Southern Oregon Active Health Casey Frieder, DC 233 4th St, Ashland, OR O: F:

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1 Patient Information Full Legal Name Preferred Name Date of Birth Age Gender Address City State Zip Code Phone # Ok to leave a message related to your healthcare? Yes No Social Security # Occupation Employer What is your marital status? Married Single Widowed Divorced Separated Name of Spouse Number of Children Emergency Contact Phone # How or from whom did you hear about Southern Oregon Active Health/Dr. Casey Frieder? Responsible Party Information Name Relationship to patient Social Security Number Address City State Zip Code Phone # Insurance Information Primary Insurance Insurance Company: Policy Holder s Name: Relationship to Patient: Policy Holder s Birth Date: Group Number: Policy ID Number: Secondary Insurance Insurance Company: Policy Holder s Name: Relationship to Patient: Policy Holder s Birth Date: Group Number: Policy ID Number: 1

2 Informed Consent for Treatment The following information is provided to enable our sharing of a common understanding of our rights and roles in the professional therapeutic relationship. Please read this agreement and sign at the bottom indicating that you understand and agree to the following: I hereby request and consent to the performance of chiropractic procedures, including spinal and extremity adjustments, soft tissue treatment, therapeutic exercises, diagnostic tests and any other procedures or supportive therapies, on me (or on the patient named below, for whom I am legally responsible) by Dr.. I understand that I will have an opportunity to discuss the nature and purpose of chiropractic treatment with the Doctor during the exam and applicable procedures, alternatives, and risks will be presented and my questions will be answered. Each procedure and/or treatment carries both risks and benefits. There may be additional or alternative treatments available. Your plan will be researched and customized to your specific needs and goals. No guarantees can be offered regarding the outcomes of treatment(s) or procedure(s). I further understand and I am informed that, as is with all healthcare treatments, in the practice of chiropractic there are some risks to treatment, including, but not limited to, muscle spasms for short periods of time, soreness, bruising, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the Doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the Doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. Patients must agree to use digital correspondence such as , text messages, Skype/video conferencing. Correspondence will be sent to the address you provide with payment and/or other correspondence. Keeping your e- mail/phone/messages/computer safely secured is the patients responsibility; if you are not willing to accept responsibility for using digital communications via /phone/text message/computer/video and the attendant conveniences and risks, then you cannot work with Dr. Frieder because Dr. Frieder uses electronic digital notes and correspondence with patients. You are encouraged to ask questions on any health-related topic and to take an active role in your health-care. Our philosophy is a team approach where other doctors play important roles in your health. Our treatment may involve encouraging you to make changes in your diet and lifestyle that can help you reach your highest level of health, fitness and performance. Information revealed during treatment sessions and office visits/consultations is confidential. Exceptions to this confidentiality include disclosure by you regarding intention to harm yourself or others. Your record and the information contained within it will not be disclosed to others unless you direct us to or unless the law authorizes or compels us to do so. Dr. Frieder is happy to work with your other healthcare providers; communication between physicians regarding the health of a patient does not require consent by the patient. Patients have the responsibility to take treatments as directed and to follow-up as needed. The contact information and health history I provided on my intake form are complete and accurate. I understand and agree to the information on this page. My questions, if any, were answered to my satisfaction. Name of Patient Signature of Patient/Parent/Legal Guardian Date 2

3 Authorization for Records Release and Assignment of Benefits I authorize Southern Oregon Active Health, LLC to release medical records required by my insurance company(s). I authorize my insurance company(s) to pay benefits directly to Dr. and I agree that a reproduced copy of this authorization will be as valid as the original. I understand that I am responsible for any amount not covered by my insurance, or any amount for a patient for which I am the guarantor. I agree that I will be responsible for any collection agency or attorney fees incurred. I understand that by signing below, I am giving written consent for the use and disclosure of protected health information for treatment, payment, and health care operations. Notice of Privacy Practices This notice will remain in effect until it is replaced or amended by changes in law. We gather personal information and health information in the following ways: Information we receive from you; Information we receive from other healthcare providers; Information we receive from third party payers. This information is used for treatment, payment and healthcare operations. You should be aware that during the course of our relationship, we will likely use and disclose health information by submitting the authorization in writing. You may specifically authorize us to use protected health information for any purpose or to disclose your health information by submitting the authorization in writing. Such disclosures will be made to any personal representation you choose to have your protected health information. This office will not use your health information for marketing communication without your written authorization. This office may send welcome letters or birthday cards via or post. ***This office may use or disclose your protected health information when required by law*** Patient Rights Upon written request you have the right to access, review or receive copies of your healthcare records. Upon written request you have the right to receive a list of your healthcare information that this office has disclosed. You have the right to request that this office place additional restrictions on disclosure of your Protected Health Information. Upon written request you have the right to amend your Protected Health Information. You have the right to receive all notices in writing. You may submit a written complaint to the U.S.A. Department of Health and Human services. Financial Policy and Cancellations Ultimately, you are responsible for payment of all health care services we provide to you at our clinic. Payment is required at the time of service, including appropriate deductibles, co-payments or co-insurance unless other arrangements have been made in advance. We reserve the right to charge you $30 for every missed appointment or cancellation with less than 24 hrs notice. After 3 missed appointments with insufficient notice, the fee will increase to $60 per missed appointment. By signing below, I acknowledge that I have read and understand all of the policies listed above and I agree to be bound by such terms. Name of Patient: Signature of Patient/Parent/Legal Guardian: Date 3

