Confidential Health History

Please fill out this questionnaire completely. Your answers will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. THANK YOU.

Name

SS #

Date

Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Email address

Birthdate

Age

Marital Status

Spouse’s Name

No. of Children

Occupation

Is your condition due to an injury at work?

Yes No

Employer's Name

Address

City

State

Zip

Who referred you to us?

Who is responsible for paying for your treatment?

Do you have health insurance?

Yes No

If yes, with which insurance company?

Have you ever had previous chiropractic care?

If yes, date of last care

Name of your medical doctor

Address

City

State

Zip

If we are able to accept your case, what type of care do you want?

Corrective Care Pain Relief Only

Please check the appropriate box for any of the following symptoms which you have experienced. Only check the box if you have experienced the symptom; otherwise please leave it blank. We need all the facts about your health history before we accept your case. THIS INFORMATION IS CONFIDENTIAL

O – OCCASSIONAL

F – FREQUENT

C - CONSTANT

GENERAL

MUSCLE & JOINT

Pain or numbness in

GASTRO-INTESTINAL

EYES, EARS, NOSE & THROAT

CARDIO-VASCULAR

RESPIRATORY

SKIN

GENITO-URINARY

FOR WOMEN ONLY

Last gynecological exam

Please check the following conditions you have had in the past

What health problem do you want us to treat?

How long have you had these symptoms?

Have you had similar symptoms in the past?

How did it happen?

What activities make your symptoms worse?

Are your symptoms getting worse?

Yes No

Are your symptoms

Constant They come and go

Is this condition interfering with your

Work Sleep Daily routine Family or spouse relationship Other

Other, Specify

What things can’t you do now that you hope to be able to do after your treatments are done?

How long has it been since you really felt good?

List previous diagnoses and treatments you have received for your present condition

What do you believe is wrong with you?

What other health problems do you have

List any surgeries and dates

Drugs you now take

Nerve pills

Pain Killers

Muscle relaxers

Heart pills

Tranquilizers

Antibiotics

Birth control pills

Other

Other, Please specify

How often do you go to the dentist?

Every six months

Yearly

Toothache or emergency only

How old is your mattress?

Do you wear

Heel lifts?

Inner soles?

Arch supports?

Have you been in a car crash (even a “fender-bender”) in the

Past year

Past five years

Five to ten years ago

Over ten years ago

Never

Please describe the crash

Have you ever had any mental or emotional disorders?

Yes No

If so, When?

Type

Have others in your family had such disorders?

Yes No

If so, When?

Type

FAMILY HEALTH INFORMATION (Many health problems are hereditary. Thus, information about your family members will give us a better picture of your total health picture.)

Add Additional Name

HAVE YOU EVER

Have you ever been knocked unconscious?

Yes No

Please describe briefly

Used a cane, crutch, or other support?

Yes No

Please describe briefly

Been treated for a spine or nerve disorder?

Yes No

Please describe briefly

Had a fractured bone?

Yes No

Please describe briefly

Been hospitalized for other than surgery?

Yes No

Please describe briefly

DO YOU

Now take vitamins or minerals?

Yes No

Please describe briefly

Think you may need vitamins or minerals?

Yes No

Please describe briefly

Have an allergy to any drug?

Yes No

Please describe briefly

DATE OF LAST

HABITS

Sleep

Heavy Moderate Light None

Exercise

Heavy Moderate Light None

List below all conditions for which you have been treated in the past 10 years

WHO SHOULD WE CONTACT IN CASE OF EMERGENCY? (Name of relative or close friend NOT living with you):

Name

Relationship

Address

Phone

City

State

Zip

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

INFORMED CONSENT TO CHIROPRACTIC TREATMENT

I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures, including examination tests, diagnostic x-ray(s) and physical therapy techniques, on me

Patient's Name

which are recommended by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working for or associated with, or serving as back-up for the doctor of chiropractic named below.

I understand that, as with any health care procedure, there are certain complications, which may arise during a chiropractic adjustment. Those Complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, Homers' syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations.

Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications and I wish to rely on the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, are in my best interest.

I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose, and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed.

I have read ( ) or have had read to me ( ) the above explanation of the chiropractic adjustment and related
treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest to undergo the chiropractic treatment recommended Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

Name / Signature

Witness

Date

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE

The Body Connection Health and Wellness Center

As required by the Privacy Regulations, I hereby acknowledge that I have received a current copy of the Body Connection Health and Wellness Center‘s “NOTICE OF PRIVACY PRACTICES,” revision date

As required by the Privacy Regulations

from The Body Connection has explained the “NOTICE OF PRIVACY PRACTICES” to my satisfaction.

As required by the Privacy Regulations, I am aware that The Body Connection has included a provision that it reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains.

Requests

I wish to file a “Request for Restriction” of my Protected Health Information

I wish to file a “Request for Alternative Communications” of my Protected Health Information

I wish to object to the following in the “Notice of Privacy Practices":

I understand that this office is not required to honor any changes to the “Notice of Privacy Practices.”

Name / Signature

Date

(OFFICE USE ONLY)

Signed form received by

Date

Good faith effort to obtain receipt: (Describe)

NOTICE OF PRIVACY PRACTICES

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.

