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Welcome to Lake Pointe Chiropractic and Wellness. Please review the Practice Information and Policies below.

Payment Payment is due at the time of service. LPCW accepts cash, checks (made payable to LPCW), Visa, and MasterCard. Payment plans are available. Insurance Insurance benefits are not a guarantee of payment by your insurance company. We will submit chiropractic claims for you when warranted. Insurance plans do not cover nutritional consultations, wellness services, supplements, herbs, and other products. Payment for these items is your responsibility and due at the time of service/purchase. It is your responsibility to notify LPCW immediately if your insurance coverage changes or if you are involved in an automobile or worker’s compensation accident. Cancellation Policy LPCW understands that from time to time there may be conflicts with your schedule. We request that you notify us 24 hours prior to your appointment if you need to cancel or change an appointment. You will be responsible in full for the charges of the appointment with less than 24 hours notice. Perfumes and Fragrances Please help those clients with compromised immune systems and sensitivities by not wearing perfumes or fragrances to the office. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) of 1996 is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared an explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your information. If you would like a complete copy of this explanation, please initial here: ______________ Please sign and print your name and provide the date below to acknowledge that you understand our Notice of Privacy Practices and Office Policies. Patient Name: ___________________________________________________________ Signature: ___________________________________________ Date: _______________________

Office Policy

5000 W 36th St. Suite 120 Minneapolis, MN 55416 Phone: 612.922.8100 Fax: 612.922.8130 lpwellness.com

Patient Information:

Patient Name: _________________________________________ _______ Social Sec. #: ________-_____-____________

Date of Birth: __________________________Today’s Date: __________________________ Sex: □ Male □ Female

Address: _______________________________________________ _______ City: ___________________________________

State: _________ ZIP ___________________ Referred by: ___________________________________________________

Phone: (Home)__________________________ (Cell)__________________________ (Work)________________________

Email: _________________________________________________________________________________________________

Would you like to be added to our email list? □ Yes □ No Best time/place to reach you? _________________

Marital Status: □ Married □ Widowed □ Single □ Divorced □ Unknown

Race: ________________________ Ethnicity: ______________________ Preferred Language: ___________________

Occupation: ______________________________________ Employer/School: __________________________________

Emergency contact: _______________________________________ Relationship to patient: _____________________

Contact Phone: _________________________________ Alternate Phone: _______________________________

Patient Condition:

When did your symptoms first appear? _________________________

Mark an X on the picture where you have symptoms.

Rate your pain on a scale from 1 (least) to 10 (severe) __________

Type of pain: □Sharp □Throbbing □ Dull □Numbness

□Aching □Burning □Tingling □Cramps

□Stiffness □Swelling □Other _______________________

How often do you have this pain? □Constant □Daily □Weekly

Does it interfere with: □Work □Sleep □Daily Activities

□Sitting □Standing □Walking □Bending □Lying down

Health History What treatment have you already received for your condition? �Acupuncture �Chiropractic Services �Massage �Medications �Physical Therapy �Surgery �None �Other ___________________

Date of Last:

Physical Exam ____________ Spinal X-Ray ___________ Blood Test ___________

Spinal Exam _____________ Chest X-Ray ____________ Urine Test ___________

Dental X-Ray ____________ MRI, CT-Scan, Bone Scan ___________________________

Please check “Yes” OR “No” to indicate if you have had any of the following:

AIDS/HIV � Yes � No

Diabetes � Yes � No

High Cholesterol

� Yes � No

Prosthesis � Yes � No

Alcoholism/Chem Dependency

� Yes � No

Eating Disorder

� Yes � No

Kidney Disease � Yes � No

Psychiatric Care

� Yes � No

Allergy Shots � Yes � No

Emphysema � Yes � No

Liver Disease � Yes � No

Rheumatoid Arthritis

� Yes � No

Anemia � Yes � No

Epilepsy � Yes � No

Mononucleosis � Yes � No

Stroke � Yes � No

Appendicitis � Yes � No

Fractures � Yes � No

Multiple Sclerosis

� Yes � No

Suicide Attempt

� Yes � No

Arthritis � Yes � No

Glaucoma � Yes � No

Osteoporosis � Yes � No

Thyroid Problems

� Yes � No

Asthma � Yes � No

Goiter � Yes � No

Ovarian Cysts � Yes � No

Tonsillitis � Yes � No

Bleeding Disorders � Yes � No

Gout � Yes � No

Pacemaker � Yes � No

Tuberculosis � Yes � No

Breast Lump/Cyst � Yes � No

Headaches � Yes � No

Parkinson’s Disease

� Yes � No

Tumors Growths

� Yes � No

Bronchitis � Yes � No

Heart Disease � Yes � No

Pinched Nerve � Yes � No

Ulcers � Yes � No

Cancer � Yes � No

Hepatitis � Yes � No

Pneumonia � Yes � No

Vaginal Infections

� Yes � No

Cataracts � Yes � No

Hernia � Yes � No

Polio � Yes � No

Venereal Disease

� Yes � No

Chicken Pox � Yes � No

Herniated Disk

� Yes � No

Prostate Problem

� Yes � No

Whooping Cough

� Yes � No

Other

Family History Living Y/N Cause of Death/Age History of Disease?

Mother Father Grandparents

Siblings

Exercise �None

�Moderate

�Daily

�Heavy

Work Activity �Sitting

�Standing

�Light Labor

�Heavy Labor

Habits �Smoking

�Alcohol

�Caffeine Drinks

�Water

�High Stress Level

Packs/Day ____________

Drinks/Week __________

Cups/Day _____________

Glasses/Day ___________

Reason _______________

Are you pregnant? �Yes �No Estimated Due Date: ____________ Home or Hospital birth? ________

Number of Pregnancies? ________ Abortions? ________ Miscarriages _______ Children? _________

Health Care Providers/Birth Team: ______________________________________________________

Symptoms specific to pregnancy? ______________________________________________________

Concerns related to pregnancy, labor and/or delivery/birth? __________________________________

Please describe any injuries or surgeries (e.g. slips/falls, head injuries, broken bones, dislocations, surgeries, auto accidents): ___________________________________________________________

_________________________________________________________________________________

Medications (indicate how long taking medication

and condition it is treating)

Allergies (including known food sensitivities)

Meals (Check what you eat on a typical day)

Vitamins/Herbs/Minerals (indicate how long taking supplement and

reason for taking it)

�Breakfast

�Snack

�Lunch

�Snack

�Dinner

�Snack

Please take a moment to assess your health.

WOULD YOU LIKE TO…

� Have more energy? � Lose weight? � Sleep better? � Improve your complexion? � Have stronger nails/healthier hair? � Feel less stressed? � Get sick less often? � Improve your digestion? � Decrease Allergies? � Decrease Drugs/OTC Meds? � Improve focus/memory/mood? � Feel fewer aches and pains? � Other ________________________

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5000 W 36th St. Suite 120 Minneapolis, MN 55416 Phone: 612.922.8100 Fax: 612.922.8130 lpwellness.com

Authorization Verbal Disclosure of Protected Health Information

Patient Name: ________________________________________________ Date of Birth: __________________________

Email: _________________________________________________________________________________________________________

Address: ______________________________________________________ City: ___________________________________

State: _______ ZIP __________ Phone:(Home)______________________________(Alternate)______________________________

I authorize Lake Pointe Chiropractic & Wellness (LPCW) to verbally discuss the following protected health information about me with the individuals listed below (check all boxes that apply):

□ Scheduling/appointment information

□ Billing/payment information

□ Medical information including symptoms, diagnosis, treatment plans, medications, and recommendations

□ Behavioral/mental health information including symptoms, diagnosis, treatment plans, medications, and

recommendations

□ Chemical dependency information including symptoms, diagnosis, treatment plans, medications, and

recommendations

□ Lab/test results

□ Other (please describe):________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

I authorize LPCW to discuss the information selected above with the following individuals:

Name: ______________________________________________________________________

Address: _____________________________________________________________________

City, State, ZIP: _______________________________________________________________

Phone: (Home) _____________________________ (Alt.) ____________________________

Name: ______________________________________________________________________

Address: _____________________________________________________________________

City, State, ZIP: _______________________________________________________________

Phone: (Home) _____________________________ (Alt.) ____________________________

I understand that I may revoke this authorization at any time, but that it will not affect any disclosures already made under this authorization prior to revocation. I understand that my revocation of this authorization must be presented in writing to LPCW.

Signature of patient/authorized representative: _____________________________________________________________________

Date: ________________________ Reason patient cannot sign: _________________________________________________________

To authorize permission for LPCW to verbally discuss your care with additional individuals, please fill out an additional

form, available upon request by phone at 612.922.8100.

This authorization is for verbal information. Please fill out a Release of Records form to authorize access to medical

records. This form is available upon request by phone at 612.922.8100.

To revoke this authorization for verbal discussion of protected health information, please write to us at the address given

below.

Lake Pointe Chiropractic & Wellness

5000 W 36th St Suite 120

Minneapolis, MN 55416

For additional information, please call 612.922.8100.