Informed Consent - Vortala...Informed consent for chiropractic care is a process and dialogue with...

Informed Consent PATIENT NAME:_______________________

Informed consent for chiropractic care is a process and dialogue with your doctor about the risks and benefits of proposed treatment and other available treatment options, to allow you to make knowledgeable decisions about your care. It is important that you, the patient, read this document in its entirety. As a patient, it is essential that you knowledgeably participate in decisions concerning the nature and course of your care. It is essential that you ask questions and receive sufficient information from you chiropractic physician about the potential risks, proposed benefits and alternative to you proposed chiropractic treatment plan. Please DO NOT SIGN this document until you’ve had the opportunity to ask questions about your care and fully understand the care to be rendered, and have read this document in its entirety.

Chiropractic Treatment

Chiropractic includes many standard examination and testing procedures. These may include a physical examination, orthopedic and neurological testing, palpation, specialized instrumentations, laboratory tests, radiology examination, and rehabilitative procedures, among others.

The primary therapy utilized in your chiropractic treatment is a spinal adjustment. A chiropractic adjustment is the application of a quick precise movement to a specified contact point of a vertebrae or other joint. Joint function can be compromised in a number of ways and can affect a patient’s overall health. Chiropractic manipulation or adjustment may cause an audible “pop” or “click”, similar to what you have experienced when you “crack” your knuckles. You may also feel a sense of movement at the area adjusted.

Probability and Nature of Risks Inherent in Chiropractic Adjustment and Treatment

There are certain complications that may arise during chiropractic adjustments and therapy. Rarely, you may incur fractures, disc injuries or dislocations. Occasionally after adjustment or therapy you may experience muscle strain, or new, increased, or tingling, numbness or pain. Some patients will feel some stiffness and soreness following the first few days of treatment.

Risks and Dangers of Remaining Untreated

Remaining untreated may result in persistent or increasing pain or other symptomatology, increase loss of function, formation of adhesions contributing to a pain reaction further reducing mobility, or worsening of your condition. Over time, if you choose to remain untreated, this may complicate future treatment, and make future treatment more difficult and less effective the longer treatment is postponed.

Availability and Nature of Other Treatment Options

If you choose to use any of the other treatment options listed below, you should be aware that there are risks and benefits of such options. You may discuss these risks with your doctor.

Other treatment options for your condition may include:

• Self-administered, over-the-counter analgesics and rest

• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers

• Hospitalization and or surgery

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. I have discussed treatment options and goals, risks of various treatment options, and alternative treatment options with a Whole Human Health doctor and have had my questions answered to my satisfaction. By 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.

Patient’s Name:_____________________ Doctor’s Name:__________________________

Signature:__________________________ Signature:_______________________________

Date:__________

Signature of Parent or Guardian (if a minor):_________________________________________

HIPAA Acknowledgment !

We are concerned with protecting your privacy especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our privacy policy and procedures. We encourage you to read this document carefully for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you have any questions or concerns regarding the use or dissemination of your personal information, we would be happy to address them.

I herby agree to give Whole Human Health permission to publish or to use in print or electronic media photographic images/video in which I may be included, in whole or in part for treatment planning, educational, promotional or advertising purposes and I waive the right to inspect and or approve the finished photographic product.

I have received a copy of the HIPAA of 1996 for Whole Human Health.

Signature ________________________________ Date _________________

Really Fun Paperwork

Contact Information

First Name:____________________ Last Name:___________________ Age:_________ DOB:________________ Email:_____________________________ Phone:___________________ Address:_________________________________________________________ City & State:____________________ Zip:__________ Occupation:_______________________ Marital Status: S M W D How did you hear about us?_________________________ Emergency contact information: Name:______________________ Relationship:___________________ Phone:_________________

UNDERSTANDING OF FINANCIAL AGREEMENT:

In considering the amount of medical expenses to be incurred, I, the undersigned, guarantee payment in full directly to Whole Human Health at the time of service. I understand that I am financially responsible for all charges regardless of any possible applicable insurance or benefit payments. I understand that it is my responsibility to ensure possible claims reach my insurer or employee health care facilitator in a timely manner. Payment is due in full at the time of service, no exceptions. If an outstanding payment remains on my account beyond the time of service I give Whole Human Health the right to charge my card in full for any outstanding balance. Outstanding balances may not only be achieved from services; but can also be incurred from late cancellation and or missed appointments.

