Personal Information: (Mark with * required fields)
Last Name *
First Name *
Email *
Date of Birth *
Street *
City *
Zip Code *
State *
Home Phone
Work Phone
Cell Phone *
Employer *
SS#
Do you have insurance that covers chiropractic? * Yes No
If so, please provide receptionist with a copy of your card.
What is the best time and manner to contact you?
Who may we thank for referring you?*
When was your last chiropractic adjustment?
Addressing What Brought You Into This Office:
If you have no symptoms or complaints and are here for Chiropractic Wellness Services, please skip to the “General Health History”.
Health Concerns
Please list your health concerns according to their severity
Rate of severity 1 = mild 10 = worst imaginable
When did this episode start?
If you had this condition before, when?
Did the problem begin with an injury?
% of the time pain is present
Is your pain dull? Or is your pain sharp? Does it radiate/shoot anywhere? If so, where?
Since the problem started is it: About the same? Getting better? Getting worse?
What have you done for this condition? Was it of benefit?
I do (do not) have a family history of this or similar symptoms (Please explain):
Which activities aggravate your condition?
Which activities aggravate your condition? “Limited Scope” Chiropractor (focuses mainly on neck and back pain) “Wellness” Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns) Medical Doctor
Other (please describe)
Doctor’s details:
Name:
Address:
When did you see them?
What did they say was wrong?
Did it help?
Have you been "forced" or "felt the need" to make any "positive" changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.) If so, what?
Is this condition interfering with any of the following: Work Sleep Daily routine Sports/exercise Other
General Health History
Often times, accumulation of life’s stress can lead to health problems and influence our ability to heal. Please pay close attention to this as it will help us help you!
Have you had any surgery? (Please include all surgery)
Type:
When:
Doctor:
Have you had any accidents and/or injuries: auto, work-related, or other? (Especially those related to your present problems).
Hospitalized? Yes No
Have you ever had x-rays taken?
Area of body:
Where:
Do you wear orthotics or heel lifts?
Current Medicines and Supplements
Please list any medications/drugs you have taken in the past 6 months and why: (prescription and non-prescription)
Please list all nutritional supplements, vitamins, homeopathic remedies you presently take and why:
Are you interested in knowing more about how your nutrition (food you eat) affects your overall health and well-being? Yes No Maybe
If dietary changes are indicated would you be willing to make changes in your diet? Yes No Maybe
Would you take whole food supplements if indicated? Yes No Maybe
If specific exercises or stretching would help would you consider adding them to your program? Yes No Maybe
If reducing stress would you help you would you like to know ways to reduce stress? Yes No Maybe
DietPlease select any dietary selection that is appropriate for you, and grade according to the following scale:
D - Consume this daily W - Consume this weekly M - Consume this monthly O - Do not consume this
Alcohol Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Tobacco Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Coffee Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Soda Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Fried Foods Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Cooked or canned vegetables Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Eggs Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Fruit Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Beef Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Poultry Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Organic Foods Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Fasting Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Diet Food Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Refined Sugar Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Fish Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Seafood Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Artificial Sweetener Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Weight Control Diet Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Raw Vegetables Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Whole Grains Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Dairy Select dietary selection D - Consume this dailyW - Consume this weeklyM - Consume this monthlyO - Do not consume this
Past Health HistoryPlease mark the following conditions you may have had or have now ( - have had + have now):
Alcoholism - have had + have now
Back Pain - have had + have now
Diabetes - have had + have now
Gout - have had + have now
Irregular Periods - have had + have now
Miscarriage - have had + have now
Pleurisy - have had + have now
Stroke - have had + have now
Allergy - have had + have now
Cancer - have had + have now
Diarrhea - have had + have now
Headaches - have had + have now
Low Blood Sugar - have had + have now
Multiple Sclerosis - have had + have now
Pneumonia - have had + have now
Thyroid Problems - have had + have now
Anemia - have had + have now
Cold Sores - have had + have now
Eczema - have had + have now
Heart Attack - have had + have now
Acid Reflux - have had + have now
Fatigue - have had + have now
Polio - have had + have now
Dizzy upon rising - have had + have now
Arteriosclerosis - have had + have now
Constipation - have had + have now
Emphysema - have had + have now
Heart Disease - have had + have now
Crave salt - have had + have now
Neck Pain - have had + have now
Bruising easily - have had + have now
Ulcers - have had + have now
Arthritis - have had + have now
Morning Stiffness - have had + have now
Epilepsy - have had + have now
High Blood Pressure - have had + have now
Menstrual Cramps - have had + have now
Nervousness - have had + have now
Ringing in ears - have had + have now
Crave sugar - have had + have now
Asthma - have had + have now
Depression - have had + have now
Gall Bladder Problems - have had + have now
HIV (Aids) - have had + have now
Migraines - have had + have now
Neuritis - have had + have now
Sinus Problems - have had + have now
Whooping Cough - have had + have now
Other (please explain)
StressorsBecause accumulation of stress affects our health and ability to heal please list your top three stresses (you have ever had) in each category:
1.Physical stress (falls, accidents, work postures, etc.)
2.Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.)
3.Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.)
On a scale of 1-10 please grade your present levels of stress (including physical, bio-chemical and psychological or mental/emotional):
At work: : Select Grade12345678910
At Home: Select Grade12345678910
At Play: Select Grade12345678910
On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your:
Eating habits: Select Grade12345678910
Exercise habits: Select Grade12345678910
Sleep: Select Grade12345678910
General health: Select Grade12345678910
Mind set: Select Grade12345678910
How do you grade your physical health? Excellent Good Fair Poor Getting better Getting worse
How do you grade your emotional/mental health? Excellent Good Fair Poor Getting better Getting worse
Is there anything else which may help to better understand you which has not been discussed?
Why are you here at this point in time?
I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems necessary.
Print Patient Name:
Patient Signature:
Date:
PATIENT AGREEMENTS
In consideration of treatment by the doctor the undersigned agrees as follows:
1. To pay the amount charged by the doctor for all professional treatment and services to the undersigned and /or his/her family. Payment to be made to South Jordan Chiropractic, LLC. 2. All charges are due and payable at the time of service unless other financial agreements are made. 3. Any balance due 30 days after treatment will be subject to a 2% per month service charge (APR of 24%) 4. To pay all collection fees, settlement fees, reasonable attorney fees, and costs incurred in the event of referral to any collection agency, arbitration / mediation process, or suit. I further agree to pay all fees for collections, including a 40% agency commission fee. 5. That in the event of death, this obligation shall be binding on the estate, heirs or successors of the undersigned.
FINANCIAL ARRANGEMENTS
1. This office will accept payment for services by cash or all major credit cards. 2. This office has several types of financial plans available. A Chiropractic Assistant will discuss this with you upon request. Any alteration to our regular fees must be set to paper and signed by both parties to be binding. 3. I clearly understand and agree that I am responsible for the payment for all services rendered to me. I also understand that if I terminate care, any professional fees for services will become due and payable.
CHIROPRACTIC INSURANCE
1. If you have medical insurance that covers chiropractic, your estimated portion is due and payable at the time of service. If after this office receives payment from the insurance company, and a balance remains, a statement will be sent to you. 2. If an insurance payment is not received within 60 days, the full amount is due and payable by you. 3. The filing of a secondary insurance is your responsibility.
I do herby agree to the above arrangements. I give permission for the doctor and/or his designated employees to perform chiropractic services for myself. If services are for a minor I am responsible for, the name of such minor will be listed below as the patient.
Print Patient Name: *
Patient Signature: *
HIPPA / Privacy Practices
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Use and disclosure of protected informationYour health information will only be used by the doctor, our office staff and others outside of our office that are involved in your case of treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation f the physician’s practice, and any other use required by law.
Health OperationsWe may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases; Health Oversight; Abuse or Neglect, Food and Drug Administration requirements, Legal proceedings; Law Enforcement, Coroners, Funeral Directors and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; Inmates. Under the law we must make disclosures to you and when required by the Secretary of the department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.
Your Rights You have the right to inspect and copy your protected health information other than psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal or administrative action or proceeding and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
ComplaintsYou may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003Signature below is only acknowledgement that you have received this notice of our Privacy Practices:
Security Code:
