We thank you for choosing our facility for your wellness needs. It is very important to us to deliver the best possible care to you and to all our clients. In trying to do so, we ask that you follow the plan of care given to you which includes your home exercise program and your scheduled appointments. We strongly value timeliness in our office and we try to minimize waiting periods. We realize that your time is just as valuable as ours. Therefore we would like for you to respect our 24 hour cancellation policy so we can schedule appointments most efficiently. We value your business and the business you provide us with your referrals. If you are satisfied with our services, we encourage you to refer a friend or a loved one or write us your testimonial. Also, if you have any suggestions on how to improve our services please let us know. Our mission is to provide the best care possible through chiropractic, physical therapy, massage and supplement (vitamin)/nutritional therapy. We also make foot orthotics in this practice to help correct foot misalignments and restore normal pain free foot function. It is a comprehensive type practice and we encourage you to explore all we have to offer. It is mandatory that you have your paperwork (attached to this document) filled out ahead of the appointment and provide us with current bloodwork reports. If your bloodwork is greater than 6 months, we will send you to have it done after your first visit. Every section of the forms serves a purpose in trying to determine the best course of action. FILL THEM OUT COMPLETELY, PLEASE. Again, on the first visit you should have with you: 1. All the attached paperwork completed. 2. All relevant bloodwork results. We look forward to serving you. Best wishes of Health, Your Healthcare Team at Active Lifestyles. Active Lifestyles Wellness and Performance Center, LLC. 1715 37 th Place, Third Floor, Vero Beach Florida, 32960. www.activevero.com, [email protected]Ph. No. 772-978-7379, Fax No: 772-539-8515
Transcript
We thank you for choosing our facility for your wellness needs. It is very important to us to deliver
the best possible care to you and to all our clients. In trying to do so, we ask that you follow the
plan of care given to you which includes your home exercise program and your scheduled
appointments.
We strongly value timeliness in our office and we try to minimize waiting periods. We realize that
your time is just as valuable as ours. Therefore we would like for you to respect our 24 hour
cancellation policy so we can schedule appointments most efficiently.
We value your business and the business you provide us with your referrals. If you are satisfied
with our services, we encourage you to refer a friend or a loved one or write us your testimonial.
Also, if you have any suggestions on how to improve our services please let us know.
Our mission is to provide the best care possible through chiropractic, physical therapy, massage
and supplement (vitamin)/nutritional therapy. We also make foot orthotics in this practice to help
correct foot misalignments and restore normal pain free foot function. It is a comprehensive type
practice and we encourage you to explore all we have to offer.
It is mandatory that you have your paperwork (attached to this document) filled out ahead of
the appointment and provide us with current bloodwork reports. If your bloodwork is greater
than 6 months, we will send you to have it done after your first visit. Every section of the forms
serves a purpose in trying to determine the best course of action. FILL THEM OUT
COMPLETELY, PLEASE.
Again, on the first visit you should have with you:
1. All the attached paperwork completed.
2. All relevant bloodwork results.
We look forward to serving you.
Best wishes of Health,
Your Healthcare Team at Active Lifestyles.
Active Lifestyles Wellness and Performance Center, LLC. 1715 37th Place, Third Floor, Vero Beach Florida, 32960.
How did you hear about our office? ___________________________________________________________________
Who may we thank for referring you to this office? _______________________________________________________
Current Health Condition Current health state: _______________________________________________________________________________ Past Surgical History: _____________________________________________________________________________
___________________________________________________________________________________ Allergies: ________________________________________________________________________________________ Work History/Exposure: ____________________________________________________________________________ Sleep (hrs/quality):________________________________________________________________________________ Food Preference (vegetarian, vegan, no preference):___________________________________________________
Past Family History
Please indicate any health issues that are present in your family and that you suffer from too:
If you will be providing us with a written or typed list, do not complete the table below.
Medication Name Dosage Frequency When did you start taking
Supplement Name Dosage Frequency When did you start taking
Below is a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be
answered carefully as these problems can affect your overall course of care.