Name of person financially responsible:______________________________ Signature of person financially responsible:___________________________ Date:_____________ Witnessed by:___________________________

PAIN & Discomfort CHART

Patient:________________________

!!If coming to the office for pain or discomfort please circle the area below.

Describe what the pain or discomfort feels like: _______________________________________!!!!!!! Please label the area below and mark an “X” where your discomfort level is.

PAIN CHART

Patient: DOB: Date: File #:

Show area(s) of pain or unusual feeling on the diagrams below.

Mark the areas on the diagrams where you feel the described sensations. Use the indicated symbols and include all affected areas.

NUMBNESS PINS & NEEDLES BURNING ACHING STABBING

- - - - - - - - - OOOOOOOOOO XXXXXXX ******* /////////

Patient Signature Doctor’s Initials

VISUAL PAIN SCALE


The lines below are used to represent the intensity of discomfort you might have in your body. Please indicate the area or region of the body, then place an “X” at the position on the line that indicates how much discomfort you feel in that area.

AREA #1:

No Discomfort Worst Pain Imaginable

AREA #2:


AREA #3:


AREA #4:


AREA#5:



VISUAL PAIN SCALE


The lines below are used to represent the intensity of discomfort you might have in your body. Please indicate the area or region of the body, then place an “X” at the position on the line that indicates how much discomfort you feel in that area.

AREA #1:


AREA #2:


AREA #3:


AREA #4:


AREA#5:



Patient'Name:__________________________' '

'Date:___________''''''''DOB_______________' ' ' ''''

' ' ' ' '

'

Sleep%questions:%%1. ESS:''How%likely%are%you%to%drift%off%to%sleep%while…%(0=%no%chance%of%sleep,%3=%high%chance)'

a. Reading' ' ' ' ' '''''' 0% %%%1% %%%%2% %%%%3'b. Watching'TV' ' ' ' ' ' 0% %%%1% %%%%2% %%%%3'c. Sitting'in'a'meeting/presentation' ' ' 0% %%%1% %%%%2% %%%%3'd. Passenger'in'a'car'for'extended'time' ' 0% %%%1% %%%%2% %%%%3'e. Sitting'talking'to'someone' ' ' ' 0% %%%1% %%%%2% %%%%3% 'f. Sitting'quietly'after'lunch'with'no'alcohol' ' 0% %%%1% %%%%2% %%%%3'g. In'a'car'while'stopped'in'traffic' ' ' 0% %%%1% %%%%2% %%%%3'h. Take'a'nap'if'time'permits' ' ' ' 0% %%%1% %%%%2% %%%%3'

2. STOP:''Do%you………'a. Snore'loud'enough'to'hear'through'a'door?' ' YES% % NO'b. Feel'Tired,'fatigued'or'sleepy'during'the'day?' ' YES% % NO'c. Anyone'Observed'you'stop'breathing'in'your'sleep?' YES% % NO'd. Have'high'blood'Pressure'or'being'treated'for'it?'' YES% % NO'

3. Do%you……%a. Have'diabetes'or'been'told'you'may?' ' ' YES% % NO'b. Get'headaches,'especially'in'the'morning?'' ' YES% % NO'c. Have'erectile'dysfunction?' ' ' ' ' YES% % NO'd. Have'trouble'with'memory'or'focusing?' ' ' YES% % NO'e. Get'up'multiple'times'per'night'to'urinate?'' ' YES% % NO'f. Drink'alcohol'in'the'evening?' ' ' ' YES% % NO'g. Grind'your'teeth'or'a'dentist'told'you'so?' ' ' YES% % NO'h. Have'jaw'pain'or'TMJ'issues?' ' ' ' YES% % NO'i. Get'acid'reflux?' ' ' ' ' ' YES% % NO'

