Adult Form

1Case History

2HIPPA Privacy Policy

3Metabolic Assessment

4New Patient Consult

5Records Release Authorization

Location(Required)

Email(Required)

Today's Date(Required)

MM slash DD slash YYYY

Name(Required)

First Last

Age(Required)

Please enter a number from 0 to 120.

Birthday(Required)

Gender at Birth

Male

Female

Address(Required)

Street Address City State

Zip Code(Required)

Zip Code

Home Phone

Work Phone

Cell Phone(Required)

Best Place to Reach You(Required)

Home

Work

Cell

Employer(Required)

Length Of Employement(Required)

Marital Status

Single

Married

Partner

Widowed

Divorced

Spouses Name(Required)

Spouses Phone Number(Required)

Emergency Contact(Required)

Relationship(Required)

Phone(Required)

Do you have Medicare?(Required)

Yes

Do you have Medicaid?(Required)

Yes

How did you hear about RedRiver?

Radio

Internet Search (Google, Yahoo, etc.)

Instagram

Podcast

Facebook

Physician

Staff Member

Patient

Family/Friend (not a patient)

Other

What channel?(Required)

What radio station?(Required)

Instagram name of referral(Required)

Podcast name of referral(Required)

Name of Physician(Required)

Name of Staff Member(Required)

Name of Patient(Required)

Primary Care Physician(Required)

Phone(Required)

Current Specialist, if applicable

Phone

What is/are your main problem(s)/symptom(s) prompting your request for a consultation with the Dr.?(Required)

Would you consider this/these problem(s)(Required)

MINIMAL (Annoying, but causing NO limitations)

LIGHT (Tolerable, causing few limitations)

MODERATE (Sometimes tolerable, but definitely causing limitations)

SEVERE (Causing significant limitations)

EXTREME (Causing near constant--more than 80% of the time--limitations)

What are your other symptoms?(Required)

When did your symptoms begin?(Required)

Although you are not a doctor, you are in fact the person who knows more about your condition than anyone else.In your own words and in your own opinion what do you think the real problem is?(Required)

Please list all prescription medications, over the counter drugs, and supplements (vitamins) you are currently taking(Required)

Have you ever been diagnosed with an auto-immune thyroid condition? (Hasimoto's Thyroiditis)(Required)

Yes

When?(Required)

Have you ever been diagnosed with a Thyroid problem?(Required)

Yes

When?(Required)

What condition?(Required)

Have you ever been diagnosed with any other diseases?(Required)

Yes

Please list diagnosis and dates:(Required)

Do you have a family history of any major illnesses/diseases?(Required)

Yes

Please list them(Required)

Is there anything you have done outside of medical advice that improved your condition?(Required)

Have you been seen by any specialists for your condition/symptoms?(Required)

Describe what will be different in your life if you can finally be relieved of these problems(Required)

Due To Your Main Problem.....

Have you lost any time from work?(Required)

Yes

How much time and what tasks have been limited?(Required)

Have you lost any time from your chores/tasks at home?(Required)

Yes

How much time and what tasks have been limited?(Required)

Have you lost any time from your family?(Required)

Yes

How much time and what tasks have been limited?(Required)

Have you lost any time from your leisure activities? (Hobbies, Travel, Sports, etc...)(Required)

Yes

How much time and what tasks have been limited?(Required)

On a Scale of 0-10 (10 being the most motivation possible, 0 being no motivation at all) please rate your motivation toachieve your health goals.(Required)

List ANY surgeries that you have had and the corresponding dates

Surgery #1

Surgery #2

Surgery #3

Surgery #4

Surgery #5

Surgery #6

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. It is effective January 1, 2011, and applies to all protected health information contained in your health records maintained by us. We have the following duties regarding the maintenance, use and disclosure of your health records:

We are required by law to maintain the privacy of the protected health information in your records and to provide you with this Notice of our legal duties and privacy practices with respect to that information.
We are required to abide by the terms of this Notice currently in effect.
We reserve the right to change the terms of this Notice at any time, making the new provisions effective for all health information and records that we have and continue to maintain.

There are a number of situations in which we may use or disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgment that you received this Notice of Privacy Practices. These include treatment, payment, and health care operations. Any use or disclosure of your protected health information required for anything other than treatment, payment or health care operations requires you to sign an Authorization. Certain disclosures that are required by law, or under emergency circumstances, may be made without your Acknowledgement or Authorization. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.

We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information for the following purposes.

Treatment: We will use your health information to make decisions about the provision, coordination, or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to your care. These are only examples of uses and disclosures of medical information for treatment purposes that may or may not be necessary in your case.

Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of services for the purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system.

There are certain circumstances under which we may use or disclose your health information without first obtaining your Acknowledgement or Authorization. Those circumstances generally involve public health and oