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NewPatientConfidentialRecord

Name_______________________________________________________Date____________________________________

Sex____________Age___________DOB__________________________

CurrentAddress_____________________________________________________________________________________

City____________________________________________State_______________Zip_____________________________

PrimaryPhone_____________________________________________(home/cell)

Email__________________________________________________________________________________________________

Occupation___________________________________________________________________________________________

Employer_____________________________________________________________________________________________

EmergencyContactName___________________________________________________________________________

EmergencyContactPhone__________________________________________________________________________

HaveyoueverbeentoaChiropractor?____________________________________________________________

Ifyes,whatdoctor?__________________________________________________________________________________

Wasitapositiveexperience?_______________________________________________________________________

Doyouhaveaprimarycareprovider?Ifso,name?_______________________________________________

PhoneNumber_______________________________________________________________________________

Howdidyouhearaboutouroffice?________________________________________________________________

AreyouaCrossfitIlluminemember?_______________________________________________________________

Ifyes,howlonghaveyoubeentrainingCrossfit?_________________________________________________

Whatdoyoudotostayactive?_____________________________________________________________________

_________________________________________________________________________________________________________

Isyourjobsedentary?Pleasedescribe.____________________________________________________________

_________________________________________________________________________________________________________

ActiveHealthSpine&Sport 1852JankeDr.NorthbrookIL60062 www.activehealthchicago.com 2

MarkanXonallareaswhereyouareexperiencingpainanddiscomfort

MainComplaint

Howwouldyoudescribeit?_________________________________________________________________

Howwouldyourateitoutof10?12345678910

Whendiditstart?____________________________________________________________________________

Whatmakesitworse?_______________________________________________________________________

Whatmakesitbetter?_______________________________________________________________________

Haveyouseenanyoneforthiscomplaint?_________________________________________________

SecondaryComplaint

Howwouldyoudescribeit?_________________________________________________________________

Howwouldyourateitoutof10?12345678910

Whendiditstart?____________________________________________________________________________

Whatmakesitworse?_______________________________________________________________________

Whatmakesitbetter?_______________________________________________________________________

Haveyouseenanyoneforthiscomplaint?_________________________________________________

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Whatareyourgoalsforcomingtothisclinic?

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Whatlimitationsdoyouhave,ifany,inworkingwiththedoctorsofActiveHealth?

(Workinginexcessof60hoursperweek,unwillingtodoathomeexercises,etc.)

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Rateyourcurrentstresslevelonascalefrom1-10(10beingthemoststress)________________

Whatstepsareyoucurrentlytakingtoreduceyourstress?_____________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Doyouexercise?______________________________Howoften?_________________________________________

Whattypeofexercise?_______________________________________________________________________________

Doyoucurrentlysmoke?_______________________________Howmuch?_______________________________

Howlonghaveyousmoked?________________________________________________________________________

Pleaselistanymedicationsyouarecurrentlytakingorhavetakenprescribedbyyour

doctorinthepast.Statethereasonfortakingit.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Pleaseindicateanysurgeries,traumas,fractures,caraccidents,hospitalizations,etcthat

youhavehad.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Pleaselistifanyfamilymemberorimmediaterelativethathasahistoryofarthritis,blood

disorders,cancer,diabetes,epilepsyandanypertinentfamilyhistoryweneedtobeaware

of:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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OfficeGuidelinesandPolicies

PreparationGuidelinesPriortoyourinitialvisityouneedtoobtainallthenecessarypaperwork.Weaskyoutoreadandcompletethis

paperworkathome(innon-urgentcases)togiveyoutimetothinkthroughyouranswersandtomakethemostoutof

yourtimeinouroffice.Youmayalsowanttovisitourwebsite(www.activehealthchicago.com)tolearnmoreaboutthe

servicesofferedinouroffice,whattoexpectonyourfirstvisit,andtofindanswerstosomequestionsfrequentlyaskedby

patients.

