Intake
Please complete this questionnaire. Your answers will help us determine if we can help you. If we do not sincerely believe your condition will respond satisfactory, we will not accept your case. THANK YOU
Email address *
Name
Your answer
Gender
Marital Status
other
Your answer
Age
Your answer
Date of Birth
MM
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DD
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YYYY
Social Security Number
Your answer
Home Address
Your answer
Phone Number
Your answer
Email Address
Your answer
Employers Address
Your answer
Work Number
Your answer
Occupation
Your answer
How did you hear about us?
Your answer
Contact Information
Name
Your answer
Address
Your answer
Relationship
Your answer
Phone Number
Your answer
Reason For Visit Today (check all that apply)
A. MAJOR COMPLAINTS
1. What are your major complaints?
Shoulder Pain
Shoulder Numbness
Shoulder Tingling
Arm Pain
Arm Numbness
Arm Tingling
Forearm Pain
Forearm Numbness
Forearm Tingling
Hand Pain
Hand Numbness
Hand Tingling
Buttock Pain
Buttock Numbness
Buttock Tingling
Hip Pain
Hip Numbness
Hip Tingling
Thigh Pain
Thigh Numbness
Thigh Tingling
Leg Pain
Leg Numbness
Leg Tingling
Foot Pain
Foot Numbness
Foot Tingling
2. Date problems began
Your answer
3. Describe how problems began (fall, lifting, etc)
Your answer
4. Current pain level
No pain
Unbearable pain
5. How often do you experience symptoms
6. Are your symptoms worse in the
7. Since it began is it
8. What makes symptoms better
Your answer
9. What makes symptoms worse
Your answer
10. What daily activities are being affected
Your answer
11. Prior care/treatments for current complaints
Your answer
B. REVIEW OF SYSTEMS
Are you presently suffering (or within the past 6 months suffered) from any of the following?
1. A. General
Other
Your answer
2. What are your habits?
Never
Occasionally
Moderately
Excessively
Smoking
Alcohol
Recreational Drugs
Exercise
Stress
Poor Diet
C. MEDICAL HISTORY
1. A. Have you been to a chiropractor?
B. Do you have a family physician?
C. (Women) To the best of your knowledge are you pregnant?
(Women) Are you under the regular care of an OB-GYN?
D. Have you been hospitalized in the last 5 years?
E. Are you currently taking any medications?
If yes, which of the following
Other
Your answer
2. Which of the following illness have you had?
Other
Your answer
3. Prior injury history
Other
Your answer
4. Fractures/Broken bones (location & year)
Your answer
5. Surgery (location & year)
Your answer
D. FAMILY HISTORY
Cancer
Diabetes
Heart Trouble
High Blood Pressure
Stroke
Multiple Sclerosis
Headaches
Neck Problems
Back Problems
Disc Problems
Joint Problems
Arthritis
Pinched Nerve
Osteoporosis
Scoliosis
Bad Posture
E. INSURANCE INFORMATION
Is there insurance coverage for the vehicle you where in?
Who?
Your answer
How is this person related to you?
Other?
Your answer
Name of your auto insurance carrier?
Your answer
Have you reported this injury to your insurance carrier?
Claim adjusters name:
Your answer
Claim adjusters phone number:
Your answer
Claim number:
Your answer
Were the police called to the scene?
Was either driver cited by police?
Your answer
Other driver vehicle insurance company:
Your answer
Do you have an attorney representing you?
If yes please provide attorneys name, address and phone number
Your answer
Our office will provide insurance billing services for you if you so desire as a courtesy
Remember that you are ultimately responsible for any charges incurred in this office. It is your responsibility to pay any deductible amount, co-insurance, and or any other balances not paid by your insurance carrier. It is essential that if your insurance carrier sends you forms that need to be signed for authorization for records that you sign these documents and send the completed forms back to the carrier as soon as possible
Your signature on this document indicates that you:
1) Agree to pay for any outstanding bills incurred in this office.
2) Authorize the release of information necessary to secure the payment of benefits.
3) Authorize insurance payments to be made directly to Back In Line Health Care.
4) Authorize the use of this signature on all insurance submissions.
5) Authorize us to communicate through text/email. (Treatment related only and will NOT be shared)
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically.
Signature
Your answer
MM
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AUTOMOBILE CRASH QUESTIONNAIRE
Patient Name
Your answer
Date
MM
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DD
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YYYY
Date of injury
MM
/
DD
/
YYYY
Time of injury
Time
:
City where crash occurred
Your answer
Street (location) where crash occurred
Your answer
Road conditions
Estimated damage to your vehicle
Your answer
Who made estimate
Your answer
Model & Make of your vehicle
Your answer
Model & Make of other vehicle
Your answer
IMPACT DETAILS
Number of vehicles
Type of impact
Other
Your answer
Your vehicle was
Other vehicle was
During/after impact vehicle
What did vehicle hit
Your answer
Indicate if any of the following body part was hit or hit by something
Head
Your answer
Face
Your answer
Shoulder
Your answer
Arm/Hand
Your answer
Front chest wall
Your answer
Side chest wall
Your answer
Abdomen
Your answer
Hip
Your answer
Leg
Your answer
Knee
Your answer
Foot
Your answer
Where you wearing a seatbelt
Drivers foot on break at impact
Driver holding steering wheel with
Was the door(s)/trunk/hood of your vehicle damaged to the point where you could not open them
Did any airbag deploy
If yes, which bag
Your answer
Did you have any bruising after the crash
If yes where
Your answer
Awareness & Body Position Descriptions (Check all that apply)
Did you have your head and/or torso turned at the time of collision
If yes how far and why
Your answer
Were you leaning forward at the time of the impact resulting in a gap between your body and seat back
If yes how far and why
Your answer
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically.
Signature
Your answer
Date
MM
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DD
/
YYYY
FUNCTIONAL RATING INDEX
AREA OF COMPLAINT
1. Pain Intensity
No pain
Worst possible pain
2. Sleeping
Perfect sleep
Totally disturbed sleep
3. Personal Care (washing, dressing, etc.)
No pain; no restrictions
Severe pain; 100% assistance
4. Travel (driving, etc.)
No pain on long trips
Sever pain on short trips
5. Work
Can do usual work
Cannot work
6. Recreation
Can do all activities
Cannot do any activities
7. Frequency of Pain
No pain
Constant pain; 100% of the day
8. Lifting
No pain with heavy weight
Increased pain with any weights
9. Walking
No pain; any distance
Increased pain with all walking
10. Standing
No pain after several hours
Increase pain with any standing
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically.
Signature
Your answer
MM
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YYYY
Disclosure Forms
PATIENT PRIVACY SUMMARY
We are committed to preserving the privacy of your personal health information. In fact, we are required by law to protect the privacy of your medical information and to provide you with notice describing:

HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.

We are required by law to have your written consent before we use or disclose to others your medical information for the purposes of providing or arranging for your health care, the payment for or reimbursement of the care that we provide to you, and related administrative activities supporting your treatment.

We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization.

As our patient, you have important rights relating to inspecting and copying your medical information that we may maintain, amending or correcting that information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

We have available a detailed Notice of Privacy Practice which fully explains your rights and our obligations under the law. We may revise our Notice from time to time. The effective date at the top right hand side of this page indicates the date of the most current Notice in effect.

You have the right to receive a copy of our most current Notice in effect. If you have not yet received a copy of our current Notice, please ask at the front desk and we will provide you with a copy.

If you have any questions, concerns or complaints about the Notice or your medical information please contact Back in Line Health Care 360-977-3532

HIPPA CONSENT FORM
I consent to the use or disclosure of my protected health information by Back in Line Health Care for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Back in Care Health Care.

I understand that diagnosis or treatment of me by Back in Line Health Care may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice. Back in Line Health Care is not required to agree to the restrictions that I may request. However, If Back in Line Health Care agrees to a restriction that I request, the restriction is binding.

I have the right to revoke this consent, in writing, at any time, except to the extent that Back in Line Health Care has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, Aaron Herbert, DC., a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Back in Line Health Care’s Notice of Privacy Practices prior to signing this document.

The Back in Line Health Care’s Notice of Privacy Practices has been provided to me.

The Notice of Privacy Practices described the type of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Back in Line Health Care.

This Notice of Privacy Practices also describes my rights and the duties of Aaron Herbert, DC. with respect to my protected health information.

Aaron Herbert, DC. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

I may obtain a revised notice of privacy practices by calling Back in Line Health Care (Aaron Herbert, DC) and requesting a revised copy be sent via email, mail or asking for one at my next appointment.

I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically. titled Title
Signature
Your answer
MM
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PATIENT RECORD OF DISCLOURES
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures.

I wish to be contacted in the following manner (check all that apply)
I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically. titled Title
Signature
Your answer
MM
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DD
/
YYYY
CONSENT TO TREAT
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures by Dr. Aaron Herbert and/or other licensed doctors of chiropractic who may practice with, or are employed by Dr. Herbert.

Chiropractic care is the science, philosophy and art of locating and correcting spinal subluxations (misalignments) and, as such is oriented toward improvement of spinal function relative to range-of-motion, muscular and neurological aspects. Extremities may also be treated as related to spinal function. There has been no promise, implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment at this clinic.

I understand that the chiropractor will use his hands or a mechanical device upon my body to locate and treat involved areas. He may apply pressure on certain spots in my muscles to the point I can tolerate. I am to communicate with the doctor at all times to let him know if any procedure is painful or in any way uncomfortable for me.

It is my intention to rely on the doctor to exercise professional judgment during the course of any procedures, which he feels at the time to be in my best interest.

Neither the practice of chiropractic nor medicine is an exact science, but relies upon information related by the patient, information gathered during the examination, and the doctor's interpretation thereof, as well as the doctors’ judgment and expertise in working with like cases.

It is not reasonable to expect the doctor to be able to anticipate, or explain, all possible risks and complications of a given procedure on any particular visit. I understand that if I have questions or concerns, I must ask.

An undesirable result or side effect does not necessarily indicate an error in judgment or an improper procedure. The doctor may recommend altering my activities of daily living and/or recommend further diagnostic testing or medical referral. Noncompliance with the doctor's recommendations could be detrimental to my health.

As with any health care procedure, there are certain complications that may arise during chiropractic treatment. Those complications include burns, sprains/strains, dislocations, fractures, disc injuries, or cerebral-vascular accidents (strokes). These complications are rare occurrences.

Some very effective chiropractic soft tissue treatment techniques require exposure of the skin in the areas being treated. A proper gown and/or cover up will always be provided. However, due to individual levels of personal modesty, if you feel at all uncomfortable, please immediately tell the doctor or assistant. A different treatment technique will be used.

Generally chiropractic treatment is a safe and cost effective conservative treatment for many musculoskeletal conditions and has a documented high level of patient satisfaction toward treatment and outcome. However, there are other treatment options available to you such as medical, drugs and sometimes surgery.

I have read the above consent, or have had it read to me, and have had the opportunity to ask questions and receive answers. I am comfortable with the information provided and consent to chiropractic treatment and management on that basis.

I acknowledge that typing my name below will be considered as my signature since forms are submitted electronically. titled Title
Signature
Your answer
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