Satisfaction%of%sleep%(10=very%satisfied)% % 0% 2% 4% 6% 8% 10% %%

Bed%partner%questions:%1. Does%your%bed%partner%snore?'''' YES% % NO% % (if%yes%answer%APG)'

Does%the%snoring…..%a. Keep'you'up'at'night?' ' ' ' ' YES% % NO' '

b. Wake'others'because'of'snoring?' ' ' ' YES% % NO'c. Increase'with'alcohol'or'fatigue?' ' ' ' YES% % NO'd. Occur'every'night?' ' ' ' ' ' YES% % NO'e. Change'with'position?' ' ' ' ' YES% % NO'

Snoring%characteristics:%%%f.'''''Intensity:' (0'='no'sound,'10'='Loud'yell)'''' 0%%%1%%%2%%%3%%%4%%%5%%%6%%%7%%%8%%%9%%%10'g.''''Stop'breathing?'

How'often?''' 1P5%times/night%% 5P10%times/night%%% 10+%times/night''How'long?' 1P5%seconds% % 5P10%seconds% % 10+%seconds'

2. Does%your%bed%partner…..%a. Make'odd'movements'in'sleep'with'limbs?' ' YES% % NO'b. Wake'suddenly?' ' ' ' ' ' YES% % NO'c. Sweat'during'sleep?' ' ' ' ' ' YES% % NO'd. Make'unusual'noises'including'snorts'or'choke?' ' YES% % NO'

MEDICATION LIST


Prescription Medications Follow-up Dates

Name Dosage How Often

Reason Date Started

Over-the-counter Medications

Supplements/Herbs/Homeopathic Remedies

ALLEGERIES:

COMPREHENSIVE MEDICAL HISTORY


NAME OF GENERAL PRACTITIONER:

DATE OF LAST PHYSICAL EXAMINATION: INSTRUCTIONS FOR LAST MEDICAL SYSTEMS REVIEW: Please check if you now, or ever, have experienced the following: CONSTITUTIONAL 1. ___ Cancer 2. ___ Allergies 3. ___Fever or Chills 4. ___Weight loss or gain 5. ___Night sweats 6. ___Fatigue 7. ___Insomnia or changes in sleep 8. ___Other

ENDOCRINE 9. ___Diabetes 10. ___Thyroid disease 11. ___Intolerance to heat or cold 12. ___Increased thirst 13. ___Other

EYE, EAR, NOSE, THROAT 14. ___Glaucoma 15. ___Sinusitis 16. ___Poor vision 17. ___Pain in eye 18. ___Deafness/Difficulty hearing 19. ___Nosebleeds 20. ___Dental problems 21. ___Hoarseness 22. ___Other

PULMONARY 23. ___Asthma 24. ___COPD 25. ___Tuberculosis 26. ___Pneumonia 27. ___Difficulty breathing/shortness of

breath 28. ___Wheezing 29. ___Chronic cough or phlegm 30. ___Coughed up blood 31. ___Other

GASTROINTESTINAL 32. ___Appendicitis 33. ___Jaundice, Hepatitis, or Cirrhosis 34. ___Ulcer 35. ___Gallbladder disease 36. ___Colon polyps 37. ___Hemorrhoids 38. ___Poor appetite 39. ___Abdominal pain 40. ___Black or bloody stool 41. ___Frequent heartburn 42. ___Frequent bloating or gas 43. ___Frequent nausea or vomiting 44. ___Frequent diarrhea or

constipation 45. ___Difficulty swallowing 46. ___Other

CARDIOVASCULAR 47. ___Heart disease 48. ___High cholesterol or triglycerides 49. ___High blood pressure 50. ___Stroke 51. ___Rheumatic fever 52. ___Chest pain 53. ___Irregular/rapid heartbeat 54. ___Fainting/lightheadedness 55. ___Ankle swelling 56. ___Varicose veins 57. ___Other

BLOOD/LYMPH 58. ___Anemia 59. ___Bleeding disorder 60. ___Enlarged lymph nodes 61. ___Other

