ELC E and A or tr s ng s ith o r child children a l ing as a ent s in o r clinic. e are a ver ni e tea s eciali ing in researched, evidence- ased, s inal
ediatric ad s ng and ost ral reha ilita on that has hel ed in ants, o ng children, and even teenagers ith earl onset to advanced s inal distor on and in ries no n to ca se develo ental and li elong health ro le s. eca se o this s eciali ed a roach,
e a not acce t o r child as a a ent n l e are a sol tel certain e no the ca se o their condi on er or the necessar tests to deter ine the o al rogra o correc on, and e are co letel con dent o and o r child lace their health as a
P P . At that e e ill a e s eci c reco enda ons. han o again or giving o r child the o ort nit to a l as a a ent.
Please use the following nota!ons on the figures below to indicate the type and loca!on of your child’s symptoms, as it relates to the purpose of your visit today.
If you marked “O” for Other on any part, please explain below:
Health Conditions o r s ine is the o nda on o health and core strength in o r od . hi s in the verte rae or sec ons o the s ine ill s read l atel ca sing ea ness and distor on to ALL the areas o the s ine. hese distor ons are re ected in a nor al ost re. esearch
sho s a nor al ost re leads to chronic ain, disease and ossi l a shortened li e s an.1 Please ans er the ollo ing es ons acc ratel so e a deter ine the ll e tent o o r child s condi on.
HISTORY OF TRAUMA he elo -listed tra as a lead to isalign ent o the individ al verte rae, so ss e in r to the s or ve str ct res o the
s ine, as ell as shi s and distor ons in hole c rves and sec ons o the s ine. Please chec an o the ollo ing i o r child has e erienced s ch if you check an item with an asterisk, please offer a detailed explanation
ell ro a height o t o 2 eet or ore as an in ant E erienced a all that le a r ise or l on their head or other res l ng tra a o gh sha ing as an in ant ere involved in a car accident if you check this item, please ask the front desk person for the corresponding form E erience ro en ones or de ilita ng in ries i c lt irth see elo
E lana on o ite s
Birth ExPEriEncE:
o long as la or
escri e an co lica ons
e o deliver q Vaginal q C- ec on q ac E trac on q orce s Assistance
VACCINATION HISTORY hat vaccina ons has o r child received lease note at hat age and here each as received
Age q Mos. q rs. here received
Age q Mos. q rs. here received
Age q Mos. q rs. here received
Age q Mos. q rs. here received
Age q Mos. q rs. here received
P
elling, redness, heat hardness o site od rash or hives igh ever over 10 degrees
igh- itched screa ing E tre e slee iness or nres onsiveness od t itching or aral sis
