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Initial Visit Forms

Initial Visit Forms

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Published by Bertie Synowiec

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Published by: Bertie Synowiec on Feb 15, 2011
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01/30/2013

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Grosse Ile Family Chiropractic Bertie R. Synowiec, MS, DC
Welcome to Grosse Ile Family Chiropractic!
New Patient History
Date of Initial Visit / / 2010 _________Name (Please Print)_____________________________________________ Date of birth__________________ Age_________Address______________________________________________________ State ______________ Zip____________________Phone ________________________ Cell Phone _____________________ Marital status: S _____M ____ # of Children _____Occupation___________________________________________________ Employer_________________________________Primary Insurance Plan__________________________________________ Patient ID #_______________________________Secondary Insurance __________________________________________ Secondary ID#_____________________________Spouse’s name________________________________________________ Date of birth ______________________________Referred by___________________________________________________ Primary MD ______________________________
indly circle your level of pain
: (No Pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst Possible)
lease explain your reason for coming into chiropractic care today: Please mark areas of discomfort below:
Major area of concern_______________________________________________
_______________________________________________________________________Pain/Problem started on_____________________ Check the type of pain you are feeling:Sharp _____ Dull Ache _____ Constant _____Intermittent _____Other ______Does this pain shoot, radiate, or travel in your body?__________ Where?_____________Are you experiencing numbness or tingling anywhere? ________ Where? ____________Since it began, is it: Same _____ Better _____Worse at certain times _______What activities aggravate your condition? _____________________________________Is the pain interfering with work______ sleep ______activities of daily living ________What other doctors have you seen for this condition___________ Diagnosis? _________Are you under medical care for any condition at this time? _______ How long? ________ Have they taken X-rays_________ MRI ________CT Scan _______ Are you able to obtain a copy for this office? _____ Location where they were taken? _______________________Have you had any spinal surgery? ____ When ____________ What level? ____ Neck (C/S) ____ Mid Back (T/S) ____ Low Back (L/S) ____What side effects have you experienced from the drugs and surgery? ___________________________________________________________
edications/ Vitamins
:
List any vitamins or medications are you now taking? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
Grosse Ile Family Chiropractic Bertie R. Synowiec, MS, DC
Early
 
Childhood
: Describe any challenges that you may know of? ___
____________________________________________________
 Ear infections/colic/asthma ___________Attention Deficit ___________ Antibiotics ___________ Broken bones _______________________Any traumas? _____________________ Car accidents ______________ Chair pulled from under you________________________________
Current Health Habits:
Did/do you smoke? ____ Drink alcohol? ____Do you eat healthy foods? ____ Do you exercise regularly? ________Do you have dental/eye/hearing problems? _____ Did/do you have occupational stress?________ Physical/ emotional/mental stress? ________Do you sleep well______________ Hours of sleep/ night____ Sleeping posture: Side ____ Stomach ____ Back ____ Arms over head _______In your adult life have you ever been in a car accident of fallen?_______ Please explain ______________________________________________________________________________________________________________________________________________________________
lease mark any of the following conditions or symptoms that you have now or have experienced:
O Headaches O Pain in Hands or Arms O Chest Pains O Loss of BalanceO Neck Pain O Numbness in Hands or Arms O Heart Attack O Ringing in EarsO Sleeping Problems O Pain in Legs or Feet O High Blood Pressure O Jaw/TMJ ProblemsO Low Back Pain O Numbness in Legs or Feet O Stroke O Menstrual CrampsO Nervousness O Fatigue O Cancer O MenopauseO Tension O Depression O Painful Urination O Cold HandsO Irritability O Lights Bother Eyes O Diabetes O Cold FeetO Dizziness O Loss of Memory O Diarrhea O Weight LossO Pain Between Shoulders O Shoulder Pain O Constipation O Loss of Smell or TasteO Stiff Neck O Sinus O Stomach Upset O FeverO Joint Swelling O Shortness of Breath O Heartburn/Reflux O Asthma O Allergies
Please list any other conditions diagnosed by your medical doctors in the past or present that you would like us to include. _____
__________________________________________________________________________________________________________________
ark with an “X” any condition listed below that has affected your family history:
Heart disease Lung disease Arthritis Cancer Diabetes ___________Father’s side O O O O O OMother’s side O O O O O O
lease sign below
: I hereby certify that the statements and answers given on this form are accurate to the best of myknowledge. I do understand that it is my responsibility to inform this office of any changes in my health as they occur. I agree to allow the doctor to examine me for further evaluation and acceptability into chiropractic care.
Patient Signature______________________________ Date ____________ E-Mail ___________________________________Cell phone # _________________________________ Emergency Contact _______________________Phone______________
- - -
 Doctor’s Notes
- - -
__________________________________________________________________________________________________________________
 
