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Notice of Privacy Practices Acknowledgement

Initial Uses Authorization Form
Effective: 4-15-2003

By signing this form, you acknowledge that you were presented with a copy of the Notice of Privacy Practices of Bender Chiropractic Health and Vitality Center. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

Our Notice of Privacy Practices is subject to change. The most current Notice of Privacy Practices will be placed on display in the office at all times. You may obtain additional copies of our most current notice by requesting it from our privacy official, Dr. William L. Bender

Bender Chiropractic Health and Vitality Center also uses protected health information for the following reasons: (you may opt out of this authorization). Marketing; internal referral board, testimonials, pictures on bulletin board, or information unrelated to healthcare and other marketing materials. (please initial to give us authorization)
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If you have any questions regarding this notice or our health information privacy policies, please contact:
Dr. William L. Bender

You can reach the Privacy Official at: Bender Chiropractic Health and Vitality Center, 33580 Harper Avenue, Clinton Township, MI, 1-586-738-6833
Hours Available: A message may be left for our privacy official any time the clinic is open and your call will be returned within 7 business days.
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	Rare / Never	1-3 times a month	1+ times per week / New condition
1. Stomach Discomfort
2. Lung Congestion
3. Dehydrated or thirsty
4. Gas-type indigestion
5. Circulation problems
6. Intestinal upsets
7. Yeast infections
8. Burping or belching
9. Hoarseness or laryngitis
10. Swollen feet
11. Fats hard to digest
12. Sweat easily
13. Alcohol intolerance
14. Constipation
15. Cold sores
16. Nose discharge or dryness
17. Bladder problems
18. Earaches
19. Restless sleep
20. Abdominal bloating
21. Athlete's Foot
22. Mucus in throat
23. Sensitivity to touch
24. Sensitivity to cold air
25. Grinding of teeth
26. Mood swings
27. Variable appetite
28. Crave carbohydrates
29. Gums bleed easily
30. Skin rash/irritations
31. Urination problems
32. Finger nail problems
33. Burning in soles of feet
34. Nose itches
35. Crave sugar-type foods
36. Feelings of nausea
37. Eczema or dry skin
38. Hearing/Ear sensitivities
39. Jaw problems
40. Headaches from the sun
41. Loss of libido
42. Film/Coating on tongue
43. Allergy-type symptoms
44. Anxiety/Nervous feelings
45. Carpal Tunnel symptoms
46. Lack of balance
47. General flu symptoms
48. Arthritic pain
49. Fatigued and irritable
50. Overly sensitive
51. Sensitive scars on body
52. Lack of coordination
53. Body achiness
54. Tooth pain
55. Hay Fever symptoms
56. Weeping or sobbing
57. Localized itching
58. Acid Reflux symptoms
59. Sinus/Head pressure
60. Muscular pain/spasm
61. Dizziness or vertigo
62. Dry mouth
63. Stiffness in joints
64. Stomach cramping
65. Sore throat
66. Overexertion pain
67. Migraines or headaches
68. Voracious appetite
69. Strained ligaments
70. Trouble swallowing
71. High temperature/fevers
72. Bone pain
73. Sporadic low back pain
74. Feeling overworked
75. Hemorrhoids
76. Heartburn-type pain
77. Ears feel under water
78. General aches and pain

NEW PATIENT INFORMATION FORM

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WELLNESS CHECK QUESTIONNAIRE

Notice of Privacy Practices Acknowledgement