Confidential Client Questionnaire · I have: Indigestion Belching GERD Intestinal Gas Bloating Immediately after eating 1-2 hours 3-5 hours 6+ hours No odor Some odor odor usually

Dr. Laura Connor, DCBCN 505 W Glen Street

Crandon, WI 54520 715-478-5202 /fax: 715-478-5205 [email protected]

Confidential Client Questionnaire

Patient information

First Name Middle Name

Last Name Suffix Nick Name

Address

City State Zip Code

Mobile Phone Home Phone

Home Email

Date of Birth Age Gender (check one) □ Male □ Female □ Unspecified

Referred by:

Marital Status (check one) □ Single � Married � Widowed � Divorced □Partner

Spouse’s Name:

Employment Status (check one)

□ Employed □ FT Student □ PT Student □ Other □ Retired □ Self Employed

Emergency Contact Information: Full Name Relationship:

Address: City

State Zip Code Phone Number:

Health History

Reason for appointment (Be sure to give a detailed account, including when and why it started, what has been done to date,

the results you have had, and if the problem is getting better, worse, or is the same):

Give any secondary health problems you are experiencing. Listing the most severe first.



Nutritional Supplements

Name of Supplement

Company Amount Reason for taking

How long?

Prescription Medications

Allergies:

Please list all allergies you have to food, drugs, or other substances, along with the symptoms they produce and indicate how long you have suffered from each:

Allergy Symptoms How long?

Surgeries: Please list all surgeries you have had, including the date, why it was done, and any complications: Date Surgery Why done? Complications

Name of Prescription

Amount Reason for taking

How long?



Answer the following questions to the best of your ability. If you do not know the answer, leave blank. □ yes □ no My mother was healthy while pregnant with me. If no, describe: □ yes □ no Was your birth Natural? If no, please check: □ anesthesia □ forceps □ c-section □ yes □ no Were you breastfed for at least the first 6 months? □ yes □ no Were you fed anything other than breast or formula containing lactose in the first 6 months? List items:

□ yes □ no Were you a colicky baby? If so, until what age? □ yes □ no Have you ever been to or lived in a foreign country? □ yes □ no Have you ever fainted or had a convulsion? If yes, describe: Please Check if you have had any of the following: Childhood Illnesses:

□ADD □ Depression □Lyme Disease □Rash/Psoriasis □ Diabetes □Allergies/Hayfever □ Ear Infections □Anemia □ Headaches □Asthma □ Scoliosis □Bedwetting □ HIV □Cerebral Palsy □ Measles

□ Chicken Pox □ Other:

Adult Illnesses: □ADD □ CVA(stroke) □ Heart disease □ Parkinson’s □ Suicide Attempt(s) □Alzheimer’s □ Chicken Pox □ Hepatitis □ Pleural effusion □ Thyroid Problems □Arthritis □ Kidney Disease □ HIV □ Pneumonia □ Vertigo □Asthma □ Depression □ Hypertension □ Psoriasis □ Other: □Cancer □ Diabetes □ Influenza □ Psychiatric Conditions □Cerebral palsy □ Eczema □ Liver Disease □ Scoliosis □Chicken pox □ Emphysema □ Lung Disease □ Seizures □Colitis □ Eye problems □ Lupus Erythema □ Shingles □CRPS(RSD) □ Fibromyalgia □ Multiple Sclerosis □ STD’s (unspecified)



Diet History Give the amount of each you consume: oz water Daily Not daily oz alcohol Daily Not daily oz coffee/tea Daily Not daily oz soda Daily Not daily oz juice Daily Not daily other List your 10 most favorite foods eaten most frequently: Give percentages for each of the following. Total for each line to equal 100% Where daily diet prepared: Home Restaurant Fast Food Vending Machines How food prepared: Baked Broiled Fried Steamed Micro Grilled My appetite is: □ Normal □ Excessive □ Poor I crave: □ Sweets □ Salt □Chocolate □ Water □ Dirt □ Other: Type of water used for drinking/cooking: □Tap or city □Spring □Well □Rain □bottled distilled □bottled filtered □reverse osmosis If purchase water, is it in: □ Soft Plastic □ Hard Plastic □ Glass Foods that disagree with you: □ Raw Vegetables □ Raw fruit □ Fats □ Fried □ Beans □Sugar □Milk/dairy

□ Greasy □ Eggs □Onions □Cabbage □Highly spiced □Other:

What symptoms do you get from foods that disagree with you? Do you fast? □ Yes □ No If yes, how often and how long? Have you ever done a detoxification program? □ Yes □No Explain:



Check any of the following diets you have ever tried: □ Low Cholesterol □ Low Salt □Low Purine □ all energy □Low fat □Diabetic □Renal/Kidney □ High Fiber □ Ulcer □ Diverticulitis □ Complex Carbohydrate □ High Protein □ Weight Loss (List which ones) What is your current weight? Most ever weighed? At what weight do you feel best?

Have you gained or lost more than 5 pounds in the past 6 months? □ Yes □ No

Exercise- How many days per week? Minutes per day? Type?

Bowel Health BM=Bowel Movement or stool

How many times do you have a BM? Times/day Times/week Do you use laxatives? □ Yes □ No How often? Do you get the urge to have a BM? □ Yes □ No Do you have pain with BM? □ Yes □ No

Answer the following using the following: 0=Never 1=Rarely 2= Frequently 3= Always Stool Size Stool Consistency Stool Color 2” wide & 6+” length Float like a submarine Med/dark Brown 1” wide & 4+” length Float on top of water Very dark/black thin, long, or narrow Sink to bottom Yellow/tan/clay Small, hard Loose but not watery Greenish Large, hard Diarrhea Blood is visible Difficult to pass Alternate hard/diarrhea Mucous in/around Have you ever had worms or parasites? □ Yes □ No How treated? Do you presently have rectal itching? □Yes □ No If yes, is it during: □ Day □ Night □ Continuously



Digestion

Mark any areas of distress associated with food intake on the diagrams:

I get heartburn: □ Before Eating □ After Eating □ When Lying down □ Upon Rising I have: □Indigestion □Belching □GERD □Intestinal Gas □Bloating □ Immediately after eating □1-2 hours □3-5 hours □6+ hours □ No odor □ Some odor □ odor usually □ foul smelling □ Hiatal hernia □Esophageal burning/reflux □ raise head of bed to sleep List any prescriptions or natural remedies you take for any stomach or bowel symptoms:

Product Dose How frequently? Results



Head, Mouth, Throat

Mark any areas of headache or pain

My teeth are: □ Good □ Some fillings □ Bad □ Some missing □ All missing □ Root canal I wear dentures: □ Upper □ Lower □Partial □ Crowns □ Different metals in mouth My breath is: □ Good □ Slight Odor □ Odor off/on □ Offensive odor usually My tongue is: □ Covered with small taste buds □ Sore □ Furrowed □ Coated color My tonsils are: □ Normal □ Removed at age □ Enlarged □ Spotted My sense of taste is: □ Normal □ Poor □ No taste □Over-salted foods □ Canker sores My lips are: □ Normal □ Dry □ Peel a lot □ Fever blisters often □ Cracked in corners I get headaches: □ Daily □ Weekly □ Rarely □ Never □ Wake up with □ Get in morning □ Get in evening □ Of different types □ With some foods or drinks □ With aura □ With nausea/vomiting

Muscle, Ligament, Joint, Nerve I have pain in: □ Neck □ Mid-Back □ Low back □ Hips □ Knee □ Ankle □ Feet □ Shoulder □ Elbow □Wrist □ Hands □ Other: I get: □ Swollen joints □ Sore joints □ Joints pop or crack □ jaw pops □ leg cramps at rest □ leg cramps with activity □ worse at night □ foot cramps at rest □ foot cramps with activity □ Flat feet □ burning feet □ tingling in hands and feet □ restless leg syndrome I have: □ Nervous tic or twitching, where? □ Bell’s Palsy □ Ringing in ears □ Parkinson’s □ Sciatic Neuritis □ Multiple Sclerosis □ Had spinal surgery, Where?



