New Patient Questionnaire

List current medications and supplements/herbs/vitamins and minerals
List major surgeries, illnesses, and broken bones you have had
Please list your health concerns*
What makes you feel worse?*
What makes you feel better?*
Are you pregnant and due date
Date of last menstrual cycle
Please describe your menstrual cycle and PMS symptoms, if any
Describe your urinary flow. frequency, and urgency. Do you wake up during the night to urinate
Additional Comments:
Do you smoke or chew tobacco?
What do you commonly eat for breakfast
What do you commonly eat for lunch
What do you commonly eat for dinner
What are your snack choices
What are your beverage choices How many glasses of water to you drink each day
What type of exercise do you perform. How many times per week and for how long.
What stressors affect you. Some choices include work, finances, family, health, and relationships
Describe your sleep. please include how many hours, position(s), type of mattress, blankets, and pillow. Do you feel rested in the morning?
When you think about a health improvement program, what fears do you have
INFORMED CONSENT

To the patient: Please read this entire document before signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything unclear.

THE NATURE OF THE CHIROPRACTIC ADJUSTMENT:

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible "pop" or "click", much as you have experienced when you "crack" your knuckles. You may feel a sense of movement.

ANALYSIS/EXAMINATION/TREATMENT:

As a part of the analysis, examination, and treatment, you are consenting to the following procedures: Spinal manipulative therapy; range of motion testing, orthopedic testing, basic neurological testing, vital signs, postural analysis, Kinesiology (muscle testing), NervExpress heart rate variability testing, allergy sensitivity testing, urine testing, saliva testing, nutritional imbalance testing, physio-therapy including cold laser, electrical stimulation, sound wave therapy, moist heat, and ice, nutritional and herbal therapy.

THE MATERIAL RISKS INHERENT IN THE CHIROPRACTIC ADJUSTMENT:

As with any healthcare procedure, certain complications may arise during chiropractic manipulation and therapy. These complications include but are not limited to fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries of the neck leading to or contributing to serious complications including stroke. Some patients will feel stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care, however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

THE PROBABILITY OF THOSE RISKS OCCURRING:

Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during the examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

THE AVAILABILITY AND NATURE OF OTHER TREATMENT OPTIONS:

Other treatment options for your condition may include self-administered, over-the-counter analgesics and rest; medical care and prescription drugs such as anti-inflammatories, muscle relaxants, and painkillers; hospitalization and surgery. If you choose to use one of the above-noted "other treatment" options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

THE RISKS AND DANGERS ATTENDANT TO REMAINING UNTREATED:

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I HAVE DISCUSSED THIS WITH ROBERT A. SCHWARTZ D.C. AND HAVE HAD MY QUESTIONS ANSWERED TO MY SATISFACTION. BY ELECTRONICALLY SIGNING BELOW I STATE THAT I HAVE WEIGHED THE RISKS INVOLVED IN UNDERGOING TREATMENT AND HAVE DECIDED THAT IT IS IN MY BEST INTEREST TO UNDERGO THE TREATMENT RECOMMENDED. HAVING BEEN SIGNING BELOW I STATE THAT I HAVE WEIGHED THE RISKS INVOLVED IN UNDERGOING TREATMENT AND HAVE DECIDED THAT IT IS IN MY BEST INTEREST TO UNDERGO THE TREATMENT RECOMMENDED. HAVING BEEN INFORMED OF THE RISKS, I HEREBY GIVE MY CONSENT TO THAT TREATMENT.
PLEASE INITIAL TO ACKNOWLEDGE TERMS OF THE INFORMED CONSENT
NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and you can get access to this information.

Your rights:

·        Request a copy of your paper or electronic medical record.

·        Correct your paper or electronic medical record.

·        Request confidential communication.

·        Ask us to limit the information we share.

·        Request a list of those with whom we have shared your information.

·        Get a copy of this privacy notice.

·        Choose someone to act on your behalf.

·        File a complaint if you believe your privacy rights have been violated.

Your choices: how we may share your information

·        Tell family and friends about your condition.

·        Provide disaster relief.

·        Include you in a hospital directory.

·        Provide mental health care.

·        Market our services and sell your information.

·        Raise funds.

Our Uses and Disclosures: how we may use and share your information

·        Treat you.

·        Run our organization.

·        Bill for your services.

·        Help with public health and safety issues.

·        Do research.

·        Comply with the law.

·        Respond to organ and tissue donation requests.

·        Work with a medical examiner or funeral director.

· Address Worker’s compensation, law enforcement, and other government requests

·        Respond to lawsuits and legal actions

When it comes to your health information, you have certain rights:

·        You can ask to see or get an electronic or paper copy of your medical record and other health info we have about you. This may take up to 30 days.

·        You can ask us to amend your medical record that you think is incorrect or incomplete

·        You may request confidential communications. This may include cell, home, or work phone, email, or text.

·        You can ask us to not share or limit certain health information for treatment, payment, or our operations.

·        If you pay in full for a service, you can ask that we do not share your health insurance unless that violates a law.

·        You can request a list of those we have shared with your health information for the prior 6 years from the date of request.

·        You can request a copy of this notice

Choose someone to act for you:

·        A designated power of attorney or a legal guardian can exercise your rights.

·        You can complain to us if you feel we have violated your privacy rights.

·        You can file a complaint with the U.S. Department of Health and Human Services for Civil rights by sending a letter to: 200 Independence Ave, S.W., Washington D.C. 20201, or by calling 1-877-696-6775, or by visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

·        We will not retaliate against you for filing a complaint.

Your choices: Tell us what and how to share your information

·        Share with family, friends, or others involved in your care.

·        Share information in a disaster relief situation.

·        If you are unable to tell us your preference, we may at our discretion share information if we feel it is in your best interest.

·        We may share information when needed to lessen a serious and imminent threat to health and safety.

We never share your information without your written permission in the following situations:

·        We do not sell any information.

·        Marketing purposes

·        Fundraising

·        Other healthcare providers – This requires a request for medical records authorized by you.

Our uses and disclosures

·        We share information with your health insurance or other entities to bill and get payment.

·        Public health and safety issues. For more information:

www.hhs.gov/ ocr/privacy/hipaa/understanding/consumers/index.html

·        Preventing disease – preventing or reducing a serious threat to anyone’s health or safety.

·        Helping with product recalls.

·        Reporting suspected abuse, neglect, or domestic violence.

·        Reporting adverse reactions to medications.

·        Comply with the law.

·        Respond to organ and tissue donation requests.

·        Work with a medical examiner or funeral director.

·        Comply with State or Federal law.

·        Worker’s compensation claims.

·        Law enforcement purposes or with a law enforcement official.

·        With health oversight agencies for activities authorized by law.

·        For special government functions such as military, national security, and presidential protective services.

·        Respond to lawsuits and legal actions.

Our responsibilities:

·        We are required by law to maintain the privacy and security of your protected health information.

·        We will inform you promptly if a breach occurs that may have compromised the privacy and security of your protected health information.

·        We must follow the duties and privacy practices described in this notice and give you a copy of it.

·        We will not use or share your information other than as described in this notice unless you tell us we can in writing. You may change your mind at any time. For more information:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request.
PLEASE INITIAL TO ACKNOWLEDGE RECEIPT OF NOTICE OF PRIVACY PRACTICES.
ADVANCED BENEFICIARY NOTICE OF NON-COVERAGE SERVICES (ABN)

Health insurance requires that you are notified in advance of services that are not covered by your Chiropractic coverage. If you have Chiropractic coverage it may only cover Chiropractic manipulation and possibly physiotherapies such as muscle stimulation. Many of the services that we provide at Hygiea Health, Wellness, and Chiropractic are not covered. These include

Wellness Evaluation: $200

Wellness Re-evaluation: $160

Biofeedback, cold laser, PEMF, Kinesiology, biofeedback, and energy modalities: $90

Since we perform Chiropractic manipulation at treatment, your fee will be the difference between $90 and the payment we receive from your health insurance or other entity.

Nutritional products and supplies: Retail price

You should be aware that many Chiropractors do not provide non-covered services and will accept your insurance as payment in full plus any deductible or copay you may owe.
PLEASE INITIAL TO ACKNOWLEDGE THE ABN AGREEMENT
PLEASE PRINT NAME certify that all information provided to true to the best of my ability.
Date signed
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