The Body Connection Health and Wellness Center is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information

Treatment
We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example)

"On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with The Body Connection"

"It is our policy to provide a substitute health care provider, authorized by Albertina D. Logan, D.C. to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation."

Payment
We may disclose your health information to your insurance provider for the purpose of payment or health care operations. (example)

"As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Albertina D. Logan, D.C. for health care services rendered. If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received."

Workers’ Compensation
We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.

Emergencies
We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.

Public Health
As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

Judicial and Administrative Proceedings
We may disclose your health information in the course of any administrative or judicial proceeding.

Law Enforcement
We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes

Deceased Persons
We may disclose your health information to coroners or medical examiners.

Organ Donation
We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.

Research
We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board

Public Safety
It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

Specialized Government Agencies.
We may disclose your health information for military, national security, prisoner and government benefits purposes.

Marketing
We may contact you for marketing purposes or fundraising purposes, as described below: (example)

"As a courtesy to our patients, it is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home, we leave a reminder message on your answering machine or with the person answering the phone. No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment."

“It is our practice to participate in charitable events to raise awareness, food donations, gifts, money, etc. During these times, we may send you a letter, post card, invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates and times, and request your participation in such an event. It is not our policy to disclose any personal health information about your condition for the purpose of The Body Connection Health and Wellness Center sponsored fund-raising events.”

Change of Ownership
In the event that The Body Connection is sold or merged with another organization, your health information/record will become the property of the new owner.

Your Health Information Rights

You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that the Body Connection is not required to agree to the restriction that you requested.
You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
You have the right to inspect and copy your health information.
You have a right to request that the Body Connection amend your protected health information. Please be advised, however, that the Body Connection is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
You have a right to receive an accounting of disclosures of your protected health information made by the Body Connection.
You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices
The Body Connection reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains. Until such amendment is made, the Body Connection is required by law to comply with this Notice.

The Body Connection is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact: Albertina D. Logan, D.C. by calling this office at (630)705-1475. If Albertina D. Logan, D.C. is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

Complaints
Complaints about your Privacy rights, or how the Body Connection has handled your health information should be directed to Albertina D. Logan, D.C. by calling this office at (630)705-1475. If Albertina D. Logan, D.C is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201

This notice is effective as of

I have read the Privacy Notice and understand my rights contained in the notice

By way of my signature, I provide the Body Connection with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.

Name / Signature

Authorized Facility Signature

Date

FINANCIAL RESPONSIBILITY

It is our office policy that payment for services is due at the time those services are rendered, unless prior arrangements have been made.

Cash Payment

If you prefer to pay with cash, personal check, or Visa/MasterCard/Discover, payment is expected at the time service is rendered. If you then choose to send a claim to your insurance company, we will gladly assist you with the necessary paperwork to process the claim.

Group / Private Health Insurance

Most health insurance policies reimburse to one extent or another for chiropractic office visits. However, your policy’s particular provisions must be verified with your insurance company. We will do this for you when you bring in your insurance identification card(s). Until insurance coverage is verified, you must pay for each visit at the time of that visit. When we accept assignment of your insurance benefits, you need to pay your deductible (if it has not been met for the year) and the percentage of the charges that your insurance policy does not cover (your co-insurance or co-payment) at the time those respective services are rendered. You are also responsible for any charges not paid by your insurance company.

Worker’s Compensation

If your injury occurred in the course of your employment, your employer’s worker’s compensation insurance will pay for 100% of the care you receive, assuming there are no complications or disputes arising from the incident. As required by law, it is imperative that your employer complete an “Employer’s First Report of Injury or Illness.” You will need to pay for services as they are rendered until your Worker’s Compensation has been verified.

Personal Injury / Automobile Accident

If you have been involved in a personal injury or injured in an automobile accident, you will need to provide: 1) your auto insurance identification card, 2) the auto insurance information of the other person(s), 3) your health insurance card(s) and 4) the name, address and telephone number of the attorney(s) handling your case. Until all insurance information is obtained and verified you will need to pay for services as they are rendered.

Medicare

Medicare Part B is your primary health insurance. Medicare coverage is explained on a separate sheet of paper that we will provide to you. Currently, the deductible for Medicare is $100.

I understand and agree that the primary responsibility for payment rests with me

I understand that insurance policies are agreements between the insurance carrier and myself. I understand that the Body Connection Health and Wellness Center will assist me in making collection from my insurance company and that any payments received towards my account from my insurance company will be credited to my account. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment of these fees.

Furthermore, I understand and agree that should my account need to be turned over to a collection service or attorney because of a delinquency in payment, all collection fees and legal fees incurred by The Body Connection Health and Wellness Center will be added to my balance and I will be personally responsible for them.

Initial

Signature

Date

We believe this is a clear definition of our financial policy. If you have any questions at any time concerning your insurance coverage or financial obligations related to your care, please do not hesitate to ask. We are here to help. This financial policy has been designed to allow you and the doctor to concentrate on the primary goal – regaining and maintaining your health.

I have read and I understand my financial responsibilities with regard to my treatments at the Body Connection Health and Wellness Center and I agree to honor and abide by those responsibilities.

Name / Signature

Parent or Legal Guardian Signature, if minor

Date

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