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Elevated Health Center Muscle Work
*** To be completed AFTER a referral from Dr. Oommen ***
PERSONAL INFORMATION
First Name
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Middle Initial
Last Name
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Birth Date
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Age
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Sex:
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Male
Female
Address:
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City
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State:
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Zip Code:
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Cell Phone Number:
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Emergency Contact & Relationship
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Emergency Contact Phone Number
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Text Reminders ?
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Yes, Please!
No, Thanks.
Cell Provider:
AT&T
Boost Mobile
Cingular/AT&T
Comcast/Xfinity
Cricket
Nextel
Sprint
T-Mobile
Verizon
Virgin Mobile
Other
Email Address:
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Who can we thank for referring you or how did you hear about Elevated?
Occupation:
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Employer's Name:
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HEALTH INFORMATION
Have you had massage/bodywork before?
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No
Yes (1-2x/month)
Yes (3-4x/month)
Do you have any difficulty lying on your front, back, or side?
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No
Yes, let me explain
Yes, let me explain
Do you have any allergies to oils, lotions, or ointments?
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No
Yes, let me explain.
Yes, let me explain.
Do you sit for long hours at a workstation, computer, or driving?
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No
Yes, let me explain.
Yes, let me explain.
Do you perform any repetitive movement in your work, sports, or hobby?
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No
Yes, let me explain.
Yes, let me explain.
Do you experience stress in your work, family, or other aspect of your life?
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No
Yes, let me explain.
Yes, let me explain.
If you answered YES to the question above, how do you think it has affected your health?
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Muscle tension
Anxiety
Insomnia
Irritability
N/A
Other
Other
Are there any major injuries and/or surgeries we should know about?
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No
Yes. Please explain
Yes. Please explain
Are there any major injuries and/or surgeries we should know about?
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What is this affecting that is MOST important in your life? (List all that apply)
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Have you seen a chiropractor before?
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Yes
No
How long ago?
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Have you seen any other providers for this condition?
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No
Yes. Please list
Yes. Please list
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
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No
Yes, let me explain.
Yes, let me explain.
What health goal, if you were to complete or accomplish it, would have the greatest impact on your life?
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HEALTH CONCERNS
Select any concerns that apply to you:
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Anxiety/Depression
Arthritis
Cold hands/Feet
Diabetes
Digestive Troubles
Dizziness
Fatigue/Sleep Issues
Headaches
Hypertension
Irritability
Loss of Balance
Loss of Concentration
Memory Problems
Nausea/Vomiting
Neck/Back Pain
Pain in Arms/Legs
Ringing in Ears
Sensitivity to Light
Sinus Troubles/Allergies
Stiffness/Flexibility
N/A
Other:
Vitamins/Supplements
*
Multi-Vitamin
Vitamin D3
Fish Oil/Omega 3
Probiotics
Other:
N/A
Check any medications being used:
*
Anxiety/Depression
Blood Pressure
Pain Narcotics
Muscle Relaxants
Migraine/Headache
Cholesterol
ADD/ADHD
Diabetes
Other:
N/A
Explain any boxes checked above or add additional concerns:
STRESS QUESTIONNAIRE
Physical Stress
*
Physical Pain
Low Energy/Fatigue
Job/Hobbies Cause Discomfort
Tightness/Stiffness
History of Accidents/injuries
Inability to Exercise/Perform Physical Activities
N/A
Other
Other
Chemical Stress:
*
Fast Food/Highly Processed Food
Medications (Prescription or OTC)
Consume Alcohol
Tobacco
Amalgam Fillings
Makeup/Lotion/Other Skins Products
N/A
Other
Other
Emotional Stress
*
Work/Job
School
Health
Finances
Family
Daily Schedule/Time
N/A
Other
Other
What else about your health or your life do you feel is important for the therapist to know?
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PATIENT HIPAA CONSENT FORM
Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to define situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. I also understand that I can request in writing that you restrict how my personal information is used and disclosed.
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Client Name
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Date:
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AUTHORIZATION FOR CARE
At Elevated Health Center, we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctors/clinic will not be held responsible for any pre-existing medical conditions. I certify that the above information is correct to the best of my knowledge. I will not hold the doctors or any staff member of Elevated Health Center responsible for any errors or omissions that I may have made in the completion of this form. While the care offered is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Muscle work/bodywork is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you. I hereby authorize the doctors and staff at Elevated Health Center to treat my condition as deemed appropriate.
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Client Name
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Date:
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CANCELLATION POLICY
Here at EHC, we have a strict 24-hour notice cancellation policy. You may cancel your appointment anytime 24 hours or more before the appointment without a charge. Unless it is an emergency, if a client does not show up OR call to cancel a scheduled appointment, the client will be charged $50.00 for the scheduled visit. Any cancellations or rearrangements within 24 hours preceding said appointment will be charged at $25.00 for the scheduled visit. We understand sometimes life can throw us unexpected emergencies and these unanticipated things are not always within our control. Thank you for your understanding and we look forward to helping you elevate your health! I have read the above statement and agree to the above terms.
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Client Name
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Date:
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