Hair, Skin, Nails

Hair: □ Course □ Fine □Falls out excessively □ Turned gray at age □ Oily □ Dry Male Beard: □ Heavy □ Light or sparse □ None □ Ethnic Background Female: □ Facial hair always □ Facial hair started at age □ Hair on abdomen and/or breasts Fingernails: □ Normal □ Brittle/break easily □ Soft □ Ridged Vertically □ White Spots □ Grow Fast □ Ridged Horizontal □ Grow Slow □ Shaped Oddly □ Hangnails Skin: □ Normal □ Oily □ Dry □ Flaky □ Acne □ Psoriasis □ Boils □ Small bumps on upper arms □ Skin cancer removed from Spots on skin: □ Warts □ Moles □ Small red □ Large red □ Brown □ White Hands and feet: □ Dry cracked, or bleeding areas □Ingrown toenails □ Fungus on feet or nails

□ Athlete’s foot

Chest and Heart Mark any areas of pain or discomfort on diagram

I have chest pain that is: □ Sharp □ Dull □ Severe □ Radiates to my arm, neck or back □ Worse at rest □ Worse on exertion □ Better with exercise □ No changes with exercise My pulse/heartbeat is: □ Too fast □ Too slow □ Skips beats I have: □ High blood pressure □ Low blood pressure I am: □ On high blood pressure medications □ On Diuretics I have had: □ Heart attack □ Bypass surgery □ Angioplasty □ Stroke I have been told I have: □ Heart disease □ Lung disease

□ Clogged arteries I have: □ Varicose Veins □ Spider Veins □ Hemorrhoids □ Had vessel surgery



Respiratory, Lungs, Allergy

I have nasal congestion: □ Daily □ Several times per week □ Only on occasion I have nasal discharge: □ Daily □ Several times per week □ Only on occasion □ Clear □ Yellow □Green □Blood Tinged □ Other: I have: □ Non-productive cough (dry, no mucous) □ Productive cough (with mucous) □ Allergies to □ Hoarseness of voice □Post Nasal Drip □ Hay Fever □ Asthma □ Wheezing □ Snoring I have/have had: □ Frequent colds □ Flu once or more times per year □ Pneumonia □ Sinus Infections

□ Antibiotics three or more times in lifetime □ Allergic to:

I take: □ Allergy shots □ Allergy medication □ Decongestants □ Nasal Sprays □ Steroids I use: □ Cigarettes packs per day □ Snuff/Chew □ Cigars □Exposed to 2nd hand smoke I have been told I have: □ Lung disease □ Emphysema □ COPD

Emotional, Nervous, Metabolism

I am/have: □ Nervous □ Anxious □ Depressed □ Sensitive to noise □ Fatigue easily

□ Confused easily □ Sleepy during day □ Exhausted a lot □ Loss of appetite □ Rage □ Hear voices □ Fearful □ Weakness □ Poor Memory □ Irritability □ Morbid thoughts

I am/have: □ Suspicions of others □ Thoughts of Suicide □ Quick Mood Changes □ Fear of insanity □ Fear of serious diseases like □ Avoid Crowds □ Friends avoid me □ Have hypoglycemia or low blood sugar

□ Had glucose testing and it was: □ Positive □Negative

I: □ Take daytime naps □ Dream too much □ Have no dreams at all □ Have nightmares □ Wake up tired □ Am cold when others are comfortable □ Feel too hot □ Have cold hands □ Have cold feet □ Perspire too much □ Have inadequate perspiration when exercising Do you feel well rested when you wake up in the morning? □ Yes □ No Rate the quality of your sleep (with 1 being awful and 10 being great)