SKIN 62. ___Change in mole 63. ___Itching or rash 64. ___Other

Doctor Comments:

COMPREHENSIVE MEDICAL HISTORY


GENITOURINARY 65. ___ Kidney disease or stones 66. ___Urinary infection 67. ___Sexually-transmitted disease 68. ___Sexual difficulties 69. ___Frequent or painful urination 70. ___Bloody or discolored urine 71. ___Incontinence 72. ___Other

MALE SPECIFIC 73. ___Prostate disease 74. ___Testicular pain or swelling 75. ___Impotence/erectile dysfunction 76. ___Difficulty urinating 77. ___Other

FEMALE SPECIFIC 78. Date last period began: 79. ___Live births 80. ___Miscarriage or abortion 81. ___Painful periods 82. ___Irregular or heavy periods 83. ___Breast lump or pain 84. ___Hot flashes 85. ___Other

NEUROLOGIC/PSYCH 86. ___Epilepsy or seizures 87. ___Headache 88. ___Psychiatric disorder 89. ___Weakness 90. ___Numbness/tingling 91. ___Dizziness 92. ___Tremor or twitching 93. ___Arm/leg pain 94. ___Depression of Anxiety 95. ___Other

MUSCULOSKELETAL 96. ___Fracture or dislocation 97. ___Arthritis 98. ___Scoliosis/Spinal curvature 99. ___Neck or upper back pain 100. ___Lower back pain 101. ___Swollen/painful joint(s) 102. ___Other

CHILDHOOD DISEASES 103. ___Measles 104. ___Mumps 105. ___Chicken Pox 106. ___Other

TRAUMA 107. ___Motor vehicle accident 108. ___Other HOSPITALIZATIONS and SURGURIES (list dates and reasons) 109. _____________ 110. _____________ SOCIAL HISTORY 111. ___Smoking/tobacco use 112. ___Alcohol use 113. ___Recreational drug use 114. ___Sexually active with multiple

partners 115. Are you married/partnered? Yes No

Describe your exercise: 116. _____________ Describe your diet: 117. _____________ What is your occupation? 118. _____________ Do you have a supportive home environment? 119. _____________

FAMILY HISTORY 120. ___Kidney Disease 121. ___Heart disease or stroke 122. ___High blood pressure 123. ___Cancer 124. ___Thyroid disease 125. ___Diabetes 126. ___Neurological disease 127. ___Musculoskeletal disease 128. ___Psychiatric disease 129. ___Other

Doctor Comments:

Doctor’s Initials

As your chiropractor, my main objective is to offer chiropractic and wellness services that will allow you to respond as quic

least amount of time and in the most cost-effective fashion.

cannot do it alone, we need your help.

As a practice member of Whole Human Health you have responsibilit

Your Job… 1. Keep your appointment times as scheduled based on Dr. Hopper’s recommended care plan.

2. Follow your out of office corrective exercise, rehabilitative and or general exercise p

3. Follow the recommended nutritional and supplemental advice.

In addition… 1. Please consult us before you seek any other health or in

your progress and ultimate recovery.

2. It is our mission to see to it that every member of your family is living their most optimal life.

Optimal Life exam on any member of your immediate family, regar

member(s) at your earliest convenience.

In order to provide the chiropractic care you need as conveniently and rapidly as possible, we have established special hours

receive your adjustments with the absolute minimum time spent waiting. In order to make this possible the following have been established:

Consultations: If a consultation is needed with the doctor we request you schedule during “expanded patient hours”

necessary to solve any problems and answer all questions such as:

Examinations: Examination and report of finding visits will require extra time.

these visits will need to be scheduled during expanded patient hours.

Missed appointments: Changes in appointments require

must call within 24-hours of the appointment time; and reschedule for the next available time slot.

are after. Cancelling an appointment early also allows the opportunity for other patients in need of care to fill that time slot.

cancelled less than 24-hours prior may be subject to a late cancellation fee of $25.

$40 charge.