reathing ro le s asth a, etc. E cessive leeding or ane ia ead anging
E cessive diarrhea or chronic cons a on Loss o e or ogg state scle ea ness
Chronic ear or res irator n ec ons ision or hearing dist r ances oint ain
Crossing o e es ei res ther lease e lain
E lana on s
1. Postural and Degenerative Kyphosis: Freeman JT. Posture in the Aging and Aged body. JAMA 1957, Oct 19: 843-846.
CERVICAL SPINE (NECK) isalign ent o the individ al verte rae or distor on o the co lete cervical c rve nec origina ng in the nec or a co ensa on
ro ost ral distor ons in other areas o the s ine a res lt in an health condi ons. as o r child e erienced an o these s to s resentl or in the ast
P n n P P
ec Pain eadaches in si s Pain in sho lders ar s hands i iness Allergies a ever ness ngling in ar s hands is al dist r ances ec rrent colds l earing dist r ances Coldness in hands Lo Energ a g e ea ness in gri h roid condi ons Pain Clic ing Colic Ear n ec ons l to ach disorders ore throats Learning disa ili es erac vit A A to- ne iseases ther lease e lain
E lana on s
THORACIC SPINE (UPPER BACK) isalign ent o the individ al verte rae or distor on o the er thoracic c rve er ac origina ng in the er ac or a
co ensa on ro ost ral distor ons in other areas o the s ine a res lt in an health condi ons. as o r child e erienced an o these s to s resentl or in the ast
P n n P P
eart Pal ita ons eart r rs Asth a hee ing hingles hortness reath ach cardia ast heart eat er ac Pain Pain n ee ns ira on E ira on ther lease e lain ec rrent L ng n ec ons ronchi s Pne onia
E lana on s
THORACIC SPINE (MID BACK) isalign ent o the individ al verte rae or distor on o the id thoracic c rve id ac origina ng in id ac or a co ensa on
ro ost ral distor ons in other areas o the s ine a res lt in an health condi ons. as o r child e erienced an o these s to s resentl or in the ast
P n n P P
id ac Pain a sea ia etes Pain in i s Chest lcers astri s ogl ce ia ndiges on eart rn e ia etes Liver ro le s leen ro le s ther lease e lain ired rrita le a er ea ng or hen not having eaten or a hile
Health Conditions continued... LUMBAR SPINE (LOW BACK)
isalign ent o the individ al verte rae or distor on o the l ar c rve lo ac origina ng in the lo ac or a co ensa on ro ost ral distor ons in other areas o the s ine a res lt in an health condi ons. as o r child e erienced an o these
s to s resentl or in the ast
P n n P P
Pain in hi s legs eet ea ness in ries in hi s nees an les Lo ac ain ness ngling in o r legs eet ec rrent ladder in ec ons Coldness in legs eet re ent di c lt rina ng scle cra s in legs eet Cons a on iarrhea enstr al irreg lari es cra ing e ales ther lease e lain
E lana on s
OTHER Please list an health condi ons not en oned
Please list an edica ons incl de na e, dose, or hat condi on, and ho long o r child has een ta ing it
Please list an s rgeries incl de t e o s rger and date it as er or ed
Family Health History ave an o o r a il e ers ever een diagnosed ith the ollo ing i P o o
i
A Allergies a ever Ane ia A endecto Arthri s Asth a ed e ng lood s gar ro le s ro en ones ract res Cancer Cere ral Pals Chic en o shingles Circ lator ro le s Crohn s Coli s e ression ia etes Ear n ec ons Ec e a Ec e a Psoriasis E ile s sei res etal dr g e os re ood allergies all ladder eadaches eart disease eart r r e a s ernia igh lood ress re n ec o s disease n en a idne isease Liver disease L ago L ng disease easles etal i lants igraine headaches s e rological ro le s steo orosis Paral sis Ple ris Pne onia ronchi s Polio ash he a c ever coliosis ei re disorder ic le cell ane ia all Po inal i da tro e h roid ro le s onsillecto
Experience with Chiropractic as o r child seen a Chiro ractor e ore q Yes q o ho
eason or visit s
id the revio s chiro ractor ta e e ore and a er -ra s q Yes q o hat as the diagnosis
id he or she reco end a s eci c co rse o treat ent q Yes q o id the reco end a o e ealth Care rogra q Yes q No
es, hat
o long as o r child treated Last treat ent
o did o r child res ond
Are o a are o an oor ost re ha its in o r child q Yes q o s there an histor o s inal ro le s in o r a il q Yes q No
es, e lain
Pregnancy Release his is to cer that to the est o no ledge that child is not regnant and the a ove doctor and his associates have er ission to er or an -ra eval a on. have een advised that -ra can e ha ardo s to an n orn child.
ate o last enstr al c cle
ardian ignat re ate
Authorization of Care a thori e and agree to allo the doctor and or his designated sta to or ith child s s ine or the s ine o the charge re resent
thro gh the se o s inal ad st ents and reha ilita ve e ercises or the sole r ose o ost ral and str ct ral restora on o nor al io- echanical and ne rological nc on.
nderstand that a res onsi le or all ees inc rred or the services rovided, and agree to ens re ll a ent o all charges.
he octor and or his sta ill not e held res onsi le or an health condi ons or diagnoses hich are re-e is ng, given another healthcare rac oner, or are not related to the s inal str ct ral condi ons diagnosed at this clinic.
also clearl nderstand that i child charge does not ollo the doctors and or sta s s eci c reco enda ons at this clinic that he she ill not receive the ll ene t ro these rogra s and that i ter inate this care re at rel that all ees inc rred ill e d e and a a le at that e.