Check any of the following you have had in the past six months: Nervous System _____________
Nervous
Numbness
Paralysis
Dizziness
Forgetfulness
Depression
Fainting
Convulsions
Cold / Tingling Extremities
Stress
Musculo-Skeletal
Low Back Pain
Gas/Bloating After Meals
Pain between Shoulders
Heartburn
Neck Pain
Black/Bloody Stool
Arm Pain
Colitis
Joint Pain/Stiffness
Walking Problems
Difficult Chewing/Clicking Jaw
General Stiffness
C-V-R
Chest Pain
Short Breath
Blood Pressure Problems
Irregular Heartbeat
Heart Problems
Lung Problems/Congestion
Varicose Veins
Ankle Swelling
Stroke EENT _____________
Vision Problems
Dental Problems
Sore Throats
Ear Aches
Hearing Difficulties
Stuffed Nose
Genito-Urinary
Bladder Trouble
Painful/Excessive Urination
Discolored Urine
Gastro-Intestinal
Poor / Excessive Appetite
Excessive Thirst
Frequent Nausea
Vomiting
Diarrhea
Constipation
Hemorrhoids
Liver Problems
Gall Bladder Problems
Abdominal Cramps
Check any of the following
diseases you have had:
Pneumonia
Mumps
Influenza
Rheumatic Fever
Small Pox
Pleurisy
Polio
Chicken Pox
Arthritis
Tuberculosis
Diabetes
Epilepsy
Whooping Cough
Cancer
Mental Disorder
Anemia
Heart Disease
Lumbago
Measles
Thyroid
Eczema
General
Fatigue Allergies
Loss of Sleep
Fever
Headaches
Significant Weight Loss
Females Only
When was your last period?
____________________________ Are you pregnant?
Yes No Not Sure
Male / Female
Menstrual Irregularity
Menstrual Cramping
Vaginal Pain / Infections
Breast Pain / Lumps
Prostate / Sexual Dysfunction
Lifestyle Stress Levels
High
Moderate
Very Little
Intake
Coffee (cups per day :___)
Tea (cups per day: ___)
Alcohol: ___glasses/week
Cigarettes: __/wk., for __/years
White Sugar
Street Drugs: ____________
Satisfaction with Diet
Satisfied
Somewhat satisfied
Dissatisfied
Do you exercise?
Yes. How many times per wk?
Walk:___ Run:___Swim:___Gym:___
Golf:___ Tennis:___Other:_________
No
Please outline on the diagram the area of
your discomfort and any radiation of pain.
Revised Thursday, September 13, 2018
COMPENSATION FOR SERVICES In consideration of services rendered by the physicians and therapists at Active Lifestyles W & P ctr, which may include, but not be limited to, chiropractic care, acupuncture, physical therapy, massage therapy, strength training protocols/programs, or nutritional therapy I recognize that I am responsible for the fees associated with my care. I understand that my insurance coverage may not cover all my charges and therefore I will be required to cover any gap created. A health insurance policy is an agreement between a policyholder and an insurance company and any disagreement regarding coverage must be determined between the parties. Active Lifestyles W& P ctr is therefore not responsible for settling policy disputes. Our office will be responsible for preparing notes, billing receipts and informal reports as needed to aid in insurance payment/reimbursement.
BENEFITS, RISKS, ALTERNATIVES There are many approaches to health care. You are here today seeking our expertise in the way we approach health issues and you can be assured that your case will be managed to the best of our ability. The benefits of chiropractic care, acupuncture, physical therapy, massage therapy, strength training, and nutritional therapy are well documented in research. Although there can be great benefits inherent in any of the above modalities, the patient must also be informed that there may be risks involved as well. Those risks, although in our opinion minimal, may manifest themselves in post therapy soreness/stiffness/tenderness, sprains/strains, dislocations, fractures, disc injuries, strokes, allergic reactions. Your alternatives may include; no care, allopathic care, naturopathy, acupuncture, etc. It is impossible for the doctor/ therapist to foresee every complication or risk that may be possible. You are encouraged to ask your doctor any questions you may have regarding any therapy proposed. Although the human organism has a biological framework similar from one to the next, each individual is unique. Results may therefore vary. No guarantee of improvement or success can be made. For pregnant females: In the event radiographs are recommended you are advised to inform the doctor and/or radiologist of the date you began your last period and/or pregnancy.
Office Policies We try our best to get you well, but like any good relationship, cooperation and communication is a must. We therefore ask you: 1. Respect the appointment time given to you. For cancellations, we expect a call 24 hours ahead of your scheduled appointment for Tuesday through Friday appointments and Friday before 4 pm for Monday appointments. I understand there is a missed appointment fee of $40 if this is not respected. 2. Follow the recommendations given to you with respect to exercise, nutritional recommendations and activity levels. 3. Communicate all concerns and problems you may encounter with treatment with your therapist/ chiropractor at the next visit. Witnessed by my signature below, I hereby certify that I am above the age of 18 and or emancipated, and have read the above in its entirety, recognize/agree to its content and hereby CONSENT FOR TREATMENT today and all future visits. My Printed Name _______________________________My Signature_____________________________ Witnessed By __________________________________ Date _________________
Regular Fee Schedule (FOR THE MOST COMMON PROCEDURES ONLY)
Code CPT Description Fee Physical Therapy
PT Eval 3 97163 Evaluation level 3 $125
PT Eval 2 97162 Evaluation Level 2 $80
PT Eval 1 97161 Evaluation Level 1 $75
PT ReEval 97164 Re-evaluation $80
M-Ther 97140 Manual Therapy 1+ regions $47.04 (per 15 min.)
Chiropractic
OV5 99205 Office visit level 5 $436.82
OV3 99203 Office visit level 3 $228.60
OV1 99201 Office visit level 1 $91.16
SM 98940 Spinal manipulation 1-2 regions $56.98
SM3 98941 Spinal manipulation, 3-4 regions $84.44
SM5 98942 Spinal Manipulation, 5 regions $108.58
MX1 98943 Manipulation Extraspinal, i.e. Extremities $57.82
Therapies used in Chiropractic and Physical therapy (per 15 minutes)
Gait 97116 Gait Training Therapy $44.52
THER-EX 97110 Therapeutic Exercise $49.98
NEURO 97112 Neuromuscular re-education $51.46
THER-ADL 97530 Therapeutic Activities of daily living $52.00
Modalities used in Chiropractic and Physical therapy (per area)
GROUP 7AlnsomniaNervousnessCan't gain weightlntolerance to heatHighly emotionalFlush easi lyNight sweatsThin, moist skinlnward tremblingHeart palpitatesIncreased appetite without weight gainPulse fast at restEyelids and face twitchInitable and restlessCan't work under pressure
GROUP 78Increase in weightDecrease in appetiteFatigue easi lyRinging in earsSleepy during daySensitive to coldDry or scaly skinConstipationMental sluggishnessHair coarse, fal ls outHeadaches upon arising, wear off during daySlow pulse, below 65Frequency of urinationlmpaired hearingReduced initiative
GROUP 7CFail ing memoryLow blood pressureIncreased sex driveHeadaches, "spl i t t ing or rending" typeDecreased sugar tolerance
GROUP 7DAbnormal thirstBloating of abdomenWeight gain around hips or waistSex drive reduced or lackingTendency to ulcers, colitisIncreased sugar toleranceWomen: menstrual disordersYoung gir ls: lack of menstrual function
GROUP 7EDizzinessHeadachesHot flasheslncreased blood pressureHair growth on face or body (female)Sugar in urine (not diabetes)Masculine tendencies (female)
GROUP 7FWeakness, dizzinessChronic fat igueLow blood pressureNails weak, r idgedTendency to hivesArthritic tendenciesPerspiration increaseBowel disordersPoor circulationSwollen anklesCrave saltBrown spots or bronzing of skinAllergies - tendency to asthma
Weakness after colds, influenzaExhaustion - muscular and nervousRespiratory disorders
GROUP 8ApprehensionInitabi l i tyMorbid fearsNever seems to get wellForgetfulnessIndigestionPoor appetiteCraving for sweetsMuscular sorenessDepression; feelings of dreadNoise sensit ivi tyAcoustic hal lucinationsTendency to cry without reasonHair is coarse and/or thinningWeaknessFatigueSkin sensitive to touchTendency toward hivesNervousnessHeadachelnsomniaAnxietyAnorexiaInability to concentrate; confusionFrequent stuffy nose; sinus infectionsAllergy to some foodsLoose joints
FEMALE ONLYVery easily fatiguedPremenstrual tensionPainful mensesDepressed feelings before menstruationMenstruation excessive and prolongedPainful breastsMenstruate too frequentlyVaginal dischargeHysterectomy / ovaries removedMenopausal hot f lashesMenses scanty or missedAcne, worse at mensesDepression of long standing
MALE ONLYProstate trouble &
Urination dif f icult or dribbl ingNight urination frequentDepressionPain on inside of legs or heelsFeeling of incomplete bowel evacuationLack of energyMigrating aches and painsTire too easilyAvoids activityLeg nervousness at nightDiminished sex drive
1 .
2 .
2
4 .
5 .