New Injury: If you experience a new injury or re

additional time to re-evaluate your care plan.

Courtesy: As a courtesy to others, please turn off your cell phone or leave it in your car.

turn your phone to silent or vibrate and take the call outside of the building.

I have read and understand all patient requirements. Signature:

426 S 3

Our office is designed and dedicated to fulfill your whole health needs. services, please feel free to discuss them with Dr. Hopper.

Practice member guidelines

As your chiropractor, my main objective is to offer chiropractic and wellness services that will allow you to respond as quic

effective fashion. We will do everything in our power to see that this goal is reached.

As a practice member of Whole Human Health you have responsibilities to ensure you are working toward our mutual goal of

Keep your appointment times as scheduled based on Dr. Hopper’s recommended care plan.

Follow your out of office corrective exercise, rehabilitative and or general exercise plan as laid out by Dr. Hopper.

Follow the recommended nutritional and supplemental advice.

Please consult us before you seek any other health or in-home treatments during your care. Other care or treatments may alter

e recovery. (this of course excludes emergency care)

It is our mission to see to it that every member of your family is living their most optimal life. To do this, allow us to perform a free

Optimal Life exam on any member of your immediate family, regardless of age or present health status.

member(s) at your earliest convenience.

In order to provide the chiropractic care you need as conveniently and rapidly as possible, we have established special hours

adjustments with the absolute minimum time spent waiting. In order to make this possible the following have been established:

If a consultation is needed with the doctor we request you schedule during “expanded patient hours”

necessary to solve any problems and answer all questions such as: New injuries, nutrition, supplements, exercises and financials.

Examination and report of finding visits will require extra time. To ensure you get the proper

these visits will need to be scheduled during expanded patient hours.

Changes in appointments require 24-hour advance notice. If you cannot make you scheduled appointment you

of the appointment time; and reschedule for the next available time slot. This will ensure

Cancelling an appointment early also allows the opportunity for other patients in need of care to fill that time slot.

hours prior may be subject to a late cancellation fee of $25. Missed appointments with no cancel may be subject to a

ry or re-aggravate an old injury please notify us as soon as possible as your next visit may require

evaluate your care plan.

As a courtesy to others, please turn off your cell phone or leave it in your car. If you are waiting on an important phone call please

phone to silent or vibrate and take the call outside of the building.

I have read and understand all patient requirements. Date:

Whole Human Health

426 S 3rd

street Geneva, IL 60134 630.487.1810

www.wholehumanhealth.com

Our office is designed and dedicated to fulfill your whole health needs. If you have any questions about any aspect of your care or our ces, please feel free to discuss them with Dr. Hopper. Your health care is our top priority!

As your chiropractor, my main objective is to offer chiropractic and wellness services that will allow you to respond as quickly as possible, in the

We will do everything in our power to see that this goal is reached. However, we

ies to ensure you are working toward our mutual goal of optimal health.

lan as laid out by Dr. Hopper.

Other care or treatments may alter

To do this, allow us to perform a free

dless of age or present health status. Please schedule your family

In order to provide the chiropractic care you need as conveniently and rapidly as possible, we have established special hours in which you can

adjustments with the absolute minimum time spent waiting. In order to make this possible the following have been established:

If a consultation is needed with the doctor we request you schedule during “expanded patient hours”. This will allow the time

New injuries, nutrition, supplements, exercises and financials.

To ensure you get the proper amount of time and attention

If you cannot make you scheduled appointment you

ensure you obtain the results you

Cancelling an appointment early also allows the opportunity for other patients in need of care to fill that time slot. Appointments

Missed appointments with no cancel may be subject to a

s soon as possible as your next visit may require

If you are waiting on an important phone call please

If you have any questions about any aspect of your care or our Your health care is our top priority!

After your first adjustment you will experience one of these scenarios: 1. No change at all.

2. Immediate feeling of relief and relaxation.

3. Increase in symptoms/discomfort or a change in the way you were feeling prior to the

What you will experience is much the same as muscle soreness after exercising. It is merely the result of your spine moving and becoming correctly aligned. adjustment, your body will become accustomed to the new changes.