MedicalRecordsIfapplicable,pleasebringcopiesofyourlatestlaboratoryandimaging(x-ray,MRI,CT)reports—nofilmrequired—onthe

dayofyourinitialexam.Ifyourdoctorrequiresan‘AuthorizationtoReleaseMedicalRecords’formpleasecontactour

officeandwewillprovideoneforyou.Oftenyourlaboratoryandimagingreportscanbefaxedoremaileddirectlytoyou

byyourdoctor.

FeesOurgoalistoprovideyouwiththebest-personalizedhealthcareatanaffordableprice.

Non-MedicareHealthInsuranceWeare“out-of-network”forall*insurancecompanies.Tofindoutaboutyourout-of-networkbenefits,callthecustomer

servicenumberonyourinsurancecardandinquireaboutyourchiropracticcoverage.Wedonotbillordirectly

communicatewithinsurancecompanies;however,wearehappytoprovideyouwitha“superbill”thatincludesthe

informationyouneedtofileaclaim.Anyreimbursementwillthenbemaileddirectlytoyoufromyourinsurance

company.Thereisnoout-of-networkreimbursementforMedicare,TricareorKaiser/HMOpatients.IfyouhaveaHealth

SavingsAccount(HSA)orFlexibleSpendingAccount(FSA)the“superbill”willalsovalidateyourexpensesinourofficeas

healthcare-relatedtothoseentities.Paymentforeachvisitisrequiredatthetimeofservice.Outsidelabsandimagingare

performedatourcost,withnoaddedmark-up.

Medicare:WedoacceptMedicareasa“non-participatingphysician.”ThismeansthatwecollectthefullamountofyourvisitchargesatthetimeofserviceandthensendinyourMedicarebillingforyou.Medicareandyoursecondary

insurancepolicy(ifyouhaveoneinplace)willthenreimburseyou,basedonthedetailsofyourhealthcoverage,by

sendingacheckdirectlytoyou.Medicareisparticularonwhatchiropracticservicestheywillcoverandwewillgoover

thesedetailswithyouduringyourfirstvisit.NoShow&CancellationPolicyWearecommittedtoofferingexceptionalpatientcareduringeveryvisit.Weaskthatyouprepareforyourappointment

accordingly.Pleasesilenceyourcellphonepriortoyourvisit.Pleasecomedressedappropriatelyfortheareatobe

treated(ex:don’tweartightjeansifwearegoingtobeworkingonyourknee).Wehavea24-hourcancellationpolicyon

allappointments.No-showsorcancellationswithlessthana24-hournoticewillbebilledthefullfeeoftheappointment.

Ourstaffwillmakeeveryattempttoremindyouofyourappointment,butitisultimatelyyourresponsibilityto

remember.Ifyouarerunninglatepleasecalltoletusknowwhenyouanticipatearrivingforyourvisit.Wewilldoour

besttoaccommodateyourrevisedvisittimeintothedoctor’sschedule.However,ourofficemakesapolicyofnotpushing

theentireday’sscheduleoutbecauseasinglepatientislatetotheirappointment.Wewillrunontimeasaruleandwe

askthatyoushowupontimeforyourappointments.PaymentAgreementPaymentfortheinitialconsultationandtreatmentsisrequiredatthetimeofservice.Foryourconvenience,weaccept

cash,checks,Mastercard,andVisa.

ReleaseofInformation:Iauthorizethereleaseofanyinformationconcerningmyhealthandhealthcareservicestomy

insurancecompanies,pre-paidhealthplanorMedicare.

I,theundersigned,agreetoalltheaboveOfficeGuidelinesandPolicies.Ihaveasked,andhadansweredtomysatisfaction,

anyquestionsIhaveregardingthesepolicies.Bymysignature,Iacknowledgereceiptoftheprovider’sNoticeofPrivacy

Practices(HIPPA)andtheprovider’sPatientRightsandhavebeengiventheopportunitytoreadthem.Iunderstandthat

thisinformationisavailabletomeuponmyrequest.

