Adult New Patient Form
Please enter your full name:
Age:
Today's Date:
Address: City: State: Zip:
Home Telephone:
Work Phone:
Gender: Male Female
Social Security #:
Birthday:
Occupation/Employer's Name and Address:
Maritial Status: Single Married Divorced Widowed
Spouse's Occupation/Employer:
Number of children:
Reason for consulting our office?:
Who may we thank for referring you to our office?:
E-mail:


Your Health Profile

Why this form is important
As a full spectrum of Chiropractic office, we focus on your ability to be healthy. Our goals are, first, to address the issues that brought you to this office, and second, to offer you the oppurtunity of improved health potential and wellness services in the future. On a daily basis we experience physical, chemical and emotional stresses that can accumulate and result in serious loss of health potential. Most time the effects are gradual: bot even felt untile they become serious. Answering the following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to better assess the challenges to your health potential.

The Beginning Years (to age 17)
Research is showing that many of the health challenges that occur later in life have their origins during the developmental years, some starting at birth. Please answer the following questions to the best of your ability.

Your Childhood Years
Did you have any childhood illnesses?: Yes No Unsure
Did you have any serious falls as a child?: Yes No Unsure
Did you play youth sports?: Yes No Unsure
Did you take/use any drugs?: Yes No Unsure
Did you have any surgery?: Yes No Unsure
Have you fallen/jumped from a height of over three feet?(i.e. crib, bunk bed, trees): Yes No Unsure
Were you involved in any car accidents as a child?: Yes No Unsure
Was there any prolonged use of medicine such as antibiotics or an inhaler?: Yes No Unsure
Did you suffer any other traumas?(physical or emotional): Yes No Unsure
Were you vaccinated?: Yes No Unsure
As a child, were you under regular Chiropractic care?: Yes No Unsure

Comments:


Adult(18 to present)
Do/did you smoke?: Yes No
Do/did you drink alcohol?: Yes No
Have you been in any accidents?: Yes No
Have you had any surgery?: Yes No
Do/did you play any adult sports?: Yes No
Do/did you participate in extreme sports?: Yes No
On a scale of 1 to 10 (1=none/10=extreme)describe your stress level:
Occupational:
Personal:
On a scale of Poor, Good, and Excellent, describe your:
Diet Poor Good Excellent
Excercise Poor Good Excellent
Sleep Poor Good Excellent
General Health Poor Good Excellent

Addressing The Issues That Brought You To The Office
If you have no symptoms or complaints, and are here for wellness services, please select yes Yes "Wish to have Chiropractic Wellness Services" and skip to "Family Health Profile."
Others need to briefly describe the chief area of complaint, including the effect it has had on your life.

If you are experiencing pain, is it... Sharp Dull Comes and goes Travels Constant No pain
Since the problem started, it is... About the same Getting Better Getting Worse I have no pain
What makes it worse:
Yes, it interferes with: Work Sleep Walking Sitting Hobbies Leisure
 Other Doctors seen for this problem(please list):
Chiropractor

Medical Doctor

Other

 Please check all symptoms you have ever had, even if they do not seem related to your current problem.
Headaches
Pins and needles in arms
Dizziness
Numbness in fingers
Fatigue
Sleeping Problems
Diarrhea
Cold Sweats
Mood Swings
Pins and Needles in legs
Loss of Smell
Buzzing in ears
Numbness in toes
Deppression
Stiff neck
Constipation
Light bothers eyes
Menstrual Pain
Fainting
Back pain
Ringing in ears
Loss of taste
Irritability
Cold hands
Fever
Problems urinating
Menstrual irregularity
Neck Pain
Loss of balance
Nervousness
Stomach Upset
Tension
Cold feet
Hot flashes
Heartburn
Ulcers
 List any medications you are taking:


Family Health Profile:
At our office we are not only interested in your health and well-being,but also the health and well-being of your family and loved ones. Please mention below any health conditions or concerns you may have about your:
Children
Spouse
Mother
Father
Brothers
Sisters
Others
Have you ever:
Bought bottled water: Yes No
 Belonged to a health club: Yes No
 Consumed vitamins or supplements: Yes No

 The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation:
Yes, I agree No, I don't

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ROSSI FAMILY CHIROPRACTIC
FRED ROSSI, JR.,DC

1027 "A" VALLEY ROAD
STIRLING, NJ 07980
908-903-9400


TERMS OF ACCEPTANCE


When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective.
Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to attain it. This will prevent any confusion or dissapointment.

Adjustment: The adjustment is the specific application of forces to facilitate the body's corection of vertebral subluxation. Out chiropractic method of correction is by specific adjustments of the spine.
Health: The state of potimal physical, mental and social well being, not merely the absence of disease of infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertabra in the spinal column which vauses alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

We do not offer diagnosis or treat any disease. We only offer to diagnosis either vertabral subluxations or neuro-musculoskeletal conditions. However, during the course of a chiropractic spinal examinatgion we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustments.

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Rossi Family Chiropractic HIPPA Compliant Form

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
In the course of your care as a patient at Rossi Family Chiropractic we may use or disclose personal and health related information about you in the following ways: *Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assesment or treatment.
*Your health care records as well as your billing records may be disclosed to another pary, such as an insurance carrier, and HMO, a PPO, or your employer, if they are or maybe responsible for the payment of services provided to you.
*Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the agreement of this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other related information, a message may be left on your answering machine or with a person in your hosehold. You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
*If we provide health care services to you in an emergency. *If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so. *If there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care.
*If we are ordered by the courts or another appropriate agency.
You have a right to receive an accounting of any such disclosures made by this office.
Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorisation for release of information you have the right to revoke that authorization at a later date.
Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.
We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to reveice this information at an addreww other than your home or, if you would like the information in a specific form please advise us in writing as to your preference.
We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.
We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notigy you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.
If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaints to: Dr. Fred Rossi. ________________________________________________________________________________________________________________________
If you would like further information about our privacy policies and practices please contact: Dr. Fred Rossi. ________________________________________________________________________________________________________________________ You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Sevretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever. Your authorization is requested for purposes of delivering your care in an open-adjusting or open-door adjusting environment as described in the office's privacy notice. In the course of your care in either of these environments routine details of your condition and care may be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details of your care will be addressed and considered as confidential by other patients.
We are requesting your authorization in this regard to assure that you are fully informed and in agreement with the method and circumstances in which we deliver chiropractic care. Your care will not be conditioned on your agreement to this authorization. You have the right not to sign this authorization and you also have the right to revoke this authorization at a later date if that is your wish.
If you wish to revoke this authorization at some time in the future please advise us accordingly in writing.
If you agree to this authorization a copy will be maintained by this office and a copy will be provided to you.

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