ࡱ> q` TbjbjqPqP ::~ZLLLLLLLd===> ?bn8@@x@"@@@EDEDED```````$ndhf`LHC|EDHH`LL@@/afNfNfNHXL@L@`fNH`fNfNc]0LL_@,@ ;.=H\^$`a0b^gXKgH_gL_(ED9EfNEsF1EDEDED``NXEDEDEDbHHHH$/==LLLLLL  Name:_________________________ Address:_______________________ ______________________________ Home Phone: ___________________ Office Phone: ___________________  MERGEFIELD PHONE_OFF  MERGEFIELD OFFICE_EXT  Cell Phone: ____________________  MERGEFIELD EMAIL  MERGEFIELD OFFICE_EXT  Email: ________________________ DOB: _____________ Age: ______ Referred By: _____________________ Your SS#: ______________________ MERGEFIELD OFFICE_EXT  Your Occupation: _________________ Your Employer: ___________________ Your Driver License #: ________________________________ Insurance Name: __________________ Policy/ID # _______________________ Military Branch: __________________ Are you a student? _______________ Marital Status: _____ # of children: ___ Spouse Name: ___________________ Spouse DOB: ____________________ Spouse Occupation: _______________ Spouse Employer: ________________ TODAYs DATE: _________________ If patient is a minor (under 18yrs old), Please fill out this section. If not, skip: Parent/ Guardians Name: _________________________________________Date of Birth: _____________Age: _________ Address: ______________________City/State: _____________Zip: _______ Phone # ___________ SS#_______________ Occupation: ___________________ Employer:________________________ Work Phone: __________________________ Please mark X for present conditions, O for past conditions _____ Fractured Bones _____ Auto Accidents ___ 0-1 years ago ___ 1-5 years ago ___ More than 5 _____ Other Accidents/Falls _____ Back Curvature _____ Arthritis _____ Diabetes _____ Swollen/Painful Joints _____ Convulsions/Epilepsy _____ Skin Problems _____ Cancer _____ Frequent Colds/Flu _____ Depressed _____ Irritable _____ Anemia _____ Tremors _____ Allergies _____ Sinus Problems _____ Eating Disorders _____ Trouble Sleeping _____ Trouble Concentrating _____ Learning Disability _____ Mood Changes _____ Headache _____ Pain/Stiff Neck R L _____Numbness/Tingling/Pain Arms/Hands/Fingers R or L _____ Jaw Pain/TMJ R L _____ Head/Shoulders Feel Tired _____ Difficulty in Excessive (Standing, Walking, Bending, Riding, Twisting, Lifting, Household Duties) _____ Shoulder Pain R L _____ Dizziness _____ Ringing in Ears R L _____ Hearing Loss R L _____ Fainting _____ Loss of Balance _____ Blurred Vision R L _____ Double Vision R L _____ Upper Back Pain/Stiffness _____ Mid Back Pain/Stiffness _____ Low Back Pain/Stiffness _____ Numbness, Tingling or Pain in buttocks, thighs, legs, feet, toes _____ Pain with cough, sneeze _____ Hip Pain R L _____ Foot Trouble R L _____ Chest Pain _____ Asthma _____ Lung Problems _____ Difficulty Breathing _____ Heart Problem _____ Stroke _____ High/Low Blood Pressure _____ Varicose Veins _____ Liver Trouble _____ Gall Bladder Trouble _____ Digestive Problems _____ Heartburn _____ Ulcers _____ Diarrhea/Constipation _____ Colon Trouble _____ Hemorrhoids _____ Prostate Problems _____ Impotence _____ Kidney Trouble _____ Menstrual Problem/PMS _____ Menopausal Problems _____ Pregnant (now) HISTORY OF COMPLAINT Please identify if you came to this office, not as a result of a complaint, but for wellness care by completing the following: Your Goals of Wellness Care: ______________________________________________________________________________________________ Please describe your current complaints_______________________________________________________ Have you suffered with this or a similar problem(s) in the past? ( No ( Yes If yes when?_____________ Please state what type of treatment you have tried for this problem(s) __________________________ ______________________________________________________________________________________________ Who provided it?: _________________________________________ When? ____________________________ What were the results? ( Favorable ( Unfavorable( please explain. ___________________________ How long were you under care: ______________________________________________________________ What were the results? _______________________________________________________________________ Have you had any surgeries? ( Yes ( No, if yes please provide dates and descriptions ______________________________________________________________________________________________ Please list all medications you are currently taking_______________________________________________ ________________________________________________________________________________________________________ SOCIAL HISTORY 1. Smoking: (cigars ( pipe ( cigarettes ( How often? ( Daily ( Weekends ( Occasionally ( Never 2. Alcoholic Beverage: consumption occurs ( ( Daily ( Weekends ( Occasionally ( Never 3. Recreational Drug use: ( Daily ( Weekends ( Occasionally ( Never 4. Hobbies -Recreational Activities- Exercise Regime: How does present problem affect the following: IDENTIFY TYPE: EFFECT: __________________________________ ( No Effect ( Painful (can do) ( Painful (limits) ( Unable to Perform __________________________________ ( No Effect ( Painful (can do) ( Painful (limits) ( Unable to Perform __________________________________ ( No Effect ( Painful (can do) ( Painful (limits) ( Unable to Perform 5. Work Activities: Please complete all questions! Hours worked per day: _____ Days per week: _____ Does your job require lifting? ( No ( Yes If yes, what is the maximum required? ( Min (<5 lbs) ( Light (5-20 lbs) ( Med (20-50lbs) ( Hvy (>50 lbs) Lifting Frequency: ( Constant (66-100%of day) ( Frequent (33-66% of day) ( Occasional (0-33% of day) Lifting Postures: ( Knee ( Torso ( Arm ( Shoulder ( Off Posture Standing: _____ Hrs per day Sitting: _____ Hrs per day Pushing: ______ Hrs per day Twisting: _____ Hrs per day Climbing: _____ Hrs per day Pulling: ______Hrs per day Kneeling: _____ Hrs per day Reaching: _____ Hrs per day Walking: ______Hrs per day 6. Repetitive Activities: Computer: _____ Hrs per day Grasping: _____ Hrs per day Hand Tools:_____ Hrs per day Machinery: _____ Hrs per day Assembly: _____ Hrs per day Phone: _____ Hrs per day Other: __________________________________ _____ Hrs per day 7. Impact of Current Condition on Work Capacity: ( No Effect ( Painful ( Limits ( Unable to work 8. How many years of school did you complete? ( 1-8 ( 8-12 (12-14 (14-16 ( 16 + FAMILY HISTORY: 1. Does anyone in your family suffer with the same condition(s)? ( No ( Yes If yes, who: ( grandmother ( grandfather ( mother ( father ( sister ( brother ( son(s) ( daughter(s) Have they ever been treated for their condition? ( No ( Yes ( I dont know Any other hereditary conditions the doctor should be aware of? ( No (Yes: (please list) _________________________________________________________________________________________________ Patient Signature________________________________________________________ Date___________________ PAST HISTORY If you have ever been diagnosed with any of the following conditions please indicate with a P for in the Past, C for Currently have and N for Never have had a: [ ] Disability [ ]Broken Bone [ ] Fracture [ ] Dislocations [ ] Tumors [ ] Rheumatoid Arthritis [ ] Osteo Arthritis [ ] Cerebral Vascular [ ] Heart Attack [ ] Diabetes [ ] Other serious conditions: ______________________________________ PLEASE, identify ALL PAST and any CURRENT conditions you feel may be contributing your present problem:______________________________________________________________________________________ Description of Symptoms AREA #1(Describe your symptoms in the sections below, in the order of severity) Current Symptom: (Please check off the boxes below to describe your symptom. The pain is located _________________________________________________________________________ The pain started____________________________________________________________________________ The pain is made better by ____________________________________________________________________ and worse by ________________________________________________________________________ How would you describe the pain: qDull qSharp qAching qCutting qThrobbing qBurning qNumbing qTingling qCramping qSpasm qStinging qShooting qPounding qConstricting [ ] There is [ ] There is not radiation into __________________________________________________ [ ] There is [ ] There is not referred pain into _______________________________________________ [ ] There is [ ] There is not parasthesia (tingling/numbness) into:_________________________________ The pain is (as far as timing is concerned: qIn the A.M. q In the P.M. qUp to 1/4 of awake time q1/4 to 1/2 of time q1/2 to 3/4 of awake time qMost all the time Actions affecting this pain Brings On Aggravates Relieves qBending forward. q q q *PLEASE MARK the areas on the diagram qBending back q q q with the following letters qBending left q q q to describe your symptoms: qBending right q q q R = Radiating B = Burning qTwisting left q q q D = Dull A = Aching qTwisting right q q q N = Numbness qCoughing q q q S = Sharp/ Stabbing T= Tingling qSneezing q q q qStraining q q q qStanding q q q qSitting q q q qLifting q q q Other Actions:_______________________ The pain is (as far as timing is concerned: i.e. comes & goes, constant, etc.)________________________________ On a scale of 1- 10 rate your pain: No Pain 0 1 2 3 4 5 6 7 8 9 10 Severe Pain Patient signature_________________________________________________ Date_________________ Description of Symptoms AREA #2 (Describe your symptoms in the sections below, in the order of severity) Current Symptom: (Please check off the boxes below to describe your symptom. The pain is located _________________________________________________________________________ The pain started____________________________________________________________________________ The pain is made better by ____________________________________________________________________ and worse by ________________________________________________________________________ How would you describe the pain: qDull qSharp qAching qCutting qThrobbing qBurning qNumbing qTingling qCramping qSpasm qStinging qShooting qPounding qConstricting [ ] There is [ ] There is not