Patient’sSignature____________________________________________________Date_________________________________

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InformedConsent

I,theundersigned,havevoluntarilyrequestedthatthedoctorsofchiropracticatActiveHealthSpine&Sport,

(herein‘thedoctors’),assistmeinthemanagementofmyhealthconcerns.Iunderstandthatthedoctorsare

chiropractorsandthattheirservicesarenottobeconstruedorserveasasubstituteforstandardmedical

care.ThedoctorrecommendsthatIundergoregularroutinemedicalcheck-upsbymymedicaldoctor.

Medicaldoctors,doctorsofchiropractic,osteopaths,andphysicaltherapistswhoperformmanipulationare

requiredbylawtoobtainyourinformedconsentbeforestartingtreatment.

I,theundersigned,doherebygivemyconsenttotheperformanceofconservativenoninvasivetreatmentto

thejointsandsofttissues.Iunderstandthattheproceduresmayconsistofmanipulations/adjustments

involvingthemovementofthejointsandsofttissues.Physiotherapymodalities(ex:GrastonTechnique,

motorneverstim,coldlaser,etc),in-officeexercises,taping,nutritionalsupplements/dietary

recommendations,amongothers,mayalsobeused.

Routinechiropracticexaminationandtreatmentinvolvesomeofthefollowingmethods:

•ObservationandInspection:Viewing/lookingatbodyparts.Visualizationincludesgeneralbodyviewingin

astandingpositionfromthefront,back,andside.Allsymptomatic(painful)bodypartsmaybeviewed.

Althoughnotusuallyrequired,ifclothinginterfereswithexaminationortreatmentofanareapatient

gowningwillbeutilized.Patientsmayrequestanobserverbepresentatanytimeduringexaminationand/or

treatment.

•Auscultation:Usingastethoscopetolistenforbloodpressureandotherbodysounds.

•Palpation:Thismeansthedoctorwilltouchyou.Thedoctorwillfeelfortenderness,heat,swelling,

nodularity,laxity/integrityoftissues,andotherabnormalities.•Percussion:Usingarubberhammerand

tappingonbonesortendons

•Orthopedic/neurologicaltesting:Thesearestandardteststoassessyourneuromusculoskeletalsystems.

•Muscletesting:testingmusclesforweaknessand/orpainwithcontraction.

•Myofascialand/orGrastonTechnique:muscleworksometimesinvolvingtoolstoincreaseflexibilityand

breakupadhesionsinmuscleormyofascialtissues.Althoughspinalmanipulation/adjustmentisconsidered

tobeoneofthesafest,mosteffectiveformsoftherapyformusculoskeletalproblems,Iamawarethatthere

arepossiblerisksandcomplicationsassociatedwiththeseproceduresasfollows:

•KinesiologyTaping:IfnecessaryRocktapewillbeusedfortreatment.Thismaycauseskinirritationoreven

arash.Ifyouhaveaskindiseaseorgetadversereactionsfromadhesivespleaseletyourdoctorknow

immediately.

RisksfromTreatment

Soreness:Iamawarethatlikeexerciseitispossibletoexperiencemusclesorenessinthefirstfewtreatments.

Dizziness:Temporarysymptomslikedizzinessandnauseacanoccurbutarerelativelyrare.Pleaseinformthe

doctorifyouexperiencethesesymptoms.

Fractures/JointInjury:Ifurtherunderstandthatinisolatedcasesunderlyingphysicaldefects,deformities,or

pathologieslikeweakbonesfromosteoporosismayrenderthepatientsusceptibletoinjury.When

osteoporosis,adegenerativedisc,orotherabnormalityisrevealed,thisofficewillproceedwithextracaution.