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Doctor’s Signature Roberta R Synowiec, DC Date / / 2010
 
Grosse Ile Family Chiropractic Bertie R. Synowiec, MS, DC
HIPAA Notice of Privacy Practices - Please read carefully
This Notice of Privacy Practices
describes how we may use/disclose your protected health information (PHI) to carry out treatment, payment or health care options and for other purposes that are permitted or required by law. It also describes your rights to access andcontrol your protected health information. Protected health information is information about you, including demographic informationthat may identify you and that relates to your past, present or future physical or mental health or condition and related health services.
Uses and Disclosures of Protected Health Information:
Your protected health information may be used and disclosed by your  physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providinghealth care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other userequired by law.
• Treatment:
We will use and disclose your PHI to provide, coordinate, or manage your health care and any related servicesincluding the coordination or management of your health care with a third party such as a home health agency, or to your  physician in the case of a referral, to ensure that the physician has the necessary information to diagnose or treat you.
• Payment:
Your PHI will be used, as needed, to obtain payment for your health care services. For example, to obtainapproval from your provider for services rendered.
Healthcare Operations:
We may use your PHI for employee review and quality assessment activities within our chiropractic business. In addition we may utilize a sign-in sheet at the front desk where you will be asked to sign your namethat we will call from the waiting room when your physician becomes available.
We may use or disclose your PHI, to occasionally, contact you, to set up or confirm an appointment. Your cell phone numberat the bottom of this form would be helpful in this regard.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: thoseRequired by Law, Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements,Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, if applicable, Research data, Criminal Activity, MilitaryActivity and National Security, Workers’ Compensation, Inmates and required uses and disclosures to the Department of Health and HumanServices, that oversee HIPAA compliance of our office.
Other Permitted and Required Uses and Disclosures
will be made only with your consent, authorization or opportunity to objectunless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Patient Rights:
You may send us a request in writing to see or have a copy of your information we have on file,
unless otherwiserestricted by law. You may notify us of any incomplete or inaccurate personal information that your wish amended. Wereserve the right to disagree with your changes. In the event of a disagreement, we will provide you with information aboutour denial of your changes and the means with which you may appeal it.
You have the right to request additional restrictions on how we may use, and to whom we may disclose your PHI.
 However, we are not legally required to agree to your request, in particular, instances where it may be prohibited by law or not in your best interest. Your request must be specific and include to whom you want the restriction to apply.
You may request us to use reasonable alternative means of contacting you
regarding health matters such as by cell phone or e-mail or direct us to an alternate address when appropriate.
You may request an accounting of any disclosures concerning your PHI,
except when these are made for treatment, payment or health care operations, or the law otherwise restricts the accounting.
You have the right to a copy of this notice upon request.Additional Information
: We are required by law to maintain the privacy of, and provide individuals with, this notice of our legalduties and privacy practices with respect to protected health information. If you have any objections to this form or have any questionsabout your rights to privacy or how these rights have been handled by this office, please contact our HIPAA Compliance Officer in person or by phone at (734)-671-1740.
 Your signature below acknowledges that you have received this Notice of Privacy Practices.
Signature________________________________________ Printed Name____________________________________ Cell Phone
number where we can leave a message:
 _(_______)__________________ Date
 
 __________________ E-mail address ( used for this office only) ______________________________________________________________ 
 

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