluid with this pregnancy? (miscarriage, preterm labor)

YesNo
Have you had any contractions or tightness in your abdomen? (a concern prior to 36 weeks of pregnancy)

YesNo
Have you had any pain in your legs? (thrombophlebitis)

YesNo
Do you have any circulatory problems?

YesNo
Have you had a fever? (UTL, PID)

YesNo
Have you had changes in urination?

YesNo
If Yes to changes in Urination, select any relevant changes:

PainFrequencyUrgencyChange in ColorChange in Odor
Did you have health problems with any previous pregnancies?

YesNo
Blood pressure at last OB appointment?
Date of next visit to obstetric care provider:

MonthDayYear
Date
Did you have back problems with any previous pregnancies?

YesNo
Is your back pain worse at night? (Predominant nocturnal back pain is less responsive to musculoskeletal tx)

YesNo
If so, is the pain relieved by changing your sleeping position?

YesNo
Have you missed work with this pregnancy? If so, please answer why in "Other" box!

YesNoOther
Do you now or have you ever had a job involving heavy work?

YesNo
Do you now or have you ever had a job lots of bending and twisting?

YesNo
Does your work involve constrained work postures or inability to take breaks at will?

YesNo
We value your referrals and support! Would you be willing to refer Dr. Nelson’s services to family, friends or Midwife/OB?

YesNo
Do you have a name/number of anyone looking for chiropractic care, so we can reach out to them?
Should be Empty:

PATIENT INFORMATION

HEALTH HISTORY

ACCIDENT INFORMATION

MISSED APPOINTMENT POLICY

Pregnancy Questionaire