Stroke:Althoughstrokeshappenwithsomefrequencyinourworld,strokesfromchiropracticadjustments

areextremelyrare.Iamawarethatnerveorbraindamageincludingstrokeisreportedtooccuronceinone

milliontoonceintenmilliontreatments.Onceinamillionisaboutthesamechanceasgettinghitby

lightning.A2009studyof100millionperson-yearsfound“noevidenceofexcessriskofstrokeassociated

withchiropracticcarecomparedtoprimarycare.”Ifyouhaveanyquestionsaboutthispleaseaskthedoctor.

Wewouldbehappytodiscussotheroptionsandansweranyofyourquestions.

ActiveHealthSpine&Sport 1852JankeDr.NorthbrookIL60062 www.activehealthchicago.com 6

TreatmentResults:Ialsounderstandthattherearebeneficialeffectsassociatedwiththesetreatment

proceduresincludingdecreasedpain,improvedmobilityandfunction,andreducedmusclespasm.However,I

appreciatethereisnocertaintythatIwillachievethesebenefits.Irealizethatthepracticeofmedicineaswell

aschiropractic,isnotanexactscienceandIacknowledgethatnoguaranteehasbeenmadetomeregarding

theoutcomeoftheseprocedures.Iagreetotheperformanceoftheseproceduresbymydoctorandsuch

otherpersonsofthedoctor’schoosing.

Reasonablealternativestotheseproceduresincluderest,homeapplicationsoftherapy,prescriptionorover-the-countermedications,exercisesandpossibleinjectionsand/orsurgery.

Medications:Medicationcanbeusedtoreducepainorinflammation.Iamawarethatlong-termuseoroveruseofmedicationisalwaysacauseforconcern.Drugsmaymaskpathology,produceinadequateor

short-termrelief,undesirablesideeffects,physicalorpsychologicaldependence,andmayhavetobe

continuedindefinitely.Somemedicationsmayinvolveseriousrisks.Wecannotadviseyouregardingany

medication/s.PleaseconsultyourM.D.

Rest/Exercise:Simplerestisnotlikelytoreversepathology,althoughitmaytemporarilyreduceinflammationandpain.Thesameistrueofice,heat,orotherhometherapy.Prolongedbedrestcontributesto

weakenedbonesandjointstiffness.Exercisesareoflimitedvaluebutarenotcorrectiveofinjurednerveand

jointtissues.

Surgery:Surgerymaybenecessaryforconditionssuchasjointinstabilityorseriousdiskrupture,amongothers.Surgicalrisksmayincludeunsuccessfuloutcome,complications,painorreactiontoanesthesia,and

prolongedrecovery.

Non-treatment:Iunderstandthepotentialrisksofrefusingorneglectingcaremayincludeincreasedpain,scar/adhesionformation,restrictedmotion,possiblenervedamage,increasedinflammation,andworsening

pathology.Theaforementionedmaycomplicatetreatmentmakingfuturerecoveryandrehabilitationmore

difficultandlengthy.

Ihavereadorhavehadreadtometheaboveexplanationofchiropractictreatment.Thedoctorhasalsoasked

meifIwantamoredetailedexplanation;Iamsatisfiedwiththeexplanationanddonotwantanyfurther

information.Ihavemademydecisionvoluntarilyandfreely.Toattesttomyconsenttotheseexamination

andtreatmentprocedures,IherebyaffixmysignaturetothisInformedConsentdocument.

*Bysigningthisdocumentyouarealsogivingpermissionforthedoctortoaddyoutohisemaillist.Thisgives

youtheabilitytostayuptodateonthepracticeinformationandreceivehealthtips.Onceontheemaillist,if

youwishtonolongerreceiveemails,youcanunsubscribeatanytime.

PatientSignature:__________________________________________________________________Date_____________________

Idiscussedtheprocedures,alternatives,andrisksinconferencewiththepatient.

DoctorSignature:___________________________________________________________________Date_____________________