Adult Form About you Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Cell Phone (###) ### #### Email Address * Date of Birth * MM DD YYYY Age * Gender Male Female Marital Status Names and ages of children Employer Name * Employer City * Employer State/Zip Code * Work Phone Number (###) ### #### Position Title About your spouse Spouse Name * First Name Last Name Spouse Employer Position Title Health Habits Do you smoke? * Yes No If yes, how much per day? Do you drink alcohol? * Yes No If yes, how much per week? Do you drink coffee, tea, soda? * Yes No If yes, how much per day? Do you exercise regularly? * Yes No Do you wear: * check all that apply Heel lifts Sole lifts Inner soles Arch supports None Chiropractic Experience Who referred you to our office? Have you seen or heard of our office because of: * Check all that apply. Newspaper Sign Internet search (i.e. Google) Community Event Mailing Social Media Other: Have you been adjusted by a chiropractor previously? * Yes No If yes, what was the reason for those visits? Doctor's Name Approximate Date of last visit MM DD YYYY Has any adult in your family seen a chiropractor? * Yes No Reason for this visit Describe the reason for this visit: * Is the purpose of this appointment related to: * Sports Auto Fall Home Injury Pregnancy wellness Other Please explain If job related, have you made a report of your accident to your employer? Yes No When did this condition begin? Has this condition: Gotten worse Stayed constant Come and gone Does this condition interfere with: Sleep Daily Routine Other Activities Has this condition occurred before? Yes No Please explain Have you seen other doctors for this condition? Yes No Doctor's Name Type of treatment Results Chiropractic Awareness Doctors of chiropractic work with the nervous system? Yes No The nervous system controls all bodily functions and systems? Yes No Chiropractic is the largest natural healing profession in the world? Yes No Goals for your care People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your Doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible. * Relief care: Symptomatic relief of pain or discomfort Corrective care: Correcting and relieving the cause of the problem as well as the symptom Comprehensive care: Bring whatever is malfunctioning in the body to the highest state of health possible with chiropractic care I want the doctor to select the type of care appropriate for my condition. Medications you take Medications Please check all that apply Cholesterol medications Blood pressure medicine Stimulants Blood thinners Tranquilizers Pain killers (including Asprin) Muscle relaxers Insulin Other medications: Vitamins & supplements Your Concerns Please check all that apply C1 C2 C3 C4 Headaches Migraines Dizziness Sinus problems Allergies Fatigue Head colds Vision problems Difficulty concentrating Hearing problems C5 C6 C7 T1 Sore throat Stiff neck Radiating arm pain Hand/finger numbness Asthma Allergies High blood pressure Heart conditions T2 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 Middle back pain Congestion Difficulty breathing Bronchitis Pneumonia Gallbladder conditions Stomach problems Ulcers Gastritis Kidney problems L1 L2 L3 L4 L5 SACRAL Constipation Colitis Diarrhea Gas pain Irritable Bowel Bladder problems Menstrual problems Low back pain Pain or numbness in legs Reproductive problems Other: Health Conditions Instructions: Please check each of the diseases or conditions that you now have or have had in the past. W hile they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care. Severe or frequent headaches Heart surgery/Pacemaker Lower back problems Digestive problems Pain between shoulders Congenital heart defect Frequent neck pain Thyroid problems Sinus problems Hepatitis Difficulty breathing Kidney problems High blood pressure Chemotherapy Pain in arms, legs, or hands Low blood pressure Rheumatic fever Ulcers/Colitis Tuberculosis Arthritis Shingles Numbness Allergies Diabetes Surgeries Asthma Loss of sleep Dizziness For women only Are you pregnant? Yes No If yes, when is your due date? Are you nursing? Yes No Are you taking birth control? Yes No Do you experience painful periods? Yes No Authorization of Care I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistant to administer chiropractic care to my child through the use of adjustments and procedures the doctor deems appropriate. I clearly understand and agree that all services rendered to my child are charged directly to me and that I am personally responsible for payment. I agree that I am responsible for all bills incurred at this office. Dr. DeVries will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand if I suspend or terminate my child’s care for any reason, any fees for professional services rendered will become immediately due and payable. I hereby authorize assignment of my child’s insurance rights and benefits (if applicable) directly to the provider for services rendered. I authorize the use of this signature to allow the insurance companies to pay TrueNorth Chiropractic, PA directly any amounts payable as my child’s assignment of benefits. I authorize the use of this signature on any insurance submissions. I have read and agree to the above authorization of care * Yes Signature * Type your full legal name to digital sign this document. Parent or guardian Signature If patient being seen is under the age of 18. By typing your full legal name, you are digital signing this document. Today's Date * MM DD YYYY Who should receive bills for payment on your account? * Patient Spouse Parent Workers Comp Auto Insurance Health Insurance Notice of Privacy Policy/HIPAA Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. • You may request restrictions on your disclosures. •You may inspect and receive copies of your records within 30 days with a request. • You may request to view changes to your records. • In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and its staff. Statement of understanding * I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly. • Obtain payment from third party payers. • Conduct normal healthcare operations such as quality assessments and physician’s certifications. I Understand Agree to Notice * I have read and understand the Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and or disclosed. Yes Terms of Acceptance When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is only when the patient understands both the objective and the method that they will be able to attain it. This will prevent any confusion or disappointment. Adjustment * An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. I understand Health * Health is a state of optimal physical, mental and social well being, not merely the absence of disease. I understand Vertebral Subluxation * Vertebral Subluxation is a misalignment of one or more of the joints of the body. This can cause pain or alteration of nerve function and interference of the transmission of nerve impulses, lessening the body’s innate ability to maintain maximum health. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our ONLY practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxation. I have read and fully understand the above statement. Any questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. Signature * By typing your name you are digitally signing this form. Witness * By typing your name you are digitally signing this document. Today's Date * MM DD YYYY Thank you!
