New Practice Member Paperwork

Name *
Name
Date of Birth *
Date of Birth
Cell Phone
Cell Phone
Home Phone
Home Phone
LIST THE HEALTH CONCERNS THAT BROUGHT YOU INTO THIS OFFICE
Have you ever seen other doctors for these conditions?
If Yes:
PAST AND CURRENT HEALTH PROBLEMS
Please mark all of the following that you've had in the PAST:
Mark all that apply (in the past)
Please mark all of the following that you CURRENTLY experience:
Mark all that apply (currently)
Have you ever been knocked unconscious? *
Fractured a Bone? *
Social History:
Smoking *
How often?
Alcohol *
How often?
Exercise *
How often?
Have you consumed any caffeine or products with caffeine in the past 48 hours? *
QUADRUPLE VISUAL ANALOGUE SCALE
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.
0 = NO PAIN 10 = WORST POSSIBLE PAIN
Enter a percentage
Enter a percentage
Practice Member Name
Practice Member Name
Date
Date
ACTIVITIES OF LIFE
Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:
Carrying Groceries
Sit to Stand
Climbing Stairs
Pet Care
Driving
Extended Computer Use
Household Chores
Lifting Children
Dressing
Shaving
Sexual Activities
Sleep
Static Sitting
Static Standing
Walking
Washing/Bathing
Sweeping/Vacuuming
Dishes
Laundry
Yard Work
Garbage
Concentration (Reading)
FAMILY HEALTH HISTORY
This form is to assist the doctors by providing past health history information for their review.
Spouse
Son
Daughter
Mother
Father
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 the 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 finding will be reported to you along with a care plan prior to beginning care.
I understand and accept that there are risks associated 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. I authorize and request payment of insurance benefits directly to Landrus Lewis, D.C. and Cepeda Carter, D.C. 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 practice member. 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.
By entering your name below you are signifying your agreement with the above statement
Signature *
Signature
IF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT THE WRITTEN CONSENT FOR A CHILD BELOW
Name of practice member who is a minor/child:
Name of practice member who is a minor/child:
I authorize Dr. Landrus Lewis, Dr. Cepeda Carter and any and all Growing Tree Chiropractic staff to perform diagnostic procedures, radiographic evaluations, render chiropractic care and perform chiropractic adjustments to my minor/child. As of this date, I have the legal right to select and authorize health care services for my minor/child. If my authority to select and authorize care is revoked or altered, I will immediately notify Growing Tree Chiropractic.
Guardian Signature
Guardian Signature
Date
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 (HIPPA). 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 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 private information is used to disclose 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 *
Signature
Date *
Date
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. Digital x-rays on a CD will be available within 72 hours of request during any regular office hours. Please note: X-rays are utilized in this office to help locate and analyze vertebral subluxations. The doctor of Growing Tree Chiropractic does 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.
Name/Signature: *
Name/Signature:
Date of Birth: *
Date of Birth:
Date Signed: *
Date Signed: