informed consent · informed consent 1. services: my health care provider has recommended...

INFORMED CONSENT

1. SERVICES: My health care provider has recommended functional, nutritional, and lifestyle evaluation, testing, consulting, and care, including dietary supplements. I understand and am informed that products and services are not provided by medical physicians and do not include prescription of legend drugs, surgery, or other conventional allopathic medical treatments. I further understand that consultations, evaluations, supplementation, lifestyle consultation,

testing, recommendations, discussion, sale of food, nutrition, nutritional supplements, vitamins or minerals, food grade herbs, or

other nutrients pertain to the functional health/whole body concept.

2. NO GUARANTEE: I have been informed that the methods of nutritional evaluation or testing made available to me are not intended to diagnose disease from an allopathic model of medicine. Rather, they are intended as a guide to developing an appropriate overall health-supportive program for me, and to monitor progress in achieving goals. I further understand that any recommendations are supportive in nature allowing the body to return to improved health. Like all other health care, results are not guaranteed and there is no promise to cure. Accordingly, I understand that payment(s) for services are not conditional on my response to care. Prorated fees for unused, prepaid services, however, will be refunded if I wish to cancel. No refunds will be available for any products purchased.

3. RISKS: I understand the nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients that may be recommended are generally considered safe, however, some nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients may be toxic in large doses. I also understand that nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients may interact with some legend drugs. Accordingly, I agree to consult with my prescribing physician about any legend drugs I am taking and the impact of supplements, vitamins, minerals, food grade herbs, and other nutrients on such drugs. I will inform my health practitioner if I experience gastrointestinal upset (nausea, gas, stomachache, vomiting), allergic reactions (hives, rashes, itching, tingling of the tongue, headache), or any unanticipated or unpleasant effects associated with the nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients.

4. PREGNANCY: I understand that some nutritional supplements, vitamins, minerals, food grade herbs, and other nutrients may be inappropriate during pregnancy, and I will notify the health practitioner if I am or become pregnant.

5. ALTERNATIVES: I understand that the alternatives to the recommendations include doing nothing and/or seeking additional allopathic medical care.

6. QUESTIONS AND ANSWERS: I have read and fully understand this consent form, and understand that I should not sign this form if all items, including all my questions, have not been explained or answered to my satisfaction or if I do not understand any of the terms or words contained in this consent form.

DO NOT SIGN UNLESS YOU HAVE READ AND FULLY UNDERSTAND THIS FORM! I have read and fully understand this consent. All items have been explained, I have had sufficient time to evaluate the information, and my questions have been answered. Knowing the alternatives and risks, I consent to the services. Signature ___________________________________ Date _____________ Name (printed)_______________________________________

WHITE OAK BRAIN & MEMORY 216 Seaboard Ln, Ste. A-2

Franklin, TN 37067 615-257-7799

BRAINANDMEMORY.COM

ONE-ON-ONE CONSULTATION CONSENT One-on-one consultation with the doctor of chiropractic:

-Review my case history to determine if the practice may be able to help me; -Review my dietary and nutritional habits, nutritional supplements, herbs, minerals, botanicals, homeopathics, etc.; and - Discuss my problems and answer questions.

The only cost I will incur is the cost of any one-on-one visit and/or initial screening tests that I choose to undergo. I am aware that after the one-on-one consultation, I may not be accepted as a patient or additional testing may be recommended. Whether or not I am accepted as a patient, I will receive a copy of any diagnostic test results. I understand that I am encouraged to communicate with my other health care providers about all of my health care, including care I receive at this office. I agree to fill out all paperwork completely to the best of my knowledge. I am under the care of the following health care provider, who is licensed to prescribe medication: Name: _______________________ Phone: _____________________ By signing below, I agree that I have read, understand, and accept the terms of the consultation: ________________________________ _______________ Signature Date


Franklin, TN 37067 615-257-7799

BRAINANDMEMORY.COM

New Patient Application and Case History (CD)

Name _____________________________________ Age _______ Sex: M F DOB _________ Today's Date ____________

Address__________________________________ City___________________________ State _________ Zip ____________________

Phone Number______________________ E-mail Address: _______________________________ Marital Status: S/ M/ W/Sep/D

May we leave a voice mail? YES NO Height _______ Weight: _______ Are you able to drive a vehicle? YES NO

How Did You Hear About Us? _________________________________ Education level: ________________________________________

Employer ______________________ Occupation _____________________ Length of Employment ______ SSN: xxx-xx-______

Power of Attorney: _______________________________________________________________________. Phone: _______________________

Support Person: ____________________________________________________________________. Phone: ___________________________

Primary Care Physician: _________________________________________________________________. Phone: ________________________

Name of person completing this form: __________________________________________. Relationship to patient: ________________________

Personal Medical History

1. Main Problem(s):

2. In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else. In your own words and yourown opinion what do you think the real problem is :

3. When were you first diagnosed with cognitive impairment: _____________ 4. What are the three things your condition has caused you to miss most:What diagnostic tools were used to achieve your diagnosis:

5. Symptoms: Please circle the symptoms you have or are currently experiencing: 6. Severity of problem (circle): Memory Loss Trouble finding words. Confusion Minimal (annoying but causing no limitation)

Getting Lost Wandering Depression Slight (tolerable but causing a little limitation) Loss of interest, motivation, or drive Anxiety Moderate (sometimes tolerable but definitely causing limitation) Irritable Aggression Suspiciousness Severe (causing significant limitation) Hallucinations (seeing, hearing, or otherwise sensing things not present) Extreme (causing near constant limitation (>80% of the time)) Delusions (ideas or beliefs not based in reality) Inability to do complex activities (shopping, cooking, managing money) Inability to do basic self-care (bathing, grooming, dressing, etc)

8. Describe the first time you remember having symptoms:7. What relieves your symptoms or causes them to return:

9. If your symptoms include pain: 10. Do your symptoms occur at a specific time, place, or environment: Y N

What is the quality (sharp, dull, stabbing, color, etc.): When and for how long do symptoms last each episode:Does the pain radiate: Y N where:

11. What types of treatment have you received: 12. List your health goals in order of Importance:Prescription/Drug therapy

White Oak Brain & Memory | Dr. Eric Ries, DC | (615) 257-7799 | 216 Seaboard Ln, Ste A-2, Franklin, TN 37067

Nutritional Alternative/Holistic

Motivation to achieve these goals: 1 2 3 4 5 6 7 8 9 10

13. What are you hoping happens today as a result of your consultation: 14. How often are you aware of your main problem (circle one):Occasionally (25% of the time) Frequently (75% of the time)

Intermittently (50% of the time) Constantly (100% of the time)

15. Due to your condition have you lost time from (describe how much time and what tasks have been limited)?

Work: Y N Describe:

Family: Y N Describe:

Leisure Activities Y N Describe:

Medications (List all prescription, over-the-counter, herbal, homeopathic, and supplements you are currently taking)

Are you currently taking or have you taken the following:

Cognex (tacrine): dosage: Side Effects: Aricept (donepezil): dosage: Side Effects: Exelon (revastigmine): dosage: Side Effects: Metrifonate: dosage: Side Effects: Vitamin E: dosage: Side Effects: Ginko Biloba: dosage: Side Effects: Aspirin: dosage: Side Effects: Anti-inflammatory (Naprosym, Aleve, Relefan, Celebrex, etc) dosage: Side Effects: Hormone Replacement Therapy: Type:

___________________________________________________________________________

dosage: Side Effects:

Can you swallow capsules and pills whole? YES NO


Have you had any of the following tests performed? Please check all that apply.

________ MRI of Brain __________ SPECT or PET Scan __________ EEG __________ Carotid Doppler

____Neuropsychological Test ____Blood Test for: Memory Loss (Thyroid, Zinc, Copper, B12, RPR) ______ C/T Scan

Dates and Facilities of above tests:

Is there any reason you cannot have an MRI Scan performed? YES NO If Yes, why?

Have you ever been diagnosed with a stroke or experienced sudden onset of weakness, numbness, clumsiness, trouble with speech, or

loss of vision? YES NO IF YES, please explain details:

Medical and Family History

Surgeries/Hospitalizations Date Trauma Date

Past/Recent Illness/Infections Date Do you use: Alcohol Y N Tobacco Y N Caffeine Y N ___ drinks/week ___ pack/day ___ cups/day

Do any of the following diseases run in your family? (Circle all that apply)

Alzheimer’s Disease Anxiety Disorders Epilepsy/Seizures Stroke/TIA Learning Disabilities Migraines Depression

Diabetes Cancer Nervous Breakdowns Schizophrenia Bipolar Hypertension/High Blood Pressure Other:____________________________________


Review of Systems: Past and Current (Have you ever had the following (circle “P” for past and “C” for current - leave blank if you do not or have not experienced)

CONSTITUTIONAL GENITOURINARY ENDOCRINE NEUROLOG ICAL P C Fatigue P C Frequent urination P C Glandular or hormone problem P C Freq./ recurring headaches P C Recent weight change P C Burning or painful urination P C Excessive thirst or urination P C Migraine headache P C Fever P C Blood in urine P C Heat or cold intolerance P C Convulsions or seizures P C Tires easily/weak P C Change in force or strain urinating P C Skin becoming dryer P C Numbness or tingling

P C Kidney stones P C Change in hat or glove size P C Tremors P C Sexual difficulty P C Diabetes P C Paralysis

EYES P C Male : testicle pain P C Thyroid Disease P C Head injury P C Blurred/double vision P C Female: pain / irregular periods P C Light headed or dizzy P C Glasses/contacts P C Female: pregnancy #__________ P C Stroke P C Eye disease or injury P C Female: date of last period ______ MUSCULOSKELETAL P C Loss of balance

P C Bladder Infections P C Back pain EAR/NOSE/MOUTH/THROAT P C Kidney Disease P C Joint pain HEMATOLOGIC/LYMPHATIC/ P C Swollen glands in neck P C Hemorrhoids P C Joint stiffness and swelling OTHER P C Hearing loss or ringing P C Muscle pain or cramps P C Slow to heal after cuts P C Earaches or drainage P C Muscle or joint weakness P C Easy bleeding or bruising P C Chronic sinus problems or rhinitis GASTROINTESTINAL P C Difficulty walking P C Anemia P C Nose bleeds P C Abdominal pain P C Cold extremities P C Phlebitis P C Mouth sores / Bleeding gums P C Nausea or Vomiting P C Past transfusion P C Bad breath / bad taste P C Rectal bleeding/blood in stool P C Enlarged glands P C Sore throat or voice change P C Painful bm / constipation INTEGUMENTARY (skin, breast) P C Blood or Plasma Transfusions

P C Ulcer P C Change in skin color P C Hepatitis CARDIOVASCULAR P C Change in bowel movement P C Change in Hair or Nails P C Cancer P C High or Low Blood Pressure P C Frequent diarrhea P C Varicose veins P C Infectious Mono P C Shortness of breath walking/lying P C Loss of appetite P C Breast pain / discharge P C AIDS or HIV+ P C Heart disease P C Breast lump P C Venereal Disease P C Chest pain or angina pectoris RESPIRATORY P C Hives or Eczema P C Chicken pox P C Palpitation P C Chronic or frequent cough P C Rash or itching P C Rheumatic Fever P C Mitral Valve Prolapse P C Spitting up blood P C Syphilis P C Feet or ankle swelling P C Pneumonia / Bronchitis P C Lyme’s Disease P C Shortness of breath P C Shortness of breath P C Herpes Simplex P C Spitting up blood P C Wheezing

P C Asthma ALLERGIES / OTHER (drugs, food, or environmental) PSYCHIATRIC P C Excessive Snoring P C Insomnia P C Memory loss or confusion RECENT TESTS (lab work, x-rays, CT, MRI) P C Nervousness P C Depression

OTHER PROVIDERS

Reviewing Doctor:____________________________________________________________________________________________________________________

Patient: Date:


NOTICE OF PRIVACY PRACTICES AND ACKNOWLEDGEMENT This notice describes how your health information may be used and disclosed. Please Review it carefully. YOUR RIGHTS You have certain rights with respect to your health information, subject to legal limitations, including: - Obtaining an electronic or paper copy of your record. We will provide a copy or summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee. - Asking us to correct incorrect or incomplete information. We may say “no,” but if we do, we’ll tell you why in writing within 60 days. - Requesting confidential communications or asking us to contact you in a specific way (e.g., home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. - Asking us to limit what we use or share for treatment, payment, or our operation. We are not required to agree to your request, and we may say “no.” If, however, you pay for a services or item out-of-pocket in full, you can request that we not share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. - Obtaining a list (accounting) of those with whom we’ve shared your information for six years prior to the date you ask, who we shared it with, and why. The list will not include disclosures for treatment, payment, and health care operations, and certain other disclosures (e.g. made at your request). We’ll provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for additional accountings. - Obtaining a paper copy of this notice at any time, even if you agreed to receive the notice electronically. - Designating someone to act for you. If you have a medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act on your behalf before we take any action. - Filing a complaint if you feel we have violated your rights by contacting: U.S. Department of Health and Human Services Office for Civil Rights, 200 Independence Ave, S.W., Washington, D.C. 20201, 1-877-696-6775, www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against anyone for filing a complaint. YOUR CHOICES - You have the right and choice to have us share information with family, friends, or others involved in your care; share information in a disaster relief situation; or include your information in a hospital directory. - We will not sell your information or share it for marketing unless you give us written permission. - We will not share psychotherapy notes unless you give us written permission. - If you are not able to tell us your choice, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

OUR USES AND DISCLOSURES - We can use your health information and share it with others for treatment, payment, and health care operations. This includes sharing information with others who are treating you, to bill and get paid, and to run our practice and improve care. - We are also allowed or required to share your information in other ways, such as:

- Providing you with information related to your health; - Contacting you regarding appointments, treatment alternatives, or other health related services; - Incidental uses or disclosures (e.g., listing your name on a sign-in sheet, etc.); - Compliance with all laws (including reports of adverse reactions, suspected abuse, neglect or violence); - Providing information to law enforcement or correctional institutions; - Providing information to a coroner, medical examiner, funeral director, or for organ procurement; - Public health activities when requested by a public health authority or the FDA. - Responding to health oversight agencies; - Responding to court or administrative orders, subpoenas, discovery requests or lawful process; - Research activities; - When necessary to avert a serious threat to health or safety; - Military affairs, veterans affairs, national security, intelligence, Department of State, or presidential protective service activities; - Providing information regarding your location, general condition or death to disaster relief agencies; - Providing information for workers’ compensation claims; or - Informing a family member, other relative, or close personal friend when:

- Information is relevant to the individual’s involvement with your care; - Notification of your location, general condition or death; - To assist in your heath care (pick-up prescriptions or documents, follow-up care instructions, etc.).

- Our practice will make other uses and disclosure of your protected health information only after obtaining your written authorization. If you authorize a use not contained in this notice, you may revoke your authorization at any time by notifying us in writing. OUR RESPONSIBILITIES - We are required to maintain the privacy and security of your protected health information and to let you know promptly if a breach occurs that may compromise the privacy or security of your information. - We must follow the duties and privacy practices described in this notice and give you a copy of it. - We will not use or share your information other than as described here unless you tell us in writing that we can. If you tell us we can, you may change your mind at any time, but please let us know in writing if you change your mind. CHANGES TO THE TERMS OF THIS NOTICE We reserve the right to change the terms of this notice. The newly effective notice will be posted in our office, on our website, and will be available upon request. This Notice is effective May 30, 2019. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

PATIENT ACKNOWLEDGEMENT I acknowledge receiving a copy of this notice regarding the use and disclosure of my health information. ___________________________________ _________________________________ Signature of Patient/Legal Guardian Date ___________________________________ _________________________________ Print Patient Name (required) Print Legal Guardian Name (if necessary) *************************************************************************************************** INTERNAL PRACTICE USE ONLY: _____________________________________ refused to sign. _________________________________________ ____________________ Signature of Practice Representative Date


Franklin, TN 37067 615-257-7799

BRAINANDMEMORY.COM

WELCOME. The doctors of chiropractic at this office are honored to be a part of your journey to achieve better health. This consent outlines our practice, policies, and your

consent to care.

FUNCTIONAL HEALTH: Doctors of chiropractic practicing in a functional health model view health as a continuum from optimal health to hidden imbalances to disease. Rather than treating disease (e.g. cancer, hypothyroid, or multiple sclerosis), we address underlying metabolic, physiologic, and functional imbalances, intervening at root causes. One effect may be the ability to reduce or eliminate the need for medications, which must be done by your prescribing provider. As doctors

of chiropractic, we do not prescribe drugs or perform surgery. Therefore, all changes to prescription medications must be made by your prescribing

provider.

ALTERNATIVES: Alternatives include doing nothing, relying solely on drug therapy, or consulting with other providers. Chiropractic is a branch of the healing arts distinct from other branches (e.g. nursing, osteopathic, or allopathic). I understand that the doctors in this practice are doctors of chiropractic who have post graduate education in functional endocrinology and clinical nutrition, and that diagnosing and treating human diseases or ailments is within the scope of chiropractic practice. Nonetheless, we encourage you to communicate with your other health providers about the care you receive.

RISKS: Nutritional remedial measures and supplements used in our practice are generally considered safe; however, they may involve some risks including, without limit, changes in blood sugar or gastrointestinal upset. They may also interact with certain drugs and may be inappropriate during pregnancy.

NO GUARANTEE: Every individual responds to care differently and no guarantee or assurance is made as to the results of care in any specific case, as care may not improve your condition or result in reducing medications. We can, however, speak of our experience treating functional imbalances, and the success seen in our office has been excellent. Success includes documented subjective or objective functional improvement.

PAYMENT, INSURANCE, AND REFUNDS: Payment for services is not conditional on response to care. We do not accept or bill insurance. All payments will be self pay. Prorated fees for unused, prepaid services will be refunded if you wish to cancel; however, no refunds are available for any products purchased.

QUESTIONS AND ANSWERS: I have read and fully understand this consent form, and understand that I should not sign this form if any of my questions have not been explained to my satisfaction or if I do not understand any of the terms or words.

DO NOT SIGN UNLESS YOU HAVE READ AND FULLY UNDERSTAND! ______________________________________________ ______________________________ Patient or Person with Authority to Consent Date

216 Seaboard Ln, Ste. A-2

Franklin, TN 37067

615-257-7799

informed consent · informed consent 1. services: my health care provider has recommended...

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