Pa ent s ignat re ate
Pa ent s a e Printed
a ent is not o r iological child, t a legal charge re iring g ardianshi or treat ent, lease co lete the ollo ing
ate ardianshi A arded Co nt , tate o ardianshi
here a thori e the doctor to ad inister care as dee ed necessar to charge as a ointed to the co rts.
Insurance e a acce t assign ent o ins rance ene ts. signing this olic , o agree to assign o r ins rance ene ts to this clinic. n
cases here ene ts are not assigna le or in an case here o r ene t is rocessed directl to o regardless o assign ent, o agree to s it an a ents received along ith the e lana on o ene ts to this clinic ithin 10 da s o recei t nless o have
aid or the services re resented said a ent in ll at the e o service. n no case ill an assign ent alleviate o o o r o liga on or a ent o services received.
o r ins rance lan is a contract et een o and o r ins rance co an . his clinic is not a art to that contract and there ore cannot odi the ter s o that contract. Pa ent or treat ent o receive ro this clinic is o r res onsi ilit hether o r ins rance co an a s or not. e cannot ill o r ins rance co an nless o rovide s ith the necessar illing in or a on, assign o r ene ts to this clinic and agree to er it s to release the necessar edical in or a on re ired to sec re a ent. n the event e do acce t assign ent o ene ts e re ire that o rovide a credit card ith a thori a on to ill that acco nt an
alance or a e other a ent arrange ents. e ill a e ever e ort to ens re that o r ins rance carrier ro erl rocesses o r services or a ent. n so e circ stances e a re ire o r assistance. o r ins rance co an has not aid o r
acco nt in ll ithin 0 da s and o re se to assist s in dealing ith o r carrier, the alance ill e a to a call e trans erred to o r credit card or the e tended a ent lan.
E Please e a are that so e, and erha s all, o the services rovided a e non-covered services and not considered reasona le and necessar nder o r ins rance rogra . o are ns re as to the nat re o the service o are receiving, lease as o r doctor. or coverage in or a on, it is o r res onsi ilit to revie o r ene t contract.
DECLARATION clearl nderstand that all ins rance coverage, hether accident, or related, or general coverage is an arrange ent et een
ins rance carrier and sel . this o ce chooses to ill an services to ins rance carrier that the are er or ing these services are strictl as a convenience to e. he doctor s o ce ill rovide an necessar re orts or re ired in or a on to aid in ins rance rei rse ent o services, t nderstand that ins rance carriers a den clai s and that a l atel res onsi le or an
n aid alances. An onies received ill e credited to acco nt. nderstand there co ld e so e services that ins rance co an does not cover, i this is the case are o illing to a or these
services q Yes q No
ignat re o Person A thori ing Care
ate
ela onshi to ns red ate o irth
E lo er
Primary Insurance Company Polic
Address Phone
ns red s a e ns red s ocial ec rit - -
Secondary Insurance Company Polic
Address Phone
ns red s a e ns red s ocial ec rit - -
NOTICE OF PRIVACY POLICIES – ChiroSolutions Center
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Understanding Your Health Record/Information Each time you visit the office, a record is made of your visit. Typically, this record contains any symptoms you may report, our assessment of you on that day, any change to your diagnosis, what procedures we performed, and any change in your care plan. This information serves many purposes: ! it helps us track your care and progress toward your health goals ! it serves as a means of communication to other health professionals involved in your health care ! it is a legal document describing the care you received ! it allows a third-party payer (insurance company) to verify that the services billed were actually provided ! it can be used as a source of data for research ! it helps you track your care and gives you a way to make sure we have accurate records about you Your Health Information Rights Although your health record is the physical property of the health care practitioner or facility that compiled it, the information in it belongs to you. You have the right to: ! request restrictions as to how your information is used or disclosed as provided by 45 CFR 164.522 ! obtain a paper copy of this notice upon request ! inspect and obtain a copy of your health record as provided by 45 CFR 164.524 ! make amendments to your record as provided by 45 CFR 164.528 ! obtain a record of any disclosures we’ve made as provided by 45 CFR 164.528 ! request confidential means of communicating your health information to you from our office Our Responsibilities Our office is required to: ! maintain the privacy of your health information ! provide you with a copy of this notice ! abide by the terms of this notice ! notify you if we are unable to agree to a requested restriction from you ! accommodate reasonable requests from you regarding communications from our office to you We reserve the right to change our privacy practices as necessary and to make the new provisions effective for all protected health information we maintain. Should our privacy practices change, we will supply a copy of our revised notice. We will not use or disclose your health information without your authorization, except as described in this notice. For More Information or to Report a Problem If you have questions or need additional information, please contact our health information director, Dr. Samantha Coleman at (757) 271-0001. If you believe your privacy rights have been violated, you can file a complaint with our health information director or with the Secretary of the U.S. Department of Health and Human Services. There can be no retaliation for filing any complaints.