List the five main complaints you have in the order of their importance:
SYMPTOM SURVEY FORM a / 'l. Lz/1{iuvrou srtvt,
u-42ue*{t"txCIient
Birth DateCl inic ian Date
Sex: Male fl Femate flVegetarian: Yes f] No D
Ragland's Test is Positive fl
Pulse: RecumbentBlood pressure: Recumbent
Approx Weight
Standing
I Standing
INSTRUCTIONS: Fi l l in only the circles which appty to you.O O O MILD symptoms (occurred once or twice last 6 months).O O O MODERATE symptoms (occuned once or twice last month).O O O SEVERE symptoms (chronic, occurred once or twice last week)O O O Leave circles BLANK if they don't apply to you!
1 2 3 G R O U P 11 O O O A c i d f o o d s u p s e t2 O O O G e t c h i l l e d o f t e n3 O O O " L u m p " i n t h r o a t4 O O O Drymouth-eyes-nose5 O O O Pulse speeds after meal6 O O O Keyed up - fail to calm7 O O O C u t h e a l s s l o w l v8 O O O G a g e a s i l y9 O O O Unable to relax; startles easily
10 O OO Extremit iescold, clammy11 O O O Strong l ightirr i tates12 OA O Ur ineamount reduced13 O O O Heart pounds after retiring14 O O O "Nervous"stomach15 OOO Appet i te reduced16 OOO Coldsweatso f ten17 OO O Fevereas i l y ra ised18 O O O Neura lg ia - l i kepa ins19 O O O Staring, bl inks l i t t le20 OOO Sours tomachof ten
GROUP 221 O O O Joint st i f fness on arising22 O O O Muscle-leg-toe cramps at night23 O O O "Butterfly" stomach, cramps24 O O O Eyes or nose watery2 5 O O O E y e s b l i n k o f t e n26 O O O Eyelids swollen, puffy27 O O O Indigestion soon after meals28 O O O Always seems hungry; feels "lightheaded" often29 OOO Diges t ionrap id30 O O O Vomiting frequent31 O O O Hoarsenessfrequent32 OO O Breath ing inegu lar33 O O O Pulse slow; feels "irregular"34 O OO Gagging ref lexslow35 O O O Difficultyswallowing36 O OO Constipation, dianhea alternating37 OOO "S lowstar te r "38 O O O Get"chi l led" infrequently39 OOO Persp i reeas i l y40 O O O Circulation poor, sensitive to cold41 O O O Subject to colds, asthma, bronchitis
GROUP 342 OO O Eatwhennervous43 OO O Excessiveappeti te44 OO O Hungrybetweenmeals45 O O O lrritable before meals46 O O O Get "shaky" if hungry47 OO O Fat igue,ea t ingre l ieves48 O O O "Lightheaded" if meals detayed49 O O O Heart palpitates if meals missed or delayed50 O O O Afternoon headaches51 O O O Overeating sweets upsets
1 2 3O O O Awaken after few hours sleep - hard to get back to sleepO O O Crave candy or coffee in afternoonsO O O Moods of depression - "blues" or melancholyO O O Abnormal craving for sweets or snacks
GROUP 4Hands and feet go to sleep easi ly, numbnessSigh frequently, "air hunger"Aware of "breathing heavily"High altitude discomfortOpens windows in closed roomsSusceptible to colds and feversAfternoon "yawner"Get "drowsy" oftenSwollen ankles, worse at nightMuscle cramps, worse during exercise; get "charley horses"Shortness of breath on exertionDuli pain in chest or radiating into left arm, worse on exertionBruise easi ly, "black and blue" spotsTendency to anemia"Nose bleeds" frequentNoises in head, or "r inging in ears"Tension under the breastbone, or feel ing of "t ightness",worse on exertion
GROUP 5DizzinessDry skinBurning feetBlurred visionItching skin and feetExcessive falling hairFrequent skin rashesBitter, metal l ic taste in mouth in morningsBowel movements painful or difficultWorrier, feels insecureFeeling queasy; headache over eyesGreasy foods upsetStools light colored &Skin peels on foot solesPain between shoulder bladesUse laxativesStools alternate from soft to wateryHistory of gallbladder attacks or gallstonesSneezing attacksDreaming, nightmare type bad dreamsBad breath (halitosis)Milk products cause distressSensitive to hot weatherBurning or i tching anusCrave sweets
GROUP 6Loss of taste for meatLower bowel gas several hours after eatingBurning stomach sensations, eating relievesCoated tonguePass large amounts of foul-smell ing gaslndigestion 112 - t hour after eating; may be up to 3-4 hrs.Mucous colitis or "irritable bowel"Gas shortly after eatingStomach "bloating" affer eating
Informed Consent for Nutritional Supplements According to the Federal Food, Drug,& Cosmetic Act, as amended, Section 201(g)(1), the term “DRUG” is defined to mean: “ Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.” A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy. Although, a Vitamin, a Mineral, Trace Element, Amino Acid, or Herb, may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as any primary treatment and/or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and bio-mechanical processes of the human body. Active Lifestyles does not recommend you stop taking any prescribed medicines and if you wish to diminish the dosage of your medicines for any reason, you should consult the physician who prescribed them to you. However, be aware that every nutritional program may diminish your need for your prescriptions. Keep all your physicians informed of your program including your symptoms. I have read and understand the above: _______________________ ________________________ Signature Date
Metabolic Syndrome A Major Cause of Ill Health in America
Metabolic Syndrome, also known as Syndrome X, may be an unfamiliar
term, but it is the most pervasive health problem in the U.S. with
approximately 60 million Americans affected. The numbers grow larger
each year and many children are now developing symptoms as well.
What is it? According to the American Medical Association, anyone with
three of the following has Metabolic Syndrome:
– Waist measurement of 40 inches or greater in men and 35 inches or
greater in women.
– Serum triglycerides level greater than 150mg/dl.
– HDL cholesterol less than 40 mg/dl. in men and
Less than 50mg/dl in women.
– Blood pressure of 135/85 mm Hg. or greater.
– Fasting serum glucose of 100mg/dl or higher.
The central issue in Metabolic Syndrome is control of blood sugar; not just
the glucose value on your blood test, but how much insulin is needed to keep
the level within normal limits. Also important is how much glucose is in
your system over time; the hemoglobin A1c test evaluates the average
glucose level over a period of two months.
What causes Metabolic Syndrome? The primary cause is poor diet,
especially excessive consumption of refined carbohydrates that rapidly
convert to blood sugar. Contributing factors include stress, lack of exercise,
and vitamin and mineral deficiencies. Over time, the body loses its ability to
normally metabolize carbohydrates, thus more and more insulin is required
to do the same work. This phenomenon is called insulin resistance.
What can this syndrome do to your health? Weight gain is the most
noticeable effect, but hypertension, atherosclerosis, fatty liver disease,
systemic inflammation, kidney damage, increased coagulability of the blood
and diabetes also have significant ties to Metabolic Syndrome.
There are some additional connections to hormones. Too much insulin in
men can lead to a decrease in testosterone. Elevated triglycerides can block
leptins from telling the brain that enough food has been consumed and
without this communication, overeating can occur. Cortisol - the stress
hormone - may cause glucose to be elevated, even when no food has been
eaten recently, but at the expense of lean muscle mass.
Blood tests related to Metabolic Syndrome. There are a number of tests
that have relevance in this insidious health challenge. These include several
tests that are typically part of comprehensive panels; glucose, cholesterol,
triglycerides, the liver enzyme SGPT, uric acid, and phosphorus. Along
with assessing levels of insulin (a review of the reference range should be
considered in light of recent research) and hemoglobin A1c, your doctor can
gain insight into your ability to metabolize sugar and carbohydrates, and
some of the related health issues that may be affecting you.
With cardiovascular disease being one of the primary concerns in Metabolic
Syndrome, several tests have significant value including C-reactive protein
and fibrinogen. The newly available Plac® test is related to the formation of
rupture prone plaque in the arteries. The NMR Lipoprofile®, which
provides the size and number of cholesterol particles, enables the doctor to
differentiate risk to a much higher degree than with the traditional
cholesterol test. Your doctor can help make informed choices regarding
which tests are appropriate for you.
What will help reverse Metabolic Syndrome? Fortunately there are a
number of supplements, along with a dietary and safe exercise program, that
will enable the body to use insulin more effectively and aid in limiting harm.
Why Do More Testing Than Insurance Allows?
The primary function of lab testing for insurance purposes is to confirm a
diagnosis or follow the course of a known disease. This is of great benefit at certain
times, but when you are interested in pursuing optimal health and desire to gather
information about your personal health, insurance does not normally extend coverage.
If you have insurance, your primary care physician may order testing that is
medically necessary. The quandary with this standard is that the doctor has significant
restrictions and limited options when ordering tests. In other words, he or she must
already have a diagnosis and use lab tests to confirm it. This doesn’t allow for testing
that may provide noteworthy insight into your personal health status.
Consider what you spend on non-essential things in life and then think about how
much your health is worth – you may find that amount is far more than an insurance