radiation into __________________________________________________ [ ] There is [ ] There is not referred pain into _______________________________________________ [ ] There is [ ] There is not parasthesia (tingling/numbness) into:_________________________________ The pain is (as far as timing is concerned: qIn the A.M .qIn the P.M. qUp to 1/4 of awake time q1/4 to 1/2 of time q1/2 to 3/4 of awake time qMost all the time Actions affecting this pain Brings On Aggravates Relieves qBending forward. q q q *PLEASE MARK the areas on the diagram qBending back q q q with the following letters  qBending left q q q to describe your symptoms: qBending right q q q R = Radiating B = Burning qTwisting left q q q D = Dull A = Aching qTwisting right q q q N = Numbness qCoughing q q q S = Sharp/ Stabbing T= Tingling qSneezing q q q qStraining q q q qStanding q q q qSitting q q q qLifting q q q Other Actions:_______________________ The pain is (as far as timing is concerned: i.e. comes & goes, constant, etc.)________________________________ On a scale of 1- 10 rate your pain: No Pain 0 1 2 3 4 5 6 7 8 9 10 Severe Pain Patient signature_________________________________________________ Date_________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ OFFICE USE ONLY: A-P LAT CERVICAL A-P LAT THORACIC A-P LAT LUMBAR FLEX EXT CERVICAL A P O M Doctors Signature ________________________________________________ Date __________________ NOTICE OF HIPAA PRIVACY PRACTICE Herba Family Chiropractic, P.A. is required to notify you in writing, that by law we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances PERMITTED DISCLOSURES: Treatment purposes -- discussion with other health care providers involved in your care. Inadvertent disclosures -- open treating area means open discussion. If you need to speak privately to the doctor please let our staff know so we can place you in a private consultation room or schedule specific time. Disclosure via calling system we have an open speaker calling system for our patients and your name will be heard by other patients in the office. For payment purposes -- to obtain payment from your insurance company, should they be involved, or any available collateral source. Emergency -- in the event of a medical emergency we may notify a family member. For public health and safety -- in order to prevent or to lessen a serious or eminent threat to the health or safety of a person or general public. To government agencies or law enforcement -- to identify or locate a suspect, fugitive, material witness or missing person. For military, national security, prisoner and government benefits purposes. Deceased persons -- discussion with coroners and medical examiners in the event of a patient's death. Telephone calls or emails and appointment reminders -- we may call your home and leave messages regarding a missed appointment or notify you of changes in practice hours or upcoming events. Spouses, household partners and other close family members. Change of ownership- in the event this practice is sold the new owners would have access to your PHI YOUR RIGHTS: To receive an accounting of disclosures To request mailings to an address different than residence To request restrictions on certain uses and disclosures and with whom we release information to To inspect your records and receive one copy of your records at no charge, with 3 business days advance notice To request amendments to information however; like restrictions, we are not required to agree to/with them COMPLAINTS: If you wish to make a formal complaint about how we handle your health information please call Zuleida Herba, our HIPAA Clinic Compliance Officer at 407-432-9428. If she is unavailable, you may make an appointment with our receptionist to her within 2 business days. Note: This office reserves the right to amend this notice of privacy practice at any time in the future and will make the new provisions effective for all information that it maintains past and present. I have received a copy of the Herba Family Chiropractic Patient Privacy Notice and understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding to the doctor. At this time, I do not have any questions regarding my rights or any of the information I have received. ___________________________________________________________________ _____________________ Patient signature Date ___________________________________________________________________ _____________________ Witness Date Herba Family Chiropractic Center THIS DOCUMENT COSTITUTES INFORMED CONSENT FOR CHIROPRACTIC CARE. When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important for each patient to understand both the objective and the method that will be used to attain it. This will prevent confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the bodys correction of vertebral subluxation. Our Chiropractic method of correction is by specific adjustment of the spine. Health: A state of optimal, physical, mental and social well being, not merely the absence of disease, symptoms or infirmity. Vertebral