Examples of Disclosures for Treatment, Payment and Health Operations
1. How we may use your health information for treatment:
! First, we have chosen to work in an open office environment, meaning that all patient treatment is done in an open treatment area. We have found that this environment is conducive to learning and enables us to provide the highest quality of service to our patients. Of course, all consultations, exams, x-rays and financial discussions will be handled in the privacy of a separate room.
! Our patients’ names may appear in a variety of places around the office. For example, all of our patients sign in on our daily sign in sheet. We have a Lifetime Wellness Wall that once patients graduate to maintenance care, their name will be displayed.
! We often display photos of office events like our Patient Luncheon or community events we’re involved in. ! On occasion, Dr. Coleman will use a patient’s x-rays to help another patient see what can be achieved with corrective
chiropractic care. Patient’s names do not appear on the X-Rays, however. ! Lastly, patient names may appear on our office mailings, postcards, newsletters, Facebook and website.
2. How we may use your health information for payment: A bill for services may be sent to you or to your insurance company or other third party payer. Information on or accompanying the bill may include information that identifies you as well as your diagnosis, procedures, and any supplies used. 3. How we may use your information for daily clinic operations: ! Members of the Chiropractic Solution Center have access to your health information for the performance of reasonable job-
related tasks such as scheduling, appointment reminders, insurance filing, report preparation, data gathering, communications with family members involved in your care, etc.
! Certain business associates of Chiropractic Solution Center may have access to your health information for the performance of outside services. These include any outside diagnostic services, lab testing services, insurance claims filing, attorneys handling legal aspects of a case and collections matters. To protect your health information, we require our business associates to appropriately safeguard your information through a signed agreement.
! Other disclosures: We may disclose health information about you to Workers Compensation programs, public health officials, the FDA, or law enforcement officials as required by state and federal law.
Effective Date: August 31, 2013 Updated: May 9, 2017
ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I have been presented with a copy of Chiropractic Solution Center’s Notice of Privacy Policies, detailing how my health information may be used and disclosed as permitted under state and federal law. I understand the contents of the notice and I request the following restrictions concerning the use of my personal health information: _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Signature:___________________________________________________Date:__________________________________________________ If not signed by the patient, please indicate relationship to patient (ex. mother, father) Relationship:________________________________________________Witnessed By:_________________________________________ IF PATIENT REFUSES TO SIGN, INDICATE YOUR ATTEMPT TO OBTAIN A SIGNATURE BELOW: q Patient refused to sign this acknowledgement Employee Name/Signature:________________________________________Date:___________________________________________
ChiroSolutions Center 287 Independence Blvd., Ste 118 [email protected] 757-271-0001 www.mychirosolutions.com The Chiropractic Physician has offered to communicate using the following means of electronic communication [check all that apply]:
____Social media (specify): Facebook, Instagram, Twitter, YouTube
____Other (specify): MailChimp
PATIENT ACKNOWLEDGMENT AND AGREEMENT: I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communication Services more fully described in the Appendix to this consent form. I understand and accept the risks outlined in the Appendix to this consent form, associated with the use of the Services in communications with the Chiropractic Physician and the Chiropractic Physician’s staff. I consent to the conditions and will follow the instructions outlined in the Appendix, as well as any other conditions that the Chiropractic Physician may impose on communications with patients using the Services. I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Chiropractic Physician or the Chiropractic Physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the Chiropractic Physician or the Chiropractic Physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the Chiropractic Physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice. Any questions I had have been answered. Patient Name: _________________________________________________________________________