NOTE: Use an icepack on the area to reduce discomfort. You may also notice symptoms in other areas of your body, especially if these subluxations have existed for anextended period of time. Your body has been attempting to compensate for these misalignments, so by restoring the normal structural alignment, areas above or below may shift. supporting soft tissues (ligaments andcorrective exercise to make a lasting correction. It is very important to remember that every body heals at a different rate because of varied physical and mental stresses. BE PATIENT! Give your body time to heal. or enhance the healing process. Listen to your body, watch your posture while sitting and lifting. reduce stressors in your life, both mental and phys

What can I expect?

After your first adjustment you will experience one of these scenarios:

Immediate feeling of relief and relaxation.

Increase in symptoms/discomfort or a change in the way you were feeling prior to the

What you will experience is much the same as muscle soreness after exercising. This is NOT a reason for concern. It is merely the result of your spine moving and becoming correctly aligned. With time and each subsequent

body will become accustomed to the new changes.

Use an icepack on the area to reduce discomfort. Apply ice for 15-20 minutes at a time.

You may also notice symptoms in other areas of your body, especially if these subluxations have existed for anYour body has been attempting to compensate for these misalignments, so by restoring

the normal structural alignment, areas above or below may shift. This compensation will also involve the supporting soft tissues (ligaments and tendons) and explains why it takes more than just one adjustment and corrective exercise to make a lasting correction.

It is very important to remember that every body heals at a different rate because of varied physical and mental Give your body time to heal. What you do outside of your appointment will either hinder

Listen to your body, watch your posture while sitting and lifting. reduce stressors in your life, both mental and physical. You are in the right place to start living optimally!

Increase in symptoms/discomfort or a change in the way you were feeling prior to the adjustment.

This is NOT a reason for concern. With time and each subsequent

20 minutes at a time.

You may also notice symptoms in other areas of your body, especially if these subluxations have existed for an Your body has been attempting to compensate for these misalignments, so by restoring

This compensation will also involve the tendons) and explains why it takes more than just one adjustment and

It is very important to remember that every body heals at a different rate because of varied physical and mental What you do outside of your appointment will either hinder

Listen to your body, watch your posture while sitting and lifting. Attempt to You are in the right place to start living optimally!

Patient Name:____________________ Date:____________ File#________ I understand that I am responsible for complete payment of the charges for services performed by Whole Human Health INC, regardless of possible 3rd party payers. Payment in full is required for all services at the time they are rendered. 3rd party payers if applicable will reimburse you the patient directly. Whole Human Health has no contracts or agreements with any 3rd party payers, it is the patients’ responsibility to ensure 3rd party payers receive all required documentation to be reimbursed. Whole Human Health Inc accepts payment in the form of cash, check, or credit card. I understand that if my account is past due 30 days, Whole Human Health, Inc will bill the credit card below to cover my out-standing balance. I understand that a $30 service fee will be charged to me on all checks returned for non- sufficient funds. I understand that a $30 fee will be charged to my account if I fail to cancel or re-schedule my appointment 24 hours in advance. I understand that in the event my account is turned over to a collection agency, a collection fee of 25% of the outstanding balance will be added to my account to cover the cost of collection. Auto pay can be set-up and the agreed upon monthly charges will be charged on the 1t-5th of every month to the credit card on file. ____ Yes, please bill my credit card automatically monthly. ____ No, I would prefer to pay at the time of service.

I understand and agree to the terms of the financial Responsibility Policy Client Name: _____________

_______________________________________________ Client Signature: _____________________________________ Date: ________________

**FORM MUST BE COMPLETED DESPITE CHARGING MONTHLY OR AT TIME OF SERVICE. THIS IS FOR SECURITY OF PAYMENT FOR RENDERED SERVICES

Credit Card Type: ____ Discover _____ Mastercard _____ Visa _____ Flex Card Credit Card #:____________________________________ Exp Date:____________ Name on Card: _________________________________ V- Code: _______________ Authorized Signature: ___________________________________________________

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