Adult New Patient Form

CURRENT CONDITIONS

OTHER TREATMENT

DAILY LIVING EFFECTS

FEET/ORTHOTIC HISTORY

How many days per week do you wear these kinds of shoes?

ACCIDENTS, INJURIES, FRACTURES, & HOSPITALIZATIONS

Please list any previous accidents, injuries, fractures, and hospitalizations and approximate date of occurence.

DIAGNOSTIC IMAGING

Please list any previous diagnostic imaging and approximate date of occurrence.

SURGERIES

Please list any previous surgeries and list the approximate date of occurence.

GENERAL HEALTH HISTORY

CURRENT MEDICATIONS/VITAMINS

WOMEN ONLY

SOCIAL HISTORY

FAMILY HISTORY

SUBSTANCE ABUSE

ALLERGIC/IMMUNOLOGIC

CARDIOVASCULAR

CONSTITUTIONAL

EARS/NOSE/THROAT/MOUTH

ENDOCRINE

EYES

GASTROINTESTINAL

GENITOURINARY

HEMATOLOGIC/LYMPHATIC

INTEGUMENTARY

MENTAL HEALTH

MUSCULOSKELETAL

NEUROLOGICAL

PRENATAL (Women only)

RESPIRATORY

Please read, sign, and date on the lines below.

Informed Consent Form

The doctor of chiropractic evaluates the patient using standard examination and testing procedures. A chiropractic adjustment involves the application of a quick, precise force directed over a very short distance to specific vertebra or bone. There are a number of different techniques that may be used to deliver the adjustment, some of which utilize specially designed equipment. Adjustments are usually performed by hand but may also be performed by hand-guided instruments. In addition to adjustments, other treatments used by chiropractor include physical therapy modalities (heat, ice, ultrasound, and soft-tissue manipulation), nutritional recommendations and rehabilitative procedures.
Chiropractic treatments are one of the safest interventions available to the public demonstrated through various clinical trials and indirectly reflected by the low malpractice insurance paid by chiropractors. While there are risks involved with treatment, there are seldom great enough to contraindicate care. Referral for further diagnosis or management to a medical physician or other health care provider will be suggested based on a history and examination findings.
Listed below are summaries of both common and rare side-effects/complications associated with chiropractic care:
Common 1.2
 *Reactions most commonly are local soreness, discomfort (53%), headaches (12%), and tiredness (11%).
 *Radiating discomfort (10%), dizziness, the vast majority of which resolve within 48 hours.
Rare 3.4
 *Fractures of joint injuries in isolated cases with underlying physical defects, deformities of pathologies
 *Physiotherapy burns due to some therapies
 *Disc herniation
 *Cauda Equina Syndrome (2) (1 case per 100 million adjustments)
 *Compromise of the vertebrobasilar artery (i.e. stroke) (range: 1 case per 400,000 to million cervical spine adjustments [manipulation]). This associated risk is also found with consulting a medical doctor for patients under the age of 42 and is higher for those older than 42 when seeing a medical doctor.4, 5 These findings suggest that neither chiropractic or medical care is the cause, but rather because patients with a dissection in progress have symptoms of headache or neck pain they seek care from a health care provider. Please indicate to your doctor if you have a headache or neck pain that is the worst you have ever felt.
 

Reasonable alternatives to these procedures have been explained to me including prescription medications, over-the-counter medications, possible surgery, and non-treatment.  Listed below are summaries of concern with the associated alternative procedures.

Long-term use or overuse of medication carries some risk of dependency with the use of pain medication the risk of gastrointestinal bleeding among other risks
Surgical risks may include unsuccessful outcome, complications such as infection, pain, reactions to anesthesia, and prolonged recovery.6
Potential risks of refusing or neglecting care may result in increased pain, restricted motion, increased inflammation, and worsening of my condition..7
Neck and back pain generally improve in time, however, recurrence is common. Remaining active and positive improve your chances of recovery.

1.             Senstad O, Leboeuf-Yde C, Borchgrevink CF. Side-effects of chiropractic spinal manipulation: type’s frequency, discomfort and course. Scand J Prim Health Care. Mar 1996;14(1):50-53.

2.             Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiropractic manipulation of the cervical spine: a prospective national survey. Spine. Oct 1 2007;32(21):2375-2378; discussion 2379.

3.             Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH. Spinal manipulation for low-back pain. Ann Intern Med. Oct 1 1992;117(7):590-598.

4.             Boyle E, Cote P, Grier AR, Cassidy JD. Examining vertebrobasilar artery stroke in two Canadian provinces. Spine. Feb 15 2008;33(4 Suppl):S170-175.

5.             Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. Feb 15 2008;33(4 Suppl):S176-183.

6.             Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. Feb 15 2008;33(4 Suppl):S153-169.

7.             Carroll LJ, Hogg-Johnson S, van der Velde G, et al. Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. Feb 15 2008;33(4 Suppl):S75-82.

 

Please read through and answer the following questions to help us determine possible risk factors. Please sign your name at the bottom where indicated.

______________________________________________________

Doctor's Signature & Date

This information may be disclosed to and used by the following organization:

Kyle J. Pankonin, D.C.

Red Rock Chiropractic Center

202 Main Street, PO Box 517

Lamberton, MN 56152

PHONE: 507-752-7650

FAX:507-752-7635

The reason for disclosure of this information is for the following reason:

1. Continued Health Care

I understand I have a right to revoke this authorization at any time yby presenting a written revocation to the medical record department. I understand the revocation will not apply to:

1. Information already released in response to this authorization
2. My insurance company when the law provides my insurer with the right to contests a claim under my policy.

I understand authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.

Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If I fail to specify an expiration date, event, or condition, this authorization will be in effect for one year from this date, for records generated as a result of services occurring on or prior to this date.