Hanna Chiropractic Wellness Center
27791 La Paz Road, Laguna Niguel, CA
www.HannaChiropracticWellnessCenter.com
949. 389. 0400
New Patient Information
Welcome! Please allow our staff to photocopy your driver’s license & insurance card (if applicable).
PRINT CLEARLY:
Today’s Date: ____/_____/20_____
Full Name: _____________________________________ DOB: ___/____/____
Age:____ Gender: M F
Address:_______________________________________________ City:__________________ State:_____ Zip: ____________
Home Phone: (_____) ___________________ Cell: (_____) ______________________ Work: (_____) ______________________
Email:_________________________________________
Marital Status: S ___ M ___ D___ W ___
May we e-mail you?
Y
N
Work Status: FT ___ PT ___ R ___ Student ___
Employer:_______________________________________ Occupation: ___________________________________________
Parent or Guardian Name: ______________________________________________
Emergency Contact Person: ________________________________________ Relationship to Patient: _____________________
Primary Phone: (______) ___________________ Work Phone: (______) _______________________
Which doctor/practitioner were you referred to? (Circle One):
Dr. Hanna
Dr. Wendy
Dr. Julie
Other: ___________________________
How did you hear about us? (Circle One):
Internet
Social Media (please indicate): _________________
Doctor (please indicate): _________________
Health Concerns: (Please list in priority order & use back of questionnaire or additional paper if needed)
1._______________________________________________________________________________________________________________________
2._______________________________________________________________________________________________________________________
3._______________________________________________________________________________________________________________________
Females: Last Menstrual Period: ______/______/_______
Pregnant? ____ Y _____ N
Nursing? _____ Y _____ N
Treatment: What type of treatment are you looking for? (More than one may apply):
_______ Symptom Relief
________ Correctional Care
_________ Total Wellness Care
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Symptoms/Complaints: (Relating to your primary complaint(s)):
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When did your symptoms begin? _____________________ What initiated the symptoms?:_____________________________________
Have you previously been treated for this condition by another provider? Y____ N____ If yes, then by whom? ____________________
Treatment received: ______________________________________________________________________________________________
Have you had any reactions to previous treatment? Y____ N_____
Describe:________________________________________________________________________________________________________
If this is a recurrence, when did you initially notice this problem?: _________________________________________________________
Has it worsened over time? Y___ N___ Same____ How long does it last?:________ Does it interfere with your: Sleep__ Daily Routine:__
Describe the pain:_______________________________________________________________________________________________
What makes it worse? (Circle One): Standing
Sitting
Lying
Bending
Lifting
Twisting
Other:____________________
Have you found things that relieve your symptoms? Y___ N___ If yes, describe:___________________________________________
Do you have other conditions or symptoms that may be related your current symptoms? Y___ N____ If yes, what?:______________
________________________________________________________________________________________________________________
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Have you ever been in an auto accident or other physical trauma? Never___ Past Year___ 1-5 Years___ 5+ Years___ Please
Describe:____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Indicate your symptoms by checking P= Prior Condition or C=Current Condition.
P / C
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P / C
Headache
Fascial Pain
Blurred Vision
Dizziness
Earache
Eye Pain
Forgetfulness
Confusion
Sinusitus
Teeth Grinding
Dry Mouth
Excessive Thirst
Unpleasant Taste
Neck Pain
Sore Throat
Lump in Throat
Swallowing Pain
Unsteady Voice
Shoulder Pain
Persistent Coughing
Chest Pressure
Slow Heart Rate
Rapid Heart Rate
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P / C
Abdominal Pains
Nausea/Vomiting
Poor Appetite
Fullness of Bladder
Urination Difficulty
Frequent Urination
Constipation
Hemorrhoids
Decreased Sex Drive
Menstrual Irregularities
Elbow/Hand Pain
Tingling in Hands
Clammy Hands
Low Back Pain
Hip Pain
Knee Pain
Poor Circulation
Swollen Joints
Joint Stiffness
Swollen Ankles
Ankle/Foot Pain
Tingling in Feet
Walking Problems
_ _ Paralysis
Please use the legend symbols to accurately mark
_ _ Shakiness
the areas in which you feel these sensations:
_ _ Sweating
Stabbing/Acute: ||| - Cramping ^^^
_ _ Insomnia
_ _ Fainting
Tingling: :::
- Numbness --_ _ Convulsions
Burning: XXX
- Dullness ###
_ _ Irritability
_ _ Impatience
_ _ Fatigue
_ _ Feel Loss of Control
_ _ High Blood Pressure
_ _ Low Blood Pressure
_ _ Sore Muscles
_ _ Weak Muscles
_ _ Other: ___________
______________________
______________________
*Additional*
(Please check all that apply)
_ _ Seizures (Epilepsy)
_ _ Transplant
_ _ Surgically Implanted Device
_ _ Pacemaker
Allergies: (Please list all that apply)
Food:____________________________________________________________________________________________________________________
Seasonal:_________________________________________________________________________________________________________________
Other (Medications on pg. 4): __________________________________________________________________________________________________
Scars/Surgical Procedures (Please list all):________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
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Miscellaneous & Habbits:
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Are you: ___ Left Handed ___ Right Handed ___Ambidextrous?
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Exercise: ___ Light ___ Moderate ___Heavy
Type:________________
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How many meals per day do you eat?: _____
How much water do you drink?:____
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Alcohol Consumption: ___ Light ___Moderate ___Heavy ___ None
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Coffee, Tea: ___ Light ___Moderate ___ Heavy ___ None
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Work Activity: ___ Heavy Labor ___ Light Labor ___ Mostly Sitting ___ Mostly Standing ___ Walking/Moving ___ Driving
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How many hours do you sleep at night? _____ Interrupted Sleep __ Y __ N Do you feel rested upon waking __ Y __ N Vivid Dreams __Y __N
Frequency: ______________
How many bowel movements do you have each day? _____
Soda, Diet Soda: ___ Light ___Moderate ___Heavy ___ None
Personal & Family History: Identify conditions that you or any of your family members have now or have previously had. (G= Grandparents, M= Mother, F=Father, S= Siblings, X=Self)
___ Allergies
___ Alcoholism
___ Anemia
___ Cancer
___ Deep Vein Thrombosis
___ Detached Retina
___ Diabetes
___ Eczema
___ Emphysema
___ Epilepsy
___ Goiter
___ Gout
___ Heart Disease
___ HIV/AIDS
___ Miscarriage(s)
___ Mumps
___ Pleurisy
___ Pneumonia
___ Polio
___ Rheumatic Fever
___ Stroke
___ Tumor(s)
___ Ulcer(s)
___ Female Organ Dysfunction
___ Over weight
___ Headaches
___ Migraines
___ Addiction
Other: ____________
Informed Consent to Chiropractic, Acupuncture, and Massage Care
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Chiropractic Adjustment: The doctor will use his/her hands or mechanical device in order to adjust your spinal joints. This procedure is called a spinal
adjustment and is intended to reduce spinal subluxation (slight dislocation of the spinal joints). You may feel a “click” or a “pop” as well as a movement of
the joint. Various ancillary procedures, such as support pillows, cold laser, traction or hot/cold packs may also be used. Risks: As with any health care
procedure, complications are possible following a chiropractic adjustment. Fracture of bone, muscular strain, ligament strain, dislocation of joints, injury to
intervertebral discs, nerves, or spinal cord are all rare occurrences and generally result from some underlying weakness of the bone or surrounding tissues.
Usually, there is an underlying, pre-existing vascular condition like atherosclerosis that contributes in a stroke resulting after a neck adjustment. A minority
of patients may notice stiffness or soreness after the first few days of treatment. We will not accept individuals for treatment unless we feel confident that
we can safely help them.
- Acupuncture: The provider will use procedures including, but not limited to, acupuncture, moxabustion, cupping, electro acupuncture, herbology, and
modes of physiotherapy. Risks: include, but are not limited to, slight bruising, tingling near the needling sites that may last a few days, nausea, infection
and blisters. There have been reported instances of fainting, scarring, spontaneous miscarriage and pneumothorax. I understand that some herbs may be
inappropriate during pregnancy.
- Massage: The provider will perform soft tissue or muscle work using his/her hands. Risks: may include weakness, muscle and joint soreness, ligament
strain, muscular strain.
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Probability of Risks: The risks and complications of chiropractic care, acupuncture, and massage therapy have all been describes as “rare”. The risk of
cerebrovascular injury or stroke has been estimated at one in one million to one in twenty million, and can be even further reduced by our screening
procedures. The probability of adverse reaction due to ancillary procedures is also considered as “rare”.
