• New Prenatal Patient Paperwork

    About 15 minutes: your health history and pregnancy, then the consent forms to sign.

  • Patient Information

  • DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you first hear about us?*
  • Marital Status*
  • Format: (000) 000-0000.

  • Your Condition

  • Please identify the condition(s), if any, that brought you to this office:
  • On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by checking the number:
  •
  • When is the problem at its worst?*
  • How long does it last?*
  • Have you seen any other doctor for these conditions?*
  • What were the results?
  • Which of these describe your symptoms?
  • Have you suffered with any of this or a similar problem in the past?*

  • Daily Activities

  • Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:
    Rows
  • How does it affect you?

  • Health History

  • If you have ever been diagnosed with any of the following conditions, please indicate with a P for in the Past, C for Currently have or N for Never have had:
    Rows
  • PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:
    Rows
  • Do you smoke?
  • How often?
  • Do you exercise?
  • How often?

  • Family Health History

  • Please mark any of the below conditions that you or your family have or have had in the past: Write "C" if current issue or "P" if past issue
    Rows

  • Quadruple Visual Analogue Scale

  • Please choose the number that best describes the question being asked. If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint in the comments. 0 = No pain, 10 = Worst possible pain.
  •

  • PRENATAL HISTORY:

  • 1. Is this your first pregnancy?*
  • 2. Any Complications during previous pregnancy/delivery?
  • 3. Previous Birth Intervention(s):
  • If C-Section, was it:
  • 4. Location of Birth(s):
  • 5. Conception History (check all that apply):

  • CURRENT PRENATAL STATUS:

  • 6. What is your estimated due date?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • 9. Are you taking any pre-natal or birthing classes?
  • 13. What are your goals for this pregnancy? (check all that apply)

  • 14. What are your current birth providers? (OB/midwife/doula/birth coach/etc.)

  • Do we have permission to communicate with your other providers regarding your plan of care in our office?
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Assignment of Benefits

  • I hereby authorize payment to be made directly to Absolute Chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Absolute Chiropractic for any and all services I receive at this office. In the event this account is referred to a collection agency, I understand and agree to pay any collection fees incurred by Absolute Chiropractic in addition but not limited to any attorneys' fees or costs of collection.
  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Informed Consent

  • We encourage and support a shared decision making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent. Chiropractic care concerns itself with the detection, analysis, and correction of vertebral subluxation, or malposition of the spinal vertebrae impacting nervous system function. It centrally involves what is known as a chiropractic adjustment, involving the use of hands or instruments with a precise direction and force to reposition anatomical structures. Potential benefits include restoring normal joint motion, reducing swelling in a joint, reducing pain in the joint, improved neurological function and overall well-being. We will conduct diagnostic or examination procedures, which, while non-invasive, may be uncomfortable in some cases. In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them. Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. In addition, there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence do not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment. I have been informed of the nature and purpose of chiropractic care, the possible consequences of care and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences, and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of care and the treatment. I have read the above content and understand the information provided. All questions I have about this information have been answered to my satisfaction. Having this knowledge, I intend this consent to cover the entire course of care from all providers in this office.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • If the patient is a minor: In addition, by signing below, I give permission for the above-named minor patient to be managed by the doctor even when I am not present to observe such care.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Notice of Privacy Practice 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/or 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 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 information is used to disclose or carry out treatment, payment, or healthcare operation. I understand that you are not required to agree to my requested restrictions, but if you agree, then you are bound to abide by such restrictions.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: