initial intake questionnaire - electronic · 1 initial intake questionnaire *instructions: please...

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Initial Intake Questionnaire *Instructions:Pleasetaketimetoprovidefullandcompleteresponsestothequestionsbelow.Ifyou

needadditionalroomtorespondtoaquestion,pleaseusethebacksideofthisquestionnaire.

PatientInformationTitle:Mr.Mrs.Ms.Miss(Checkone)

FirstName:________________MiddleInitial:_____LastName:_______________Address:____________________________________________________________City:___________________________State:_____________Zip:______________Mobile#:(____)_______-__________Sex:MaleFemaleOtherEmail:_______________________MaritalStatus:SingleMarriedOtherDateofBirth:____/_____/______SocialSecurity#:______________________EmployerData:EmploymentStatus:EmployedFTStudentPTStudentOtherEmployerName:______________________Telephone#:(____)______-_______EmergencyContact:Name:______________________Telephone#:(____)______-_______PolicyHolderonInsurance:Patient/ListedaboveOther:_______(RelationtoPolicyHolder)Ex:Spouse,ChildIfyouselectedother,pleaseputthenameandaddressbelow.FirstName:________________LastName:_______________DOB:_____Address:__________________City:______________State:______Zip:______Towhomdowesendbillsto?Patient/Addresslistedaboveother:Ifyouselectedother,pleaseputthenameandaddressbelow.FirstName:________________LastName:_______________Address:____________________________________________________________City:___________________________State:_____________Zip:______________

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Howdidyouhearaboutourclinic?□ FamilyMember □ Friend □ Physician□ Employer □ YellowPages □ Internet□ SignonBuilding □ Radio □ HealthClass□ Website □ Brochure □ Other

Whocanwethankforyourreferral?

______________________________________________________________________________

Ifyouselected“other”pleasedescribe

______________________________________________________________________________

MedicalConditions

□ Arthritis □ HeartDisease □ Stroke □ SkinDisorder□ Hypertension □ PsychiatricIllness □ Cancer □ Diabetes□ Other:______________Surgeries:

□ Appendectomy □ Hysterectomy □ Cardiovascular □ Radicalprostatectomy□ JointReplacement □ Laminectomies □ Cervicaldisc □ Transurethralprostate□ Other:___________ Allergies:

□ Eggs □ Fish&Shellfish □ MilkorLactose □ Peanut□ Soy □ Sulfites □ Wheat/Gluten □ Other:__________SocialHistory:

CaffeineUse: □ Occasionally □ Often TobaccoUse: □ Occasionally □ OftenAlcoholUse: □ Occasionally □ Often Exercise: □ Occasionally □ Often

Stress: □ Occasionally □ Often Smoke: □ 1packorless □ 1pack+Wearseatbelt: □ Always □ Never □ Usually FamilyHistory:(P)=Parent(S)=Sibling

□ Arthritis(P) □ Arthritis(S) □ Cancer(P) □ Cancer(S)□ Cholesterol(P) □ Cholesterol(S) □ Diabetes(P) □ Diabetes(S)□ Heart(P) □ Heart(S) □ H.BloodPressure(P) □ H.BloodPressure(S)□ Psychiatric(P) □ Psychiatric(S) □ Stoke(P) □ Stroke(S)□ Thyroid(P) □ Thyroid(S)OccupationalActivities:

□ Administration □ BusinessOwner □ Clerical/Secretarial □ ComputerUser□ Construction □ Daycare/childcare □ Executive/legal □ FoodService□ Healthcare □ Heavyeqpt.operator □ HeavyLabor □ Homeservices□ Household □ LightLabor □ Manufacturing □ MediumLabor

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Byusingthekeybelow,indicateonthebodydiagramwhereyouareexperiencingthefollowingsymptoms:

#=Numbness X=Burning /=Stabbing 0=Pins&Needles +DullAche

Describeyoursymptoms:______________________________________________________________________________

______________________________________________________________________________

Whendidyoursymptomsstart?Month________________Day__________Year___________

Howdidyoursymptomsbegin?______________________________________________________________________________

______________________________________________________________________________Howoftendoyouexperienceyoursymptoms?□ Constantly □ Frequently □ Occasionally □ Intermittently(76-100%oftheday) (51-75%oftheday) (26-50%oftheday) (0-25%oftheday)Whatdescribesthenatureofyoursymptoms?□ Sharp □ DullAche □ Numb □ Shooting□ Burning □ Tingling □ Stabbing Howareyoursymptomschanging?□ Gettingbetter □ Notchanging □ Gettingworse Duringthepast4weeks,indicatetheaverageintensityofyoursymptoms:(0=noneto10=Unbearable)□ 0None □ 1 □ 2 □ 3□ 4 □ 5 □ 6 □ 7□ 8 □ 9 □ 10Unbearable Duringthepast4weeks,howmuchpainhasinterferedwithyournormalwork(includingbothworkoutsidethehomeandhousework):□ Notatall □ Alittlebit □ Moderately □ Quiteabit□ Extremely

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Duringthepast4weeks,howmuchofthetimehasyourconditioninterferedwithyoursocialactivities?□ Allofthetime □ Mostofthetime □ Someofthetime □ Alittleofthetime□ Noneofthetime Ingeneral,wouldyousayyouroverallhealthrightnowis…?□ Excellent □ Verygood □ Good □ Fair □ PoorWhohaveyouseenforyoursymptoms?□ NoOne □ OtherChiro. □ MedicalDoctor □ PhysicalTherapist □ OtherWhendidyoureceivethistreatment?□ Inthelastmonth □ 2-3monthsago □ 3-6monthsago □ 6-12monthsago□ 1-2yearsago □ 2-5yearsago □ 5-10yearsago Whattestshaveyouhadforyoursymptoms□ X-Rays □ MRI □ CTScan □ OtherWhenwerethesetestsdone?□ Inthelastmonth □ 2-3monthsago □ 3-6monthsago □ 6-12monthsago□ 1-2yearsago □ 2-5yearsago □ 5-10yearsago Haveyouhadsimilarsymptomsinthepast?□ Yes □ No Ifyouhaveseentreatmentinthepastforthesameorsimilarsymptoms,whodidyousee?□ Thisoffice □ OtherChiro. □ MedicalDoctor □ PhysicalTherapist □ OtherWhatisyouroccupation?□ Professional/Executive □ FTStudent □ Tradesperson □ Laborer□ WhiteCollar/Secretarial □ Homemaker □ Retired □ OtherIfyouarenotretired,ahomemaker,orastudent,whatisyourworkstatus?□ Full-Time □ Part-Time □ Self-Employed □ Unemployed□ OffWork □ Other

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ReviewofSystems:Haveyouhadtroublewithanyofthefollowing?

Cardiovascular: No_______ Respiratory: No_______ Allergic/Immunologic: No_______Present Past No Present Past No Present Past No

PoorCirculation Asthma HivesHighBloodPressure Tuberculosis ImmuneDisorder

AorticAneurism ShortnessofBreath HIV/AIDSHeartDisease Emphysema AlergyShortsHeartAttack Cold/Flu CortisoneUseChestPain Cough/Wheezing

HighCholesterol Gastrointestinal: No_______PaceMaker Ears/Nose/Throat: No_______ Present Past No

JawPain Present Past No GallbladderProblemsIrregularHeartBeat Asthma BowelProblemsSwellingoftheLegs Tuberculosis Constipation

ShortnessofBreath LiverProblemsEmphysema Ulcers

Present Past No Cold/Flu DiarrheaHepatitis Cough/Wheezing Nausea/Vomiting

BloodClots BloodyStoolsCancer Eyes: No_______ PoorAppetite

EasyBruising Present Past NoEasyBleeding Glaucoma Musculoskeletal: No_______

Fevers/Chills/Sweats DoubleVision Present Past NoBlurredVision Gout

Neurologic: No_______ ArthritisPresent Past No Integumentary: No_______ JointStiffness

Stroke Present Past No MuscleWeaknessSeizures SkinUlcers Osteoporosis

HeadInjury SkinDisease BrokenBonesBrainAneurysm Eczema JointReplaced

Numbness PsoriasisSevereHeadaches Rashes Endocrine: No_______

PinchesNerves Present Past NoParkinson'sDisease Psychiatric: No_______ ThyroidDisease

CarpalTunnel Present Past No DiabetesSpinning/Balance Depression HairLoss

AnxietyDisorder MenopausalConstitutional: No_______ UnusualStress MenstrualProblems

Present Past NoWeightloss/gain

EnergyLevelProblemDifficultySleeping

Hematologic/lymphatic: No_______

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FinancialandOfficePolicyInsurance:

• Patientisresponsibleforunderstandingtheirinsurancebenefits.• ActiveWellnessChiropracticandRehabilitation(AWCR)isnotresponsibleforprovidingbenefit

informationandthatanyinformationgiventoPatientisnotaguaranteeofbenefits.• AWCRwillsubmitallclaimstoPrimaryandSecondaryCarriers(ifapplicable).• PatientauthorizesAWCRtosubmitinsuranceclaimsontheirbehalf,andtoacceptpaymentofmedical

benefitsforservicesrendered.• PatientauthorizesAWCRtoinitiateacomplainttotheirinsurancecompany,and/orInsurance

Commissionerontheirbehalf.• PatientauthorizesthereleaseofmedicalinformationtotheirInsuranceCompany,Adjuster,orAttorney

involvedintheprocessingoftheirclaims.• IntheeventthatPatient’sInsuranceCompanyremitspaymenttoAWCRwithacheckmadeoutin

Patient’sname,PatientauthorizesAWCRtodepositthatpaymentandcreditPatient’saccountaccordingly.FinancialAgreementandPatientBalances:

• Patientisultimatelyresponsiblefortheiraccountbalanceregardlessofinsurancecoverage.____Initial• AWCRmayaskforacopyofamajorcreditcardtokeeponfileinasecureserver.Patientauthorizes

AWCRtochargetheircreditcardonfilewithanyunpaidbalancesthataregreaterthan30daysoldthatexistaftertheInsuranceCompanysendspaymentforthatclaim.

• PatientwillprovidenewcontactandcreditcardinformationtoAWCRfrontdeskwhenevertheinformationchanges.

• AWCRwillsendmonthlystatementstoPatientswithcurrentbalances.• Patientisresponsibleforpaymentofmedicalservicesrendered.• Patientisresponsibleforanyco-payment,co-insurance,deductibleand/ornon-coveredservices.• Therewillbea$35serviceschargeforreturnedorbouncedchecks.• Ifyouraccountisturnedovertoanoutsidecollectionagency,yourbalancewillbeincreasedby33%to

coverthecostofthecollectionagency’sfee.MissedorLateAppointments:

• Appointmenttimesarereservedforyouandwemakeeveryefforttokeeptoourscheduledappointmenttimes.Ifyouaremorethan5minuteslateforanappointment,wemayaskforyoutorescheduleinordertogetthefullattentionfromourtreatmentstaff.

• Patientunderstandsthattherewillbea$65chargeforamissedorcancelledappointmentunless24hournoticehadbeengiventoAWCR.Thisfeeisnotcoveredbyinsuranceandisduebeforeyournextvisit.IunderstandandacceptthetermsoftheFinancialandOfficePolicylistedabove.PrintPatientName:____________________PrintParentorGuardianName:_____________________ElectronicSignatureofPatientorParent/Guardian:____________________________Date:________

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InformedConsentforChiropracticCare

Iherebyrequestandconsenttotheperformanceofchiropracticadjustments,physicalexaminations,andotherchiropracticprocedures,includingvariousmodesofphysiotherapyanddiagnosticX-rays,onme(oronthepatientnamedbelow,forwhomIamlegallyresponsible).Iunderstandandaminformedthat,asinthepracticalmedicine,inthepracticeofchiropractictherearesomeriskstotreatmentincluding,butnotlimitedto,fractures,discinjuries,strokes,dislocationsandsprains.Idonotexpectthedoctortobeabletoanticipateandexplainallrisksandcomplications.Iwishtorelyonthedoctortoexercisejudgmentduringthecourseoftheprocedurewhichthedoctorfeelsatthetime,baseduponthefactsthenknown,andisinmybestinterest.Ihavereadorhavehadreadtome,theaboveconsent.Ihavealsohadtheopportunitytoaskquestionsaboutitscontent,andbysigningbelowIagreetotheabovenamedprocedures.IintendthisconsentformtocovertheentirecourseoftreatmentformypresentconditionandforanyfutureconditionforwhichIseektreatment.

PatientName__________________ElectronicSignatureofPatient_______________________DateSigned________________________

ElectronicSignatureofRepresentative_____________________________Date_________RelationshiporAuthorityofPatient’sRepresentative___________________________________________________

TOBECOMPLETEDBYPATIENT

TOBECOMPLETEDBYPATIENT’SREPRESENTATIVEIFPATIENTISAMINOR

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ConsentforPurposesofTreatment,Payment&HealthcareOperations(3/03)Inthisdocument,“I”and“my”refertothepatientand“Chiropractor”referstoActiveWellnessChiropractic&Rehabilitation.Iconsenttotheuseofdisclosureofmyprotectedhealthinformationbychiropractorforthepurposesofanalyzing,diagnosingorprovidingtreatmenttome,obtainingpaymentformyhealthcarebillsortoconducthealthcareoperationsofChiropractor.Iunderstandtheanalysis,diagnosisortreatmentofmebyChiropractormaybeconditioneduponmyconsentasevidencedbymysignaturebelow.IunderstandIhavetherighttorequestarestrictionastohowmyprotectedhealthinformationisusedordisclosedtocarryouttreatment,paymentorhealthcareoperationsofthepractice.ChiropractorisnotrequiredtoagreetotherestrictionsthatImayrequest.However,ifChiropractoragreestoarestrictionthatIrequest,therestrictionisbindingonChiropractor.Ihavetorighttorevokethisconsent,inwriting,atanytime,excepttotheextentthatChiropractorhastakenactioninrelianceonthisconsent.My“protectedhealthinformation”meanshealthinformation,includingdemographicinformation,collectedfrommeandcreatedorreceivedbymyphysician,anotherhealthcareprovider,ahealthplan,myemployerorahealthcareclearinghouse.Thisprotectedhealthinformationrelatestomypast,presentorfuturephysicalormentalhealthorconditionandidentifiesme,orthereisareasonablebasistobelievetheinformationmayidentifyme.IhavebeenprovidedwithacopyoftheNoticeofPrivacyPracticesofChiropractorandunderstandthatIhavearightthatNotice’sNoticeofPrivacyPracticespriortosigningthisdocument.TheNoticeofPrivacyPracticesdescribesthetypesofusesanddisclosuresofmyprotectedhealthinformationthatwilloccurinmytreatment,paymentofmybillsorintheperformanceofhealthcareoperationsofChiropractor.TheNoticeofPrivacyPracticesforChiropractorisalsopostedinthewaitingroomat8711WindsorPkwy,Suite7,Johnston,IA50131.ThisNoticeofPrivacyPracticesalsodescribesmyrightsanddutiesoftheChiropractorwithrespecttomyprotectedhealthinformation.ChiropractorreservestherighttochangetheprivacypracticesthataredescribedintheNoticeofPrivacyPractices.ImayobtainarevisedNoticeofPrivacyPracticesbycallingtheofficeofChiropractorandrequestingarevisedcopybesentinthemailoraskingforoneatthetimeofmynextappointment.________________________________________________________________________ElectronicSignatureofPatient PrintedNameofPatient______________________________________________________________________DateofSigning DescriptionofPersonalRepresentative’sAuthority

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Informed Consent for Text Message or Email

Client Information:

Name: __________________________________ Email Address: ____________________________

Phone Number: ________________________

*Note: In order for us to correspond via txt or email, it is necessary to sign the Email Consent Form

A. Risk of using text messages. Active Wellness occasionally offer clients the opportunity to communicate via text messages. Transmitting client information by text messaging has a number of risks to be considered before making a final decision regarding its use. These include but are not limited to:

• Text messages can be circulated, forwarded or stored in electronic files • Text messages can be immediately broadcast worldwide and received by many intended and

unintended recipients. • Senders can easily misaddress a text message. • Text messaging is easier to falsify than handwritten or signed documents. • Backup copies may exist even after sender and/or recipient has deleted their copies • Text messages can be intercepted, altered, forwarded or used without detection or authorization • Text messages can be lost in transmission

B. Conditions for the use of text messaging. We will use reasonable means to protect the security and confidentiality of text messaging information sent and received; however, because of the risks outlined above, we cannot guarantee the security and confidentiality of text messaging communication and will not be liable for improper disclosure that is not caused by our intentional misconduct. Therefore, clients will need to specifically grant permission for the use of text messaging. Consent to the use of text messages includes agreement with the following conditions:

C. Instruction for communicating via text messaging • Inform us in writing of changes in text messaging address/phone number • Put the clients name and purpose of text message in the subject line • Send a reply message or delivery receipt to us to acknowledge clients’ receipt of any text messaging. • Withdraw consent to utilize text messaging only by written communication.

Patient acknowledgement and agreement: I acknowledge that I have read and fully understand this consent form. I understand the risks as outlined above and consent to the conditions outlined above. In addition I would like to receive Text Messages and Emails Please exclude me from text message appt. reminders and email information regarding my appt. Electronic Patient Signature: ____________________________________________Date: _________________

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Over18HIPAAReleaseandConsentForm

Iunderstandandacknowledgethatasofmy18thbirthday,myparentsand/orguardianswillnolongerbepermittedaccesstomymedicalrecords,information,providers,orappointmentstatuswithoutmyspecificwrittenpermission.ActiveWellnesswillnotspeakwithanyonewithoutmywrittenconsentinaccordancewiththisdocument.

____IDONOTgrantanyaccesstomymedicalinformation,records,orappointmentinformation.

_____IWISHTOgrantaccesstomyhealthcareprovidersand/ormedicalinformationtothefollowing.

__________________________/___________(PrintName;Indicatehis/herrelationshiptoyou)

__________________________/___________(PrintName;Indicatehis/herrelationshiptoyou)

Igivetheabove-namedindividual(s)permissiontocontactandspeakwithanyphysicianormemberofthestaffregardingmycare.IunderstandthatIcanwithdrawconsentatanytimebyprovidingActiveWellnessawrittennoticeindicatingthechange.

________________________________________________________________PatientPrintedNameDATE________________________________ElectronicPatientSignature