㊥SYNE RGYHealth & Wellness

Patient Name:

Chiropractic Case HistorylPatient lnfo「mation

Date:

Social Secu「fty Bi軸Date: _」。_」_ Age:　　　Gender: F M

E-mail address:　　　　　　　　　　　　　　　　　　　Ce= Phone:

Prefe「red method of appointment 「eminder: □ Ema= □ Text

Height:　　　Weight:

Ce= Phone P「ovide「

Specify Right o「 Left Handed:

Have you ever been in ou「offlce befo「e? □ Yes □ No

lf you a「e unde「 18 yea「S Of age, Who are you「 iegal pa「ents o「 guardian?

Fathe「:

Mother:

Gua「dian:

Date of Birth:　/　/　　　Phone:

Date of Birth:　/　I Phone:

Date of Birth:　/　/　　　Phone:

Maritai Status: □ Ma「ried □ Separated □Widowed □Single How many ch冊ren?

CURRENT ADDRESS

Street

Occu patio n

State

Work Add「ess

Student at

Name of Spouse

Wo「k Phone

口Fu= Time □ PartTime

Who shouId we contact in the event of an eme「gency

Spouse’s Date of Birth : /　/

Phone Number

Piease check any and a旧nsurance coverage that may be app=cabIe in this case:

PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)

□ M争jo「Medjcal　□Worker’s Compensatjon　□ Medjcaid　□ Medicare　□ AutoAccident

□ Medical Savings Account & Flex Plans □ Other

Name of P「ima「y lnsu「ance Company:

Name of Seconda「y lnsu「ance Company (if any):

Fui両ame of Policy Hoide「 Policy Holder’s Date of Birth: /　/

AUTHORIZATION AND RELEASE: l authorize payment of insurance benefits directly to the chirop「acto「 or

Chjrop「actic office・ l authorize the doctor to 「elease a旧nfo「mation necessary to communicate with pe「sonaI

PnySIcians and otner healthca「e providers ancI payo「S anCl to secure the payment of benef鵬. 1 understand ma= am

responsibIe for all costs of chirop「actic ca「e, 「ega「dIess of insu「ance coverage・ i aiso understand that i= suspend

Or terminate my schedule of care as determined by my treatjng doctor, any fees for professional services w帥be

immediateIy due and payable.

Method of payment fo「 today’s charges: □Cash □Check □Credit Card/Debit Card

Patientls Signature:

Guardian-s Signature Authorizing Care:

28963 SR 54 WesIeY ChapeしFL33543 (813) 906-2499∴ F: 〈813) 343-6093

H!STORY OF PRESENT AND PAST ILLNESS:

Chief Compla血Pu「POSe Of this appointment:

Date symptoms appeared:

Describeyourpa血ロBu「ning □ Sha「P口Du=ロAche □ Throb師g

What caused it?

What agg「avates it?

What 「e=ves it?

Days iost from wo「k:

Have you ever had the same o「 a simifa「 COndition?　□Yes □No

Ifyes, When _　」　　　」

Describe:

Please indicate any othe「 heaithca「e provide「S that you have seen for the cu「「ent cond璃OnS Or SymPtomS for which

you are seeking t「eatment:

Name Type of Licensu「e Date of Last Visit

0音音音細

り臆喜劇

Please check any of the fo=owing symptoms/conditions you have now (N) o「 have had previously (P):

