SHEPHERD CHIROPRACTIC

Patient InformationName__________________________________________________________ First M.I. Last

Street Address________________________________________City_____________________State_____ Zip_________Home # (____)_________________ Cell # (____)________________ Work # (____)________________E-mail___________________________________ May we include you in our online newsletter? Yes NoSocial Security #_______-_____-_______ Sex M F Birthdate____/____/______ Age______

Single Married Widowed Separated Divorced

Occupation___________________________________________ Emergency Contact ______________________________Employer_____________________________________________ Relationship_____________________________Parent's name (if a minor) ____________________________ Home #(____)______________ Alt (____)_____________Spouse's Name________________________________ Number of children___________To whom may we thank for referring you?________________________________________________

Injury InformationIs your condition due to an accident? Yes No Date: ________________Type of accident? Automobile Work Home OtherTo whom have you reported the accident? Insurance Worker’s Comp Employer Other__________Attorney Name (If applicable)___________________________________

Information About Your ConditionReason for visit____________________________________________________________________________________When did your symptoms begin?___________________________________________________________________Is this condition getting progressively worse?______________________________________________________How does it feel? Burning Sharp Shooting Dull Aching Stiff Tingling Throbbing Swelling Other_____________________________________How often do you have this pain?_____________________________________________________________________What makes your condition better?___________________________________________________________________What makes your condition worse?____________________________________________________________________Does it interfere with Work Sleep Daily Routine RecreationActivities or movements that are painful to perform Sitting Standing Walking Bending Lying down

Health HistoryHave you ever seen a Chiropractor before? Yes No Previous Chiropractor______________________________What treatment (if any) have you already received for your condition? Medications Surgery Physical Therapy Chiropractic services Other_____________________________How often do you exercise? Daily Moderate Heavy NoneWork activity includes Sitting Standing Light Labor Heavy Labor Smoking Packs/Day _____________ Alcohol Drinks/Week ___________ Coffee/Caffeine Cups/Day ______________ Are you pregnant? Yes No

Injuries and SurgeriesSpinal taps/injection Description:______________________________________________ Date:_____________________Accident/falls Description:______________________________________________ Date:_____________________Head injuries Description:______________________________________________ Date:_____________________Broken bones Description:______________________________________________ Date:_____________________Dislocations Description:______________________________________________ Date:_____________________Surgeries Description:______________________________________________ Date:_____________________

Medications__________________________________________________ Taking for:__________________________________________________________________________________________________ Taking for:__________________________________________________________________________________________________ Taking for:________________________________________________Vitamins/Supplements:______________________________________________________________________________________Review of Symptoms: (Circle current problems, Check significant past problems)Constitutional Breathing and Lungs Blood System___ Decreased sleep ___ Shortness of breath ___ Lymph gland swelling___ Irregular sleep ___ Wheezing or asthma ___ Easy bruising___ Excessive sleep ___ Repeated colds and flus Hormones and Metabolism___ Poor appetite ___ Cough – dry or irritating ___ Thyroid trouble___ Fevers ___ Cough up mucous or blood ___ Weight and diet trouble___ Chills Digestion and Intestines ___ Fluid retention___ Fatigue ___ Indigestion Moods, Thought, Emotions___ Food cravings ___ Belching ___ Manic episodes___ Weight loss ___ Difficulty swallowing ___ Energy problems___ Weight gain ___ Heartburn ___ Spiritual needsImmune System ___ Diarrhea ___ Depression___ Too many infections ___ Liver trouble ___ Anxiety___ Allergies to food or environment ___ Hemorrhoids, piles ___ Anger problems___ Other concerns ___ Vomiting ___ Panic or fear attacksEyes ___ Nausea Muscles, Bones, Joints___ Eye pain ___ Rectal pain or itching ___ Neck pain___ Blurred vision ___ Abdominal pain ___ Back pain___ Poor vision ___ Cramping bowels ___ Muscle pain___ Corrective lenses ___ Gassy gut ___ Muscle weakness___ Near-sighted ___ Constipation ___ Muscle cramps___ Far-sighted ___ Foods that upset system: ___ Joint swelling___ Other:_______________________ _____________________________ ___ Painful jointsSkin, Hair,Breasts Nerves, Movement, Brain ___ Elbow? ___ Shoulder?___ Breast lumps or pain ___ Seizures ___ Hip? ___ Knee?___ Rashes ___ Poor balance ___ Ankle? ___ Foot?___ Menopause ___ Poor coordination ___ Toes? ___ Fingers?___ Hair loss ___ Tremors or shaking ___ Wrist? ___ Hands?___ Dry skin ___ NumbnessEars, Nose, Mouth, Throat ___ Dizziness___ Ringing ears ___ Poor memory___ Nose bleeds ___ Trouble sleeping___ Postnasal drip Heart and Circulation___ Sinus problems ___ Chest pain___ Trouble with taste/smell ___ Lightheadedness___ Poor hearing ___ Palpitations___ Earaches ___ Fainting___ Bad breath ___ Cold hands/feet___ Headaches ___ Swelling feet___ Facial pain ___ Varicose veins___ Jaw clicks Urine, Kidneys, Bladder___ Teeth problems ___ Decreased urine flow___ Grinding teeth ___ Painful urination___ Trouble chewing ___ Frequent urination___ Sore throat ___ Sudden urges to urinate___ Mouth sores ___ Blood or pus in urine