Male Specific

I am: □ Overly tired □ Exhausted □ Getting too old for anything □ Impotent My prostate: □ Normal □ Enlarged □ Had cancer □ Removed □ Date of last prostate exam □ Date of last blood PSA Result/Number I have: □ Pain on urination □ Difficulty starting flow □ Difficulty stopping flow □ Dribbling of urine □ Decreased stream size □ Pain or pressure after sex □ Get up to urinate times per night □ Burning discharge My urine color: □ Pale yellow □ Bright yellow □ Dark yellow □ Other

□ Clear □ Cloudy □ With Mucous □ Varies a lot

My urine has: □ Odor Describe: I have: □ Hernia, where? □ Pain in testicles or scrotum I have/had: □ Veneral disease □ Genital herpes □ Herpes type 1 □ HIV/AIDS My libido is: □ Normal □ Excessive □ Increased □ Diminished □ Absent Libido means desire for sexual relations

Female Specific

Age of first period My menstrual periods are: □ Normal □ Painful first day □ Painful before and during □ flow is excessive

□ Have clots or hemorrhage □Flow is Scanty □Regular every days □ Irregular □ No period in months □ Two or more per month □ Abnormal since years of age □ Menstrual problems before first child □ Menstrual problems after first child □ Weight gain after 1st child □Weight gain after 2nd or 3rd child

Menstrual blood color is: □ Pink □ Red □ Brown □ Other I have/have had: □ Endometriosis □ Constipation with periods □ Diarrhea with periods Organ drop: □ Uterus in position □ Uterus out of position □ Bladder Prolapsed I am/have been: □ On birth control (type) Total years on birth control

□ Menopause at age □ Hysterectomy at age I am on hormone replacement: □ Estrogen □ Progestin □ Oral □Patch □Implant

□ Wild yam cream □ Bio-Identical formulation

I have breast soreness: □ Before period □ During period □ After period □ All month long I have: □ Fibrocystic breasts □ Had breast cancer □ Produce milk but not pregnant or nursing My breasts are: □ Firm □ Soft and Saggy □ Have implants □ Had reduction surgery I: □ Have children □ Been pregnant times □ Like children □ Dislike children □ Want more □ Don’t want more □ Am sterile □ Have fear of pregnancy



I get: □ Bladder infections □ Yeast infections □ Yeast infections after antibiotics □ Vaginal burning on □ Inside □ Outside □ Vaginal dryness □ Painful intercourse I urinate: □ Times per day □ Times per night □ More frequently than normal □ With pain □ With difficulty starting/stopping □ With itching or burning My urine color is: □ Pale yellow □ Bright yellow □ Dark yellow □ Other □ Clear □ Cloudy □ With mucous □ Varies a lot My urine has: □ No odor □ Odor Describe: I have/had: □ Venereal disease □ Genital herpes □ Herpes type 1 □ HIV/AIDS My libido is: □ Normal □ Excessive □ Increased □ Diminished □ Absent Libido means desire for sexual relations

All Patients:

Use the diagram below to mark all areas of pain or discomfort you have experienced in the past 90 days. Describe your pain/discomfort in the margins and connect with arrow to each area the

description applies to.



Family History

Relationship Age (now or

at death)

Serious illness/cause of death

Father □ alive □ deceased

□ no significant disease □ has/had

Paternal grandfather □ alive □ deceased □ no significant disease □ has/had

Paternal grandmother □ alive □ deceased □ no significant disease □ has/had

Mother □ alive □ deceased □ no significant disease □ has/had

Maternal grandfather □ alive □ deceased □ no significant disease □ has/had

Maternal grandmother

□ alive □ deceased

□ no significant disease □ has/had

Brother(s) □ alive □ deceased □ no significant disease □ has/had

Sister(s) □ alive □ deceased □ no significant disease □ has/had

Son(s) □ alive □ deceased □ no significant disease □ has/had

Daughter(s) □ alive □ deceased □ no significant disease □ has/had



OFFICE POLICIES

At The Center for Human Restoration, our goal is to provide quality care in a timely manner. We have implemented office policies as stated below, which enable us to better utilize available appointment times for our patients in need.

1. If it is necessary to cancel and reschedule your appointment, we require that you give at

least a 24-hour notice. Available appointments are on high demand and your early cancellation will give another patient access to that time. It also makes it possible to reschedule your appointment more efficiently. If you fail to give a 24-hour notice, a $25.00 fee will be charged. This fee will not be billed to insurance and must be paid before your next date of care.

2. A “No Show” is someone who misses an appointment without cancelling it. No shows

inconvenience those individuals who need access to our care. A $25.00 fee will be charged for all no show appointments.

3. If a patient is late, he/she will be seen as soon as possible, though the office visit time may

need to be shorter than what was originally scheduled. You will still be responsible for the scheduled time fee.

4. We have the right to refuse treatment and/or terminate care due to inappropriate or

disorderly behavior toward other patients or staff.

If a patient is more than 15 minutes late, the appointment will be cancelled and will have to be rescheduled. A $25.00 fee will be charged.

To schedule or cancel an appointment by telephone, please call 715-478-5202.

I HAVE READ AND UNDERSTAND THE CENTER FOR HUMAN RESTORATION’SOFFICE POLICIES AND AGREE TO BE BOUND BY ITS TERMS. Patient Signature Date (Parent/Guardian if under 18)

Printed Name Relationship to Patient



Patient Request for Email Communications

Patient Name: Date of Birth: Phone Number: Email Address:

Communications over the Internet and/or using the email system may not be encrypted and my not be secure. There is no assurance of confidentiality when communicated via email. To request that this provider/program communicate with you via email, you must complete this form and return it to your health care provider’s office. Please be advised that:

1. This request applies only to the healthcare provider or program that you indicate below. If you would like to request to communicate via email with another health care provider or program, you must complete a separate request for that office.

2. The Center for Human Restoration will not communicate health information tha tis specialty protected under state and federal law (e.g. HIV/AIDS, substance abuse, mental health information) via email.

3. Your request will not be effective until you receive and respond appropriately to a test email message.

Please select the question you want to use (by checking one of the boxes below) for your test email and provide your answer. □ My mothers maiden name: □ My middle name: □ The street number of my residence:

I understand and agree to the following:

1. I certify the email address provided on this request is accurate, and I accept full responsibility for messages sent to or from this address.

2. I understand and acknowledge communications over the internet and/or using the email system may not be encrypted and my not be secure; there is no assurance of confidentiality of information when communicated this way.

3. I understand all email communications in which I engage may be forwarded to other providers for purposes of providing treatment to me.

4. I agree to hold The Center for Human Restoration and all individuals with it harmless from any and all claims and liabilities arising from or related to this request to communicate via email.

Signature of patient or personal representative Date If personal representative, authority to Name of Physician act on patient behalf



HIPPA Consent to Share Information

In general, the HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information. The individual is also provided the right to request confidential communication or that communication be made by alternate means, such as sending correspondence to the individual’s office instead of the individual’s home. Patient Name: Date of Birth: Please indicate your preferred method of contact: Home Phone: May we leave a detailed message? Yes No Cell Phone: May we leave a detailed message? Yes No Work Phone: May we leave a detailed message? Yes No I authorize The Center for Human Restoration to release my medical information to the person(s) listed below. I understand that the person(s) named on this authorization will be given access to obtain results/information on my behalf. I authorize the person(s) indicated to pick up and/or receive materials pertaining to my medical care. Name: Relationship to patient: Telephone Number: Patient Signature:



Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their

Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

3. A patient’s written consent need only be obtained on time for all subsequent care given the patient in this office.

4. The 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.

5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.

7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Name of Patient Date

Confidential Client Questionnaire · I have: Indigestion Belching GERD Intestinal Gas Bloating Immediately after eating 1-2 hours 3-5 hours 6+ hours No odor Some odor odor usually

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