“Your Gateway to Optimum Performance” _____________________________________________________________________________________
New Practice Member Application Full Name _________________________________________ Date___________ Gender: M F Address ________________________________City________________ State____ Zip________ Phone (Home) __________________ (Cell) ___________________ (Work) __________________ Email Address _____________________________ (for schedule changes, newsletters) Date of Birth _________________________ Age______ Single____ Married____ Widowed____ Spouse’s Name _______________ Children’s Names and Ages ___________________________ _____________________________________________________________________________ ______________________________________________________________________________ Occupation_________________________ Previous chiropractic care? Y N When?_________ What have you heard about chiropractic?_____________________________________________ ______________________________________________________________________________ Who may we thank for referring you? _______________________________________________ Reason for visiting our office ______________________________________________________ ______________________________________________________________________________ Anything I should know about your spine and nervous system? _____________________________ ______________________________________________________________________________ Previous traumas, injuries or accidents? ______________________________________________ ______________________________________________________________________________ Previous Surgeries/ Hospitalizations? ______________________________________________________________________________ Any other medical conditions? _____________________________________________________ ______________________________________________________________________________ What do you enjoy doing when you are not working? ______________________________________________________________________________ 21 High Park Dr. Ste. 8 Blue Ridge, GA 30513 (706) 946-5433 (706) 946-5434(fax)
www.blueridgespinalhealth.com
“Your Gateway to Optimum Performance” Practice Member Agreements Acknowledgment of Fees The practice member acknowledges that these are cash fees and no 3 rd party insurance or Medicare will be billed or accepted. We do not bill patients, their insurance or Medicare for any procedures performed in this office. This includes manipulation of the spine and its articulations. We charge a fee for the Applied Kinesiology examination and the time required for muscle testing ONLY. The adjustment itself, if or when it’s performed to anyone regardless of benefits does not carry a fee, and therefore no reimbursement through Medicare is possible. Medicare does not cover muscle testing as performed through Applied Kinesiology methods. Medicare also does not cover Functional Medicine, Nutritional Supplements or Homeopathies. As an elective care office, we do not participate in any lawsuit, medical case, opinion or testimony unless required by law to do so. We do not accept any personal injury, slip and fall or workman’s compensation cases. Visits All visits are to occur during regular office hours, or unless special appointment is made ahead of time in office or over the phone. Due to the special nature of the practice, it is necessary for Dr. Smith to occasionally take time away from the office for Applied Kinesiology related events, including elective and mandatory continuing education courses and speaking events in the local community. Blue Ridge Spinal Health will make a sincere effort to notify all members of any changes to adjusting hours in advance by way of phone and online for patients with an already scheduled appointment. Recommendations Members are recommended non-therapeutic monthly spinal checks (elective care), regardless of how you may feel. Pain is not necessarily an indicator of when there is vertebral subluxation present and many other health issues that arise in the body do not necessarily carry the symptom of pain. Office visits do not necessarily mean you will receive a chiropractic adjustment, but are used to determine if vertebral subluxation is present and adjust when necessary. This Plan is Not Insurance This agreement does not constitute insurance. The care offered in this office is non-incidental, elective care provided in a non-therapeutic mode based on the practice member coming in regularly to be checked to be evaluated through Applied Kinesiology muscle testing. Release of Endorsement Blue Ridge Spinal Health has consent to the release of pictures, videos and/or testimonials promoting the services rendered for the member and additional family members listed. Blue Ridge Spinal Health also has consent to send emails and texts regarding various events, updates and services and office schedule changes if and when they occur.
I Have Read the Agreement, Had the Opportunity to Have Questions Answered and Accept the Terms. Full Name __________________________________________________ Date Signed __________________
Signature ___________________________________________________ Date Signed ___________________
21 High Park Dr. Ste. 8 Blue Ridge, GA 30513 (706) 946-5433 (706) 946-5434(fax)
www.blueridgespinalhealth.com
“Your Gateway to Optimum Performance” Terms of Acceptance/ Consent to Treat: When a person seeks the services of a Chiropractor or Applied Kinesiologist, it is essential he/she fully understands the objectives of that chiropractor. Chiropractic as it applies to this office has only one goal. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the application of a gentle and specific force to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine and it’s vertebra. Vertebral Subluxation: A misalignment of one of the 24 vertebra in the spinal column that causes alteration of nerve function and interference to the transmission of neuronal impulses, resulting in a lessening of the body’s innate ability to express its maximum potential. We do not offer to diagnose or treat or cure any disease or medical condition other than vertebral subluxation. Nor do we offer advice regarding treatment prescribed by other medical healthcare providers. THE ONLY PRACTICE OBJECTIVE is to eliminate structural interference of the body’s spinal column and facilitate the body’s natural healing. Our method is specific adjusting to correct vertebral subluxations as found through manual muscle testing. HIPAA Privacy Practices Your private healthcare information will not be shared with anyone unless you have a signed form to release your records that is signed by you, or your legal guardian, or if required by law to do so. I authorize Blue Ridge Spinal Health to use a telephone or email to use my name, address and phone number for the limited purpose of contacting me to notify me of pending office related communications. I also authorize my chiropractic provider to disclose to third parties ( i.e. family members at home etc.) who may answer my phone to leave a reminder message with them or on my voice mail system and/or answering machine if necessary. I, _____________________________________________have read and agree to the above terms. I have also had the opportunity to ask questions about any content in the Terms of Acceptance/ Consent to Treat. I therefore accept the chiropractic assessments and consent to treat on this basis. Signature: __________________________________ Date: _______________________
Consent to evaluate and adjust a minor child (if necessary) I, _____________________________being the parent or legal guardian of __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ _______________ Date:__________________ have read and fully understand the Terms of Acceptance and hereby grant permission for my child to receive chiropractic care.
21 High Park Dr. Ste. 8 Blue Ridge, GA 30513 (706) 946-5433 (706) 946-5434(fax)
www.blueridgespinalhealth.com
“Your Gateway to Optimum Performance”
CASE HISTORY
Today’s Date:
Dr. C.J. Smith D.C., CFMP, PAK PATIENT INFORMATION
Patient’s last name:
First:
Middle:
Age:
DOB:
Sex:
HISTORY Are your present problems due to an injury?
No
Has the accident been reported?
No
Are you now or have you ever been disabled? (Service Work) Have you retained an attorney? List any accidents or falls and dates:
When:
Why:
Name:
Address:
No No _________________
______
___________
_______________________ ________________________
List any broken bones (fractures) or dislocations: _______________________________________________________________ o Why? ________________________________________________________________________
_______ By Whom? ____________________ Have you ever had an X-
, When? ________________________________________________________
For what ailments were these X-rays made? ___________________________________________________________________ Do you suffer from any condition other than that for which you are now consulting us? __________________________________ Are you presently taking any medication – prescription or over-the_______________________________________________________________________________________________________ _______________________________________________________________________________________________________
Habits Smoking: Yes No If so, how many packs? Drinking: Yes No Alcohol: Caffeine: Yes No If so, how many cups?
Exercise None Light Activity Moderate Activity Active Very Active Elite Athlete
Family History Mother: Diabetes Heart Kidney Cancer Other: ____________________ Father: Diabetes Heart Kidney Cancer Other: ____________________ Brother: # of: Diabetes Heart Kidney Cancer Other: __________________________ Sister # of: Diabetes Heart Kidney Cancer Other: __________________________
21 High Park Dr. Ste. 8 Blue Ridge, GA 30513 (706) 946-5433 (706) 946-5434(fax)
www.blueridgespinalhealth.com
OPERATIONS AND PROCEDURES Procedure Date Procedure Date Vaccinations Tubes in Ears Tonsillectomy Appendectomy Gall Bladder Female Organs Back Operation Rectal Surgery Other: Other: ocedures/surgeries.
Date
Procedure Sinus Hernia Thyroid Stomach Other:
PAIN CHART Pain Symptoms: (In Order of Severity)
1.
Began-(Mo/YR)
Previous Episodes:
2.
Began-(Mo/YR)
Previous Episodes:
3. Please mark the intensity of you pain today. 1st Visit 0-
No Pain
Began-(Mo/YR) Previous Episodes: Please mark the intensity of you pain today. 2nd Visit
10- Intense Pain
1-
Example: ________NECK___________________ 1 1.
No Pain
10- Intense Pain
Example: ________NECK___________________
2 3 4 5 6 7 8 9 10 _____________________________
1
2 3 4 5 6 7 8 9 10 1._____________________________
1 2 3 4 5 6 7 8 9 10 2.____________________________
1 2
1 2 3 4 5 6 7 8 9 10 3._____________________________
1 2 3 4 5 6 7 8 9 10 3._____________________________
1 2
1
3
4
5
6
7
8
9
10
Please mark area & type of pain on the drawing using the codes listed
N – Numbness P – Pain T – Tingling A – Ache S – Soreness ST - Stiffness
Doctors Use Only
3 4 5 6 7 8 9 10 2._____________________________
2
3
4
5
6
7
8
9
10
Please mark area & type of pain on the drawing using the codes listed
N – Numbness P – Pain T – Tingling A – Ache S – Soreness ST - Stiffness
Doctors Use Only
21 High Park Dr. Ste. 8 Blue Ridge, GA 30513 (706) 946-5433 (706) 946-5434(fax)
www.blueridgespinalhealth.com
HAVE YOU HAD, OR DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?
ma 46.9 Migraine Headaches Sclerosis
787.3 Belching/Gas 789.0 Abdominal Pain 564.0 Constipation
493.9 Asthma 378.9 Crossed Eyes 389.9 Deafness
780.39 Convulsion 780.4 Dizziness 780.2 Fainting 780.79 Fatigue 780.6 Fever 784.0 Headache 780.52 Loss of Sleep 783 Loss of Weight 799.2 Nervousness 729.8 Neuralgia 780.8 Sweats 786.07 Wheezing 311 Depression
787.91 Diarrhea 783.6 Excessive Eating 575.9 Gail Bladder 455 Hemorrhoids 782.4 Jaundice 794.8 Liver Trouble 787.02 Nausea 536.8 Stomach Pain 783.0 Poor Appetite 536.8 Poor Digestion 787.03 Vomiting 578.0 Vomiting Blood 783.5 Excessive Thirst
388.70 Earache 388.60 Ear Discharge 388.30 Ear Noises 240.9 Enlarged Thyroid 460 Frequent Colds 477 Hay Fever 784.49 Hoarseness 478.1 Nasal Obstruction 784.7 Nosebleeds 379.91 Pain in Eyes 368.9 Poor Vision 461.9 Sinusitis 462 Sore Throat
536.8 Indigestion 569.3 Rectal Bleeding
463 Tonsillitis 786.2 Persistent Cough 787.2 Difficulty Swallowing 523.8 Bleeding Gums
Muscle/Joints/ Bones 724.5 Backache 719.7 Foot Trouble 550 Hernia 719.1 Pain between Shoulders 724.6 Painful Tail Bone 723.9 Stiff Neck 781.9 Spinal Curvature 719.0 Swollen Joints 781.0 Tremors/ Twitching 782 Arm Trouble
Cardio-Vascular
Never Previously Presently
995.3 Allergy: 780.9 Bronchitis 780.9 Chills
Skin or Allergies
401.9 High Blood Pressure 458.9 Low Blood Pressure 786.51 Pain Over Heart 785.9 Poor Circulation
680.9 Boils
Never Previously Presently
Respiratory
786.50 Chest Pain 786.2 Chronic Cough 786.09 Difficulty Breathing 786.3 Spitting Blood 786.4 Spitting Phlegm
Never Previously Presently
Eye/Ear Noise/Throat
Genito-Urinary
788.36 Bed Wetting 599.7 Blood in Urine 788.4 Frequent Urination 788.3 Lack of Bladder Control 590.9 Kidney Infection 788.1 Painful Urination 601.9 Prostate Trouble
Never Previously Presently
Gastro-Intestinal
Never Previously Presently
Never Previously Presently
General Symptoms
Never Previously Presently
Never Previously Presently
Never Previously Presently
Please check the correct box for each item below. Check at least one box for each or symptom listed.
For Woman ONLY
924.9 Bruising Easily
625.3 Cramps or Backaches 626.2 Excessive Flow
701.1 Dryness
627.2 Hot Flashes
691.8 Eczema
626.4 Irregular Cycle
438 Previous Heart Trouble 785.0 Rapid Heart 427.89 Slow Heart
708.9 Hives or Allergy
634.9 Miscarriage
698.9 Itching 782.0 Sensitive Skin
625.3 Painful Periods 623.5 Vaginal Discharge
436 Stroke 719.7 Swelling Ankles
782.1 Skin Eruptions
611.79 Lump in Breast Pregnant at this time?
454 Vericose Veins
21 High Park Dr. Ste. 8 Blue Ridge, GA 30513 (706) 946-5433 (706) 946-5434(fax)
Have you had a mammogram?
www.blueridgespinalhealth.com
I understand and agree that health and accident insurance policies are an arrangement between the insurance company and me. The Doctor’s office will prepare reports and forms necessary to assist me in the filing of my claim with the insurance company but cannot guarantee reimbursement from the insurance company. Direct payments made from the insurance company to the Doctor’s office will be credited to my account upon receipt and any balances due will be my responsibility. All services rendered to me are my personal responsibility and I agree to make payment for these services to the Doctor’s office. I also understand that if I suspend or terminate my care and treatment, any fees for services rendered will be immediately due and payable. Should third party collections become necessary, I agree to pay all fees involved in collection of the account. I authorize the Doctor to examine and treat my condition as deemed appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. Then amount paid to the Doctor’s office for X-rays is for the examination only; the X-ray negatives will remain the property of the Doctor’s office and will remain on file at the Doctor’s office as long as I am a patient. I am the responsible party for payment of any treatment received or incurred o the account. This Doctor provides only chiropractic care and is not responsible for any pre-existing medically diagnosed conditions or for making any medical diagnosis.
Patient’s/Guardian’s Signature X: __________________________________________________________ Date: ____________________
21 High Park Dr. Ste. 8 Blue Ridge, GA 30513 (706) 946-5433 (706) 946-5434(fax)
www.blueridgespinalhealth.com