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Other treatment options which could be considered may include:
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Over the counter analgesics which may cause irritation of the stomach, liver, and kidneys, and other side effects in 1,000 to 4,000 people per 1,000,000, and reportedly
16,500 die annually from their use.
Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these include a multitude of undesirable side effects, and patient dependence in a
high number of cases.
Hospitalization and bed rest, in conjunction with medical care adds risks of exposure to virulent communicable disease, loss of muscle tone and strength at the rate of 4%
per day.
Surgery, in conjunction with medical care adds the risk of infections, adverse reaction to anesthesia, disfiguring scars as well as an extended convalescent period in a
significant number of cases. Serious neurological complication from neck surgery are 15,600 per million, mortality rates are 6,900 per million.
- Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue, and other degenerative changes. These changes can further
reduced skeletal mobility and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future
rehabilitation more difficult.
- I have had the following risks of my case explained to me. If you/and/or the individual listed below understand the above information, please sign below.
This signature authorizes treatment, acknowledges Notice of Privacy Practices and also authorization to submit to insurances (if applicable). Patient or
guardian understands that he/she is responsible for payment of all services.
I have read or have had read to me, the explanation of care offered at this facility. I have had the opportunity to have any
questions answered. I have fully evaluated the risks and benefits of undergoing and hereby give my full consent to the items
mentioned above.
______________________________________________________
Printed/Guardian Printed Name
_________________________________________________________
Signature
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Hanna Wellness Center
Electronic Health Records Intake Form
In compliance with requirements for the government EHR incentive program
First Name:_________________________
Last Name:_________________________
*Preferred method of communication for patient reminders (Circle one): Email / Text
Cell Phone Number_______________________________ Cell Carrier company (required)_________________
Email address: ______________________________________@___________________________________
DOB: __/__/____
Gender (Circle one): Male / Female
Preferred Language: __________________
CMS requires providers to report both race and ethnicity
Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) Native Hawaiian or
Pacific Islander / Other / I Decline to Answer
Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer
Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked
Are you currently taking any medications? (Please include regularly used over the counter medications)
Medication Name
Dosage and Frequency (i.e. 5mg once a day, etc.)
Do you have any allergies to medications?
Medication Name
Reaction
Onset Date
Additional Comments
_____I choose to decline receipt of a clinical summary page after every visit (These are often blank
as a result of the nature and frequency of chiropractic care. It only shows your medication info and
DX codes.)
Patient Signature: _____________________________________________
Date:_______________
For office use only
Height: _________
Weight:____________ Blood Pressure:______ /______
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Hanna Wellness Center
Notice of Privacy Practices Acknowledgement of Receipt
HIPAA is the acronym for the federal law known as Health Insurance Portability and Accountability Act of 1996. HIPAA is a large
and complex regulation. One purpose of HIPAA is to ensure our patient’s privacy. Under this new regulation we are required to
provide all patients with our “Notice of Privacy Practices”. A copy is available to take with you upon request. The regulation also
maintains that we receive your signature as an acknowledgement that you received our “Notice of Privacy Practices”.
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We want you to know how your Protected Health Information (PHI) will be used in this office and what your rights are concerning those records. Before
we begin care, please read and sign this consent form stating understanding and acknowledgment regarding how your records will be used. If you would
like to have a more detailed account of our policies and procedures concerning of the privacy of your PHI, please ask us for our complete HIPAA Privacy
Notice as we have that available upon request at the front desk.
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The patient understands and agrees with Hanna Chiropractic Wellness Center to use their Protected Health Information (PHI) for the purpose of
treatment, payment, healthcare options and coordination care.
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The patient has the right to examine and obtain a copy of his/her own health records at any time and request corrections. Patient may request to know
what disclosures have been made and submit in writing any further restrictions on the use of their PHI. This practice is not obligated to comply with
those restrictions.
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A patient’s written consent need only be obtained one time for all subsequent care given to the patient in this office.
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A patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior
to the written request to revoke consent, but would apply to any care given after the request has been presented.
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For your security and right to privacy, the staff has been trained in the area of private privacy and a privacy official has been designated to ensure these
procedures in our office. We have taken precautions to assure that your records are not readily available to those unauthorized to access them.
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Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
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If a patient refuses to sign this consent for the purpose of treatment, payment, & healthcare operations, this facility reserves the right to refuse service.
I acknowledge that I have read the “Notice of Privacy Practices”. I am also aware that I
may request a detailed copy at any time.
Patient or Patient Representative:
Signature
Patient’s Printed Name
___________________________
Date
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