Name_______________________________________ Date__________________________________

Pain DrawingBe sure to fill this out extremely accurately. On the diagram below mark the area on your body where you feel the described sensation(s). Use the appropriate abbreviation(s), mark areas of radiating pain, and include all affected areas.

Dull/Achy Pain = D Numbness = N Stiffness = FSharp Pain = S Tingling = T Throbbing = B

Visual Analogue ScalePlease mark on the line the pain level that most accurately represents your pain. If there is more than one area write the area (example: neck, mid-back, low back, etc.) beside your mark.

Right Now: No Pain 0----------------------------------50----------------------------------100 Unbearable

At Worse: No Pain 0----------------------------------50----------------------------------100 Unbearable

www.chiroevidence.com

Informed Consent to Chiropractic Treatment

The practice of chiropractic is the application of chiropractic science in the adjustment of the spinal column, skeletal articulations, and adjacent tissue. This includes diagnosis and analysis to determine the existence of spinal subluxation and associated nerve energy expression. The doctor will establish a chiropractic program which includes, but is not limited to, chiropractic adjustments, exercise, lifestyle changes, nutrition, and other wellness oriented activities.

The risks of complications due to chiropractic care have been described as “rare”. As in any health care procedure, there are possible risks. Muscle and ligament strain is the most common complaint following chiropractic care. In patients who are elderly and exhibit bone mineral loss, an occasional rib fracture may occur. The least common occurring complication is stroke. It is estimated the risk for this problem to be 1 in 3 million per chiropractic adjustment, which statistically is less frequent that that of spontaneous stroke occurring in the general public. You can be comforted by the fact that serious injury is so infrequent that the average malpractice premium for chiropractors is less than $3,000 annually, compared to tens of thousands of dollars for traditional medical specialists.

Financial Policy for Major Medical Patients

Thank you for trusting us with your health. We will do everything we can to assist you in getting and staying well. The following policies are established so that we can provide you with the best possible service.

Our office hours are Mondays, Wednesdays, and Fridays from 8am -12pm and 2pm - 6pm andTuesdays and Saturdays from 8am – 10am. Emergency care is available by calling our office.

Please make every effort to maintain your appointments and your schedule of care. Our staff will try to reschedule you as soon as possible to make up any missed treatment so that you can stay on your schedule of care. Please call if you are going to miss your appointment time so we can make this time available to others.

We want you to be an informed partner in your health care. Please ask any questions that you may have. We loan out educational books and videos and also offer informational classes (watch for times and dates to be posted in our office).

