New Patient Packet Atlantic Chiropractic

Dr. Taylor Paul, DC www.atlanticchiropracticsc.com

BioMed Health Performance www.biomedhp.com drpaul@biomedhp.com

BioMed Health & Performance Documentation www.BioMedHP.com | P:843.705.6400

GENERAL PATIENT INFORMATION First Name: Last Name: MI: DOB: Address: City: State: Zip: Phone: Alt. Phone: Email: Gender: □ Male □ Female Ethnicity: □ African □ European □ Native American □ Mediterranean □ Asian □ Middle Eastern □ North American □ Other Emergency Contact: Phone: Primary Care Physician: Phone: Fax: Referred By: □ Google □ Friend/Family □ Other

CURRENT HEALTH HISTORY

Please describe what has brought you to seek help from us? __________________________________________________________ ____________________________________________________________________________________________________________ When did you first notice this condition? __________________________________________________________________________ Have you ever been treated for this condition or similar condition? If yes, Where and How was it treated? Was the treatment successful in your mind? ________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Please depict the location of your discomfort

Key: 1. Circle areas of

complaint. 2. If the discomfort

travels please draw arrows to depict.

**It is important to assess the entire individual from inside to out to understand why the body is performing the way it is. Hence it is important to fill out the information for all three pillars (biomechanical, metabolic, and psychologic). This information is important to provide the best care possible.**

MEDICAL HISTORY Please check appropriate box and onset

GASTROINTESTINAL □ Irritable Bowel Syndrome __________________________ □ Gastritis or Peptic Ulcer Disease _____________________ □ Inflammatory Bowel Disease _______________________ □ GERD (reflux) ___________________________________ □ Crohn’s ________________________________________ □ Celiac Disease ___________________________________ □ Ulcerative Colitis _________________________________ □ Other ___________________________________________ CARDIOVASCULAR □ Heart Attack _____________________________________ □ Hypertension ____________________________________ □ Other Heart Disease _______________________________ □ Rheumatic Fever _________________________________ □ Stroke __________________________________________ □ Mitral Valve Prolapse _____________________________ □ Elevated Cholesterol ______________________________ □ Other ___________________________________________ □ Arrhythmia ______________________________________ METABOLIC/ENDOCRINE □ Type 1 Diabetes __________________________________ □ Weight Gain _____________________________________ □ Type 2 Diabetes __________________________________ □ Weight Loss _____________________________________ □ Hypoglycemia ___________________________________ □ Frequent Weight Fluctuations _______________________ □ Metabolic Syndrome ______________________________ □ Bulimia _________________________________________ □ Insulin Resistance or Pre-Diabetes ___________________ □ Anorexia ________________________________________ □ Hypothyroidism __________________________________ □ Binge Eating Disorder _____________________________ □ Hyperthyroidism _________________________________ □ Night Eating Syndrome ____________________________ □ Endocrine Problems _______________________________ □ Eating Disorder (non-specific) _______________________ □ Polycystic Ovarian Syndrome _______________________ □ Other ___________________________________________ □ Infertility _______________________________________ CANCER □ Lung Cancer _____________________________________ □ Ovarian Cancer __________________________________ □ Breast Cancer ____________________________________ □ Prostate Cancer __________________________________ □ Colon Cancer ____________________________________ □ Skin Cancer _____________________________________ GENITAL AND URINARY SYSTEMS □ Kidney Stones ___________________________________ □ Frequent Yeast Infections __________________________ □ Gout ___________________________________________ □ Erectile Dysfunction or Sexual Dysfunction ____________ □ Interstitial Cystitis ________________________________ □ Other ___________________________________________ □ Frequent Urinary Tract Infections ____________________ MUSCULOSKELETAL □ Osteoarthritis ____________________________________ □ Chronic Pain _____________________________________ □ Fibromyalgia ____________________________________ □ Other ___________________________________________ AUTOIMMUNE / INFLAMMATORY □ Chronic Fatigue Syndrome _________________________ □ Poor Immune Function ____________________________ □ Autoimmune Disease ______________________________ □ Frequent Infections _______________________________ □ Rheumatoid Arthritis ______________________________ □ Food Allergies ___________________________________ □ Lupus SLE ______________________________________ □ Environmental Allergies ___________________________ □ Immune Deficiency Disease ________________________ □ Multiple Chemical Sensitivities ______________________ □ Herpes-Genital ___________________________________ □ Latex Allergy ____________________________________ □ Severe Infectious Disease __________________________ □ Other ___________________________________________ RESPIRATORY DISEASES □ Asthma _________________________________________ □ Pneumonia ______________________________________ □ Chronic Sinusitis _________________________________ □ Tuberculosis _____________________________________ □ Bronchitis _______________________________________ □ Sleep Apnea _____________________________________ □ Emphysema _____________________________________ □ Other ___________________________________________

SKIN DISEASES □ Eczema _________________________________________ □ Melanoma _______________________________________ □ Psoriasis ________________________________________ □ Skin Cancer _____________________________________ □ Acne ___________________________________________ □ Other ___________________________________________ NEUROLOGIC/MOOD □ Depression ______________________________________ □ Mild Cognitive Impairment _________________________ □ Anxiety ________________________________________ □ Memory Problems ________________________________ □ Bipolar Disorder _________________________________ □ Parkinsons Disease _______________________________ □ Schizophrenia ___________________________________ □ Multiple Sclerosis ________________________________ □ Headaches ______________________________________ □ ALS ___________________________________________ □ Migraines _______________________________________ □ Seizures ________________________________________ □ ADD/ADHD ____________________________________ □ Other Neurological Problems _______________________ □ Autism _________________________________________ PREVENTIVE TESTS AND DATE OF LAST TEST □ Full Physicians Exam ______________________________ □ Hemoccult Test – stool test _________________________ □ Bone Density ____________________________________ □ MRI ___________________________________________ □ Colonoscopy ____________________________________ □ CT Scan ________________________________________ □ Cardiac Stress Test ________________________________ □ Upper Endoscopy ________________________________ □ EBT Heart Scan __________________________________ □ Upper GI Series __________________________________ □ EKG __________________________________________ □ Ultrasound ______________________________________ SURGERIES □ Appendectomy ___________________________________ □ Joint Replacement ________________________________ □ Hysterectomy ____________________________________ □ Heart Surgery ____________________________________ □ Gall Bladder _____________________________________ □ Angioplasty or Stent _______________________________ □ Hernia __________________________________________ □ Pacemaker ______________________________________ □ Tonsillectomy ____________________________________ □ Other __________________________________________ □ Dental Surgery ___________________________________ □ None ___________________________________________ HOSPITALIZATIONS □ None Date Reason ALLERGIES/SENSITIVITIES

Medication / Supplements / Food: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Reaction: (Please describe the reaction you get to the listed Allergies and Sensitivities) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ OTHER MEDICAL HISTORY Please fill out applicable parts

OBSTETRIC HISTORY □ Pregnancies __________ □ Caesarean ___________ □ Vaginal Del. __________ □ Children __________ □ Post Partum Depression □ Toxemia □ Gestational Diabetes □ Breast Feeding

MENTRUAL/HORMONAL □ Use of Hormonal Based Birth Control □ Fibrocystic Breasts □ Endometriosis □ Fibroids □ Painful Periods □ PMS MEN’S HISTORY □ Prostate Enlargement □ Prostate Infection □ Change in Libido □ Urination at night □ Change in urination

MEDICATIONS (if medications do not all fit on this form please provide a complete list) CURRENT MEDICATIONS

MEDICATION DOSE FREQUENCY START DATE (MM/YYYY) REASON FOR USE PREVIOUS MEDICATIONS

MEDICATION DOSE FREQUENCY START DATE (MM/YYYY) REASON FOR USE NUTRITIONAL SUPPLEMENTS (VITAMINS/MINERALS/HERBS/HOMEOPATHY)

SUPPLEMENT AND BRAND

DOSE FREQUENCY START DATE (MM/YYYY) REASON FOR USE

OTHER MEDICATION AND SUPPLEMENTATION HISTORY

Have your medications or supplements ever caused you unusual side effects or problems? □ Yes □ No Describe: _______________________________________________________________________________ Have you had prolonged or regular use of NSAIDS (Advil, Aleve, Motrin, Aspirin)? □ Yes □ No Have you had prolonged or regular use of Tylenol? □ Yes □ No Have you had prolonged or regular use of Acid Blocking Drugs (Tagamet, Zantac, Prilosec, etc.)? □ Yes □ No Frequent Antibiotics > 3 times/year □ Yes □ No Use of steroids (prednisone, nasal allergy inhalers) □ Yes □ No

FAMILY HISTORY Please briefly describe any family members who have been diagnosed with health conditions (Heart Disease, Cancer, Diabetes) Family Member (Relation to Patient) Past of Present Conditions SOCIAL HISTORY NUTRITION HISTORY

Have you ever had a nutrition consultation? □ Yes □ No Have you made any changes in your eating habits because of your health? □ Yes □ No Describe: _____________________________________________________________________

Do you currently follow a special diet or nutritional program? □ Yes □ No Check all that apply: □ Low Fat □ Low Carbohydrate □ High Protein □ Low Sodium □ Diabetic □ No Dairy □ No Wheat □ Gluten Restricted □ Vegetarian □ Vegan □ Specific Program or Weight Loss/Maintenance Type

SMOKING Currently smoking? □ Yes □ No How many years? _______ Packs per day: _______ Attempts to quit: _______ Previous Smoking: How many years? ______ Packs per day? _______ Second Hand Smoke Exposure? _______

ALCOHOL INTAKE How many drinks currently per week? 1 drink = 5 ounces wine, 12 ounces beer, 1.5 ounces spirits □ None □ 1-3 □ 4-6 □7-10 □ >10 If none, skip to other substance Have you ever been arrested or hospitalized because of drinking? □ Yes □ No Have you ever though about getting help to control or stop your drinking? □ Yes □ No

OTHER SUBSTANCES Caffeine Intake: □ Yes □ No Coffee cups/day: □ 1 □ 2-4 □>4 | Tea Cups/Day: □ 1 □ 2-4 □ >4 Caffeinated Sodas or Diet Sodas Intake: □ Yes □ No

SLEEP/REST Average number of hours you sleep per night: □>10 □8-10 □6-8 □<6 Do you have trouble falling asleep □ Yes □ No Do you feel rested upon awakening? □ Yes □ No Do you have problems with insomnia? □ Yes □ No Do you snore? □ Yes □ No Do you use sleep aids? □ Yes □ No

ASSESSMENTS The following assessments are important in evaluating your health status. Please fill them out to the best of your ability based on how you are feeling at this time. Be aware that there is overlap and repeated questions. Please just answer the questions to the best of your ability.

READINESS ASSESSMENT Rate on a scale of 5(very willing) to 1(not willing)

In order to improve your health, how willing are you to: Significantly modify your diet □5 □4 □3 □2 □1 Take several nutritional supplements each day □5 □4 □3 □2 □1 Keep a record of everything you eat each day □5 □4 □3 □2 □1 Modify your lifestyle (e.g. work demands, sleep habits) □5 □4 □3 □2 □1 Practice a relaxation technique □5 □4 □3 □2 □1 Engage in regular exercise □5 □4 □3 □2 □1 Have a periodic lab test to assess your progress □5 □4 □3 □2 □1 What would you rate your readiness to accomplish your health care goals? (0=Not at all to 10=You will do anything)

__________

Will your family members be supportive and willing to help you accomplish your goals? □5 □4 □3 □2 □1 How confident in your ability to stick to a treatment for greater than 6 weeks to see changes?

□5 □4 □3 □2 □1

How willing are you to adhere to these changes after you are released from active care? □5 □4 □3 □2 □1 How willing are you to reach out to others including the doctor for help in your goals? □5 □4 □3 □2 □1 Is there anything that is holding you back from receiving the treatment necessary to reach these goals?

□Yes □No

If Yes, Please explain: ________________________________________________________ __________________________________________________________________________

AUTHORIZATION AND ACKNOWLEDGEMENT: I, the undersigned, certify that the information I have reported is correct. I understand that I am financially responsible for all charges. Taylor Paul, DC is not in network with any health insurance and/or Medicare/Medicaid. All lab services and nutritional supplements are to be paid prior to the ordering of the test/supplements. It is the understanding that after paying for the lab service whether it is performed or not the service is non-refundable. All lab services are performed by 3rd parties and payment is made directly to the 3rd party. I hereby authorize the physician to release all medical information necessary to secure the payment of benefits. Signature:_____________________________________________________________ Date:_______________________________

Office Use: (Please do not mark in this area)

Acknowledgement of Receipt of Notice of Privacy Practices

This form will be retained in your medical record.

NOTICE TO PATIENT

We are required to provide you with a copy upon request of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice.

Patient Name: Date of Birth:

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of BioMed Health & Performance.

I understand that the Notice describes the uses and disclosures of my protected health information by BioMed Health & Performance and informs me of my rights with respect to my protected health information.

___________________________________________ Signature of Pabent (Guarantor) ___________________________________________ Printed Name of Pabent (Guarantor) _____________________________ Date FOR OFFICE USE ONLY

We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because:

� The patient refused to sign.