Subluxations: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the bodys innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will so advise you. If you desire advice, diagnosis or treatment for those findings we will recommend that you seek the services of the health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression to the bodys innate wisdom. Our only method is the specific adjustment of vertebral subluxations. However, we may use other procedures to help your body hold the adjustments. Visits: HFC values your time and aspires to have the highest level of chiropractic education available. We have established procedures both to make your visit as efficient as possible and to bring wellness education to the community that may include the use of multimedia. As a patient of HFC, you consent to the following: Multimedia produced for ID, posture analysis, and human biomechanics analysis. You also authorize a release for all multimedia taken during HFC patient hours, patient special events, advanced patient talks, for our website, newsletters, and wellness community education. Your name will be recorded and announced aloud in our office as a part of our patient call system. POLICIES All first visit charges are payable when services are rendered, since it is impossible to determine what insurance covers without a diagnosis of severity. 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The film itself is the property of this office. Original X-rays cannot be released; however, copies can be made at minimal charge of $20 per film. I have read Herba Family Chiropractics Notice of Patient Privacy Practices. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand Herba Family Chiropractic (HFC) will prepare any necessary reports and forms to assist in making collections from the insurance company and that any amount authorized to be paid directly to HFC will be credited to my account upon receipt. However, I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for payment. In case of emergency, notify _________________________________ Phone # _________________________ I, ________________________, have read and fully understand the above statements. All questions regarding the doctors objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept and consent to chiropractic care. ________________________________________ Date_____________ (Your Signature) COMPLETE IF THE PATIENT IS A MINOR CHILD: childs name: _______________________________________ I, __________________________________ being the parent or legal guardian of the aforementioned child have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. _________________________________________________ ________________________________ (Signature) (Date) THIS CONSENT SHALL STAY IN EFFECT ANNUALLY UNTIL YOU REVOKE IT IN WRITING.__________________ Herba Family Chiropractic Center 158 Tuskawilla Road Suite 1308 Winter Springs Fl, 32708 Ph: (407) 327.9000 Fax: (407) 327.9035 Records Release Authorization Note: If we take xrays today, well have them on file for you. Should you need those in an emergency, but you were not available to request your records, please list the name(s) of individuals that would have permission to request and receive your records on your behalf: Todays Date: ___________ (Family Doctor, Hospital or Family Member) Name: __________________________________ Relationship: ___________________ Address: _______________________________________________________________ _______________________________________________________________________ I hereby authorize and request release to / from: Herba Family Chiropractic 158 Tuskawilla Road, Suite 1308 Winter Springs Fl, 32708 (407) 327-9000 The complete history records in your possession, concerning my illness and/or treatment during the period: From: ________________ To: _________________ (leave blank for indefinite permission) Patient Name: (please print) _____________________________________________________ Date of Injury or Illness: _______________________ (for specific records only) Patients Signature: _____________________________________ Date: ____________ Witness: ______________________________________________ Date: ____________     PAGE  PAGE 1 Herba Family Chiropractic PATIENT APPLICATION (Please Print, All information is confidential) Please mark X for present conditions, O for past conditions cc"ڽ[{|EFGcſǿȿ曎ssshk CJOJQJ^Jh*h&hwuOJQJ^Jhwu hwuCJhwuCJ^Jh5OJQJ^Jhh5OJQJ^J)23>?efFGHIPUVWe)fs뱦hv=jhv=UhF%5CJaJhwu5>*OJQJhiL5>*OJQJhwu h ^Jh'mhwu5^Jh'mh'm^Jh&h'm^Jh'mh'm6CJ^JaJ h'm^Jh&hwu^J hZ^J hwu^J5?fGHI>?gdR<`gd]$gdiL $ !gdwuLMNOP$gd$ $G&#$gd$&$a$$$a$ $$&dPa$$$&dPa$gdF%5 $$h`ha$gdF%5$h`hgdF%5 $&`#$gdF%5gdR<`LMNOPQRSThF%5CJaJ hh]h'< h1`h'<h'<56>*CJ \] h'<CJh'<56CJ h'<5 h'<5CJ h 0J(mHnHuh'< h'<0J(jh'<0J(Ujhv=Uhv=PQRSTgd]&gdF%5=0&P1h:pF%5/ =!"#$h%hc P 9 0&P1h:pF%5/ =!"#$h%hc U 01h:pF%5/ =!"#$%hc P0 x   Q 01h:pF%5/ =!"#$%hc0 x+  U 01h:pF%5/ =!"#$%hc P0 x   2P:p/ =!*"#$% nCv'pPNG  IHDRysRGB pHYs+tEXtSoftwareMicrosoft Office5qIDATx^oUz?!iR 5؀1@0i5ĥQn. # /0 0R-,5rj0*]r)4Zl0M 8piӖ9sf߳>A蜳g>3yyff{_8%K?' 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