Our office is built on referrals from our patients and our friends. Your referrals are always welcome. With each new patient referral, our office will thank you with a complimentary adjustment. Please look for your card in the mail.

Most major medical policies are covered here in our office. As a courtesy, we will verify your insurance benefits. This will be done after your first visit. You will be given a quotation of your anticipated insurance benefits, but this is not a guarantee. All co-pays are due at the time services are rendered. Patient balances may be subject to change due to the unpredictability of insurance payments. You will be 100% responsible for any unpaid balances by your insurance company.

I have read the explanation above of chiropractic treatment and the financial policy. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment for myself (or my child), and hereby give my full consent to treatment.

Printed Name____________________________________________

Patient/Guardian Signature___________________________________________

Date___________________________

Lien and Assignment of Insurance Benefits

I(we), the undersigned patient and/or legal representative(s) of that patient, in consideration of the services rendered or to be rendered by you, Shepherd Chiropractic, hereby understand and agree to the following:

I am personally responsible for all bills incurred by me for services rendered by Shepherd Chiropractic. I understand that you may make claims to insurance companies and other third parties for reimbursement to changes on my behalf as a result of professional services rendered by you. I agree, however, that I remain personally liable for all amounts due to you, which are not paid by such insurance companies or other third parties.

In the event that any insurance company or third party is obligated by contractual agreement to make benefit payments to me or you, I hereby authorize and direct that such insurance companies or other third parties make direct payments to you for any amounts owed to the extent allowable under such contractual terms.

In the event that any insurance company or third party under contractual obligation to make benefit payments to me or you refuses to make such payments after demand is duly made, I hereby assign, transfer, and set over to you, free and clear of any other encumbrances, the right to bring demands, claims, and other causes of actions which exist in my favor, against any such insurance companies or third parties for the total amounts owed to you. I authorize you to prosecute such actions and to compromise, settle, or otherwise resolve such claims as you determine appropriate.

In the event that the treatment provided by you was necessitated as a result of the potential negligence of any entity, I hereby give a lien to you against the proceeds of any settlement, judgments, or verdicts which may be acquired against such entity or any other third party providing indemnification or compensation to such entity.

I hereby authorize and direct that any attorney who may now or hereafter represent me make direct payments to you for services rendered out of the proceeds of any such settlement, judgments, or verdicts.

You are authorized to release information concerning my condition and treatment to my insurance company and attorney for the purposes of processing claims for benefits and payment of services rendered to me.

I hereby state that a photocopy of this document shall be as valid and binding on all parties as the original and applies to all past and future records.

Consent for Use or Disclosure of Health Information

There are several circumstances in which we may have to use or disclose your health information.

• We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.

• We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.

• We may need to use your health information within our practice for quality control or other operational purposes such as reminder cards, messages on your answering machine or voice-mail, or newsletters.

You have the right to request that we do no disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us.

You may revoke any of your authorizations at any time; however, your revocation must be made in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have the right to your health information if they decide to contest any of your claims.

By signing below, I have read and agree to the terms of the information above.

Printed Name_____________________________________________

Patient/Guardian Signature____________________________________________

Date:_______________________

Notice of Privacy PracticesInformation that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the Federal privacy rules.

Your Right to Complain

You may complain to us or to the Secretary of Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. While you may make an oral complaint at any time, written comments should be sent to us at the address listed below.

To Contact Us

If you would like further information about our privacy policies and practices please contact:

Shepherd Chiropractic2343 West Silvernail Road

Pewaukee, WI 53072262-548-9000

This notice is effective as of ________________. This notice will expire seven years after the date upon which the record was created. By signing below, I acknowledge that I have received a copy of this notice.

___________________________________Patient Name Printed

___________________________________Date

___________________________________Patient Signature

___________________________________Authorized Provider Representative

___________________________________Personal Representative Printed

___________________________________Personal Representative Signature

_____________________________________________________________________________Description of Personal Representative's authority to act for the patient