� Due to an emergency situation it was not possible to obtain an acknowledgement

� Communications barriers prohibited obtaining the acknowledgement

� Other (please specify): ________________________________________________________________

______________________________________________________________________________________

___________________________________________ Signature of Employee ___________________________________________ Printed Name of Employee _____________________________ Date

INFORMED CONSENT

Medical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required by law to obtain your informed consent before starting treatment. I______________________________________________, Do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Physical therapy and exercises may also be used. Although spinal and extremity manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware the there are possible risks and complications associated with these procedures as follows: Soreness/Bruising: I am aware that like exercise it is common to experience muscle soreness and occasionally bruising in the first few treatments. Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution. Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke is reported to occur once in a million to once in ten million treatments. Once in a million is about the same chance as getting hit by lightning. Once in ten million is about the same chance as a normal dose of aspirin or Tylenol causing death. Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase in pain and possible blistering. This should be reported to the doctor. Tests have been or will be performed on me to minimize the risk of any complication from treatment and I freely assume these risks.

TREATMENT RESULTS

I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits. I realize that the practice of medicine, including chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the performance of these procedures by my doctor and such other persons of the doctor’s choosing.

ALTERNATIVE TREATMENTS AVAILABLE

Reasonable alternatives to these procedures have been explained to me including, rest, home applications of therapy, prescription or over-the-counter medications, exercises and possible surgery. Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks. Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat or other home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Exercises are of limited value but are not corrective of injured nerve and joint tissues. Surgery: Surgery may be necessary for joint instability or serious disc rupture. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery.

Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthy. I have read or had read to me the above explanation of chiropractic treatment. Any questions I have had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely. To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.

___________________________________________ Signature of Patient ___________________________________________ Printed Name of Patient _____________________________ Date

___________________________________________ Signature of Parent or Guardian (if a minor) ___________________________________________ Printed Name of Patient _____________________________ Date

___________________________________________ Signature of Witness ___________________________________________ Printed Name of Witness _____________________________ Date

Payment Policy & Payment Procedures BioMed Health and Performance: BioMed Health and Performance is set forth to provide its patients with an individualized and personal approach to health care. Our health care model is aimed at treating and maintaining a healthy lifestyle. For this reason it is only possible to provide the care and the attention necessary outside of the health insurance paradigm. BioMed Health and Performance is not in network with any insurance company. In some cases individuals would still like to submit their bills to their health insurance company for reimbursement. With notification a record of services can be provided to the patient for submission to the insurance company. The free consultation is more about what we can do. During that time no diagnosis or treatment will be given. Any and all questions may be asked, and the patient may get a feel for the doctor and what the visit will be like. After this point it will be the patients decision to go forward and schedule their first appointment. Fee Schedule will be provided upon request for services. Lab Fees must be paid up front and in full to the doctor in order to process your lab and get you scheduled for draws. No refunds will be given for any service, procedure, or aid.

Cancellations: See Cancellation Policy Page

__________________________________________ Signature of Pabent (Guarantor) ___________________________________________ Printed Name of Pabent (Guarantor) _____________________________ Date

To Our Patients Regarding Cancellations and No-Shows

The following are our policies regarding cancellations and no-shows. We take this subject seriously because it can make a difference between responding to treatment or not. Usually your referring doctor and/or therapist have prescribed a set frequency of treatment. If you show up for treatment, it will enable you to get better. Other than that all you need to do is follow your doctor’s instructions, and you should achieve your treatment goals. We require 24 hours notice in the event of a cancellation. It is your responsibility, when you call in, to have an alternative time in mind that will ensure you get the full number of prescribed treatments that week whenever possible. A full refund will be given if a 24hr notice is given on the appointment. There is a NO REFUND POLICY if cancellation occurs within the 24hr period. This charge will not be covered by you insurance, but will have to be paid by you personally. For Workmen’s Compensation and Personal Injury patients, documentation of any missed appointments is forwarded to your case manager and primary physician. This could jeopardize your claim. You may occasionally need to see another physician other than the one who normally sees you if you do need to re-arrange your appointment. All of our physicians are experienced professional and they will study your chart. You may return to your original physician at the next appointment. Please understand that your pain will probably increase and decreases as your course of treatment progresses and before it is finally eliminated. Either condition should not be a reason not to come in: 1) Your pain is gone or 2) Your pain is worse. If the pain is gone, now is the time to really begin rehabilitating the injured area to prevent recurrence. If your pain is worse, we can do something to help. When you don’t show as scheduled, three people are hurt. 1) You, because you didn’t get the treatment you need as prescribed by your doctor; 2) The doctor who now has a hole in their schedule; 3) The person that couldn’t get in when you had your appointment scheduled. Thank you for cooperating with us on this matter. We are looking forward to working with you. ___________________________________________ Signature of Pabent (Guarantor) ___________________________________________ Printed Name of Pabent (Guarantor) _____________________________ Date