4 Current Condition What are your reasons for coming into the clinic today? What date did your symptom(s)/complaint(s) begin and what caused them to begin? What activities/positions improve your condition? What activities/positions worsen your condition? How often are your symptoms present? Constant Intermittent but frequent Intermittent and infrequent How is your condition evolving? It is improving It is the same It is worsening Is it worse at certain times of the day? Morning Afternoon Night Interfere with your work duties? Yes No Interfere with your ability to sleep? Yes No Interfere with your daily routine? Yes No If Yes, please list specific activities that are impaired, and your current ability to perform such activities on a scale from 0 to = No function, complete impairment. 100 = Perfect function, no impairment. Activity 1: Activity 2: Activity 3: Impairment rating: Impairment rating: Impairment rating: Have you had this problem in the past? When? How often? Please list any healthcare providers or therapists you have seen regarding your condition: Please list any home care/exercises/remedies you have tried to help improve your condition: Are you experiencing any other strange symptoms or is there anything else you think your doctor should know? Is your complaint the result of either: Motor Vehicle Accident On-the-job injury If so, have you filed a legal suit or workers compensation claim? 4

5 Pain Location and Radiation Please mark the area(s) where you feel discomfort. Place an X in the one area where your pain is the worst. Please rate, on a scale from 0-10, with 0 being no pain and 10 being the worst pain in your life: What level is your pain right now? What is your pain level on average? What is your pain level at its worst? What are your goals for the first visit? What questions do you have for today s visit? 5

6 Personal Health History Have you previously received chiropractic care? Yes No If yes, from who? Who is your primary care physician? When was your last physical examination? Have you been treated for any health condition by a physician in the last year? Yes No If yes, please explain: What medications are you currently taking and for what conditions? What vitamins/herbs/supplements are you currently taking and why? Please list all food, environmental, and drug allergies: Please date and describe any past serious illnesses, surgeries and/or hospitalizations: If female: Are you possibly pregnant? Yes No When was the date of your last menstrual period? Family Health History Do you or other family members have a history of any of the following? Arthritis Self Family member Cancer Self Family member Diabetes Self Family member Heart Disease Self Family member Hypertension Self Family member Kidney Disease Self Family member Depression Self Family member Mental Illness Self Family member 6

7 Review of Systems Please mark any conditions you have experienced (previous) or are now experiencing (current): Previous Current Previous Current X Sample Fainting or convulsions Headaches Heart trouble or stroke Arm or shoulder pain Chest pain Arm or shoulder weakness High blood pressure Neck pain or stiffness Dizziness Lower back pain or stiffness Poor circulation Pins and needles in arms Leg cramps or swelling Pins and needles in legs Rheumatic fever Numbness in fingers or toes Anemia Leg or foot pain Digestive or eating problems Osteoporosis Constipation or diarrhea Asthma or emphysema Nausea or vomiting Sinus trouble or allergies Gout Bleeding gums Pain or trouble breathing Easy bleeding or bruising Tuberculosis Blood in urine or stool Pneumonia Burning or frequent urination Cold, flu or cough Kidney disease or stone Sore throat Glaucoma Difficulty swallowing Blurred vision Skin disease Loss of taste Rashes Loss of smell Hives Loss of hearing Gallbladder Buzzing or ringing in ears Liver Depression or anxiety Hepatitis Nervousness Ulcers Fatigue or weakness Thyroid Problems Loss of energy Diabetes Sleeping problems Immunosuppression Seizures Abnormal menstruation Loss of memory Breast problems Loss of balance Prostate problems Parkinson's disease Sexual dysfunction 7

8 Lifestyle Overview Please rate your overall health on the line below How much are you willing to work to improve your health? How much interest do you have in learning about how to become healthier? What do you believe is your biggest obstacle to achieving better health? Do you use tobacco products? Yes No If Yes, how many per day? Do you drink alcohol? Yes No If Yes, how many drinks per week? Do you use marijuana? Yes No If Yes, how often? Do you drink coffee or black tea? Yes No If Yes, how many cups per day? Do you exercise regularly? Yes No If Yes, what do you do? If No, what keeps you from exercising? Do you follow any particular diet regimens or restrictions? How many servings of vegetables do you eat per day? In the past month, have you felt depressed or hopeless? Yes No Are your stress levels currently higher than normal? Yes No If Yes, how come? Is there anything you would like to add that has not been asked? Patient Signature Date Doctor Signature Date 8