Headaches

Frequency

Neck Pain

Stiff Neck

SIeeping P「Oblems

Back Pain

Nervousness

Tension

回向b冊y

Chest Pains爪ghtness

Dizziness

Shoulder/Neck/Arm Pain

Numbness in Fingers

Numbness活Toes

High BIood P「essure

D櫛Culty U血ating

Weakness in ExtremitiesBreathing Problems

Fatigue

Lights Bothe「 Eyes

Ears Ring

B「oken Bones/F「actu「es

Rheumatoid Arthritis

Excessive Bleeding

Osteoarth ritis

Pacemake「

St「Oke

Ru ptu res

Eating Disorde「

Drug Addiction

Ga= Bladde「 Probiems

N P

□　　　□

N P

Loss of Balance　　　　□　　　□

Fainting　　　　　　　□

Loss of Smell　　　　　　□

Loss of Taste　　　　　　□

UnusuaI Bowel Patte「ns □

Feet Cold　　　　　　　　□

Hands Cold　　　　　　　□

Arth ritis　　　　　　　　　□

Muscle Spasms　　　□

Frequent Colds　　　　□

Feve「　　　　　　　　　ロ

Sinus P「oblems　　　　□

Diabetes　　　　　　　　　□

Indigestion Problems　□

Joint Pain/Swe帖ng　　□

Menstrual D櫛Culties　　□

Weight LossIGain　　□

Depression　　　　　　口

Loss of Memory　　　□

Buzzing in Ears　　　□

Ci「culation Problems　　□

Seizu「es/Ep航epsy　　　□

Low BIood P「essure　　□

Osteoporosis

Heart Disease

Cancer

Coughing BIood

AIcoho=sm

HlV Positive

U Ice「S

□

□

□

□

田

口

□

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28963 SR 54 WesleyChapel,乱33543 (813) 906-2499　F: (813) 343-6093

□□□□□□□□□日日□□□□口□□日日□日日□□□□□□

□□口□□□日日□□□日日口□ロロロロロロロロロロロロロロ

□□□□□口日日□日日□□口田口□□日日ロロロロ日日ロロロ

Have you expe「ienced RECENT CHANGES to‥

□ Eyes (Sight) □ Ears (hearing) □ Nose (Sme=) □ Mouth (taste) □ Bladder

□ Bowels　　□ Sleep　　　　□ Emotion　　□ Appetite

PIease explain:

Se「ious冊esses o「 conditions no川Sted above?

When?

What prio「 surge「y have you had?

What medications o「 drugs are you taking?

Doyou haveany a=e「giesto any medications?口Yes　□ No

lf yes章desc「ibe:

Doyou haveanyaile「giesofany kind? □ Yes　□ No

If yes, describe二

Do you have any Congenitai Condition? □Yes　□ No lfYES’Describe

Doyou smoke?　□Yes　□ No lfYes, numbe「Ofpacks

Do you d血k?　□Yes　□ No lfYes' number ofd「inks

WOMEN ONLY: □ There is a poss酬ity i may be pregnant □Yes, I am definiteiy p「egnant

□No, l am def面tely nct p「egnant

List any p「evious accidents (automob崎On the job injuries, Slips, fa=s, SPOrtS, etC.) and provide the accident date:

l certify the information provided is accu「ate to the best of my knowledge:

Name of Patient

S鳴nature of Patient/Legal Gua「dian

28963 SR 54 Wesley Chapel, FL33543 (813) 906-2499　F: 〈813) 343-6093

ーいOいり〇〇〇〇〇いいリ　　ーい’り

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SYNE RGYHealth & Wellness

Patient AcknowIedgement and Receipt of

Notice of P「ivacy Practices Pursuant to HさPAA and Consent fo「

Use of Health Information

Na鵬e Date

The undersigned does hereby acknowIedge that he o「 she has received a copy of this o締ce’s Notice of軸vacy

Practices PLIrSuant To HIPAA and has been advised that a fu!l copy of this o情Ce’s HIPAA Compliance Manua=s

ava胞ble upon request.

The undersigned does hereby consent to the use of his o「 her hea肘=nformation in a manne「 OOnSistent w軸the

Notice of P「ivacy P胎ctices Pursuant to HIPAA- the HIPAA Compliance Manua上State law and Federal Law.

Da鳴d仙S day of

Patient’s S ignature

If patient is a minor o「 unde「 a 9uardねnship orde「 as defined bY State taW

Signature of Parent/Guardian (Circle one)

之8963 SR与4 Wes勘ChapeL乱33与43 (813) 906-2499　串813〉 3低・6093

SYNE RGYHealth & Wellness

lNFORMED CONSENT

W輔am Abrahams, D.C.

28963 State Road 54, Wesley Chapei, FL 33543813-906-2499

川ereby request and consent to the perfo「mance of chi「opractic p「OCedures直Ciuding va「ious modes of physio

the「apy, diagnostic x-rayS, and any supportive the「apies on me (Or On the patient named below, for whom l am

lega=y 「esponsible) by the doctor of chi「op「actic indicated below andlo「 Othe川CenSed doctors of chiropractic and

support statf who now or in the future treat me while empIoyed by, WOrking or associated with o「 Serving as back_uP

fo「 the docto「 of chirop「actic named below言ncluding those working at the ciinic or o鮒Ce listed below or any othe「

O用Ce Or C柵C, Whether signato「ies to this fo「m or not.

1 have had an opportunity to discuss with the doctor of chiropractic named above and/O「 With other office o「 C白面C

PerSOnnel the natu「e and pu「POSe Of chirop「actic adjustments and p「OCedures.

l understand and l am info「med that, aS is with al冊ealthca「e treatments, 「eSults are not gua「anteed and the「e is no

P「Omise to cure・ I fu輔er understand and l am informed that’aS is with ali HeaIthca「e t「eatments言n the practice of

Chiropractic there a「e some risks to treatment巾Ciuding, but no捕mifed to, muSCle spasms for short pe「iods of time,

agg「avating and/o「 temporary inc「ease in symptoms言ack in imp「OVement Of symptoms, f「actu「es, disc in」u「leS,

St「Okes, disIocations and sprains.同o not expect the doctor to be able to anticipate and explain a帖Sks and

COmP=cations, and l wish to 「ely on the doctor to exercisejudgment du「ing the cou「Se Ofthe procedu「e which the

doctor feeis at the time, based upon the facts then known言S in my best inte「ests.

I further unde「stand that Chiropractic adjustments and supportive t「eatment is designed to reduce and/O「 CO「「eCt

SubIuxations aliowing the body to retum to血proved health" It can also alleviate certain symptoms through a

COnServative approach with hopes to avoid mo「e invasive procedures" Howeve自ike al1 0ther health modalities,

results a「e not gua「anteed and there is no p「Omise to cu「e' Accordingly, l unde「stand that a= payment(S) for

t「eatment(S) a「e final and no 「efunds wi= be issued. Howeve「, PrO「ated fees for unused, PrePaid treatments w紺be

「efunded i= wish to canceI the treatment.

I fしIrthe「 unde「stand that there a「e t「eatment options avaiIable fo「 my conc陣ion other than chi「OP「aCtic procedu「es.

These treatment options include, but no川mited self-adm面stered, OVer the counter analgesics and rest; medical

Ca「e With prescription drugs such as ant両flammatories, muSCie 「eIaxants and paink紺e「S; Physica冊erapy; Ste「Oid

injections; bracing; and surgery. l understand and have been informed that用ave the right to a second opinion and

SeCure Othe「 opinions削have conce「ns as to the nature of my symptoms and t「eatment options‘

i have read, Or have had read to me, the above consent.川ave also had an opportunity to ask questions about its

COntent, and by signing below l ag「ee to the above-named procedures.冊tend this consent to cover the enti「e

COu「Se Of treatment fo「 my present condition and fo「 any future condition(S) for which l seek treatment.

Name of Patient:

Signatu「e of Patient:

Date:

Name P「inted of Guardian/Pa「ental and Relationship to Patient:

Guardian/Pa「ental Signature:

Date:

28963 SR 54 WesleY Chapeし乱33543　〈813) 906-2499∴ F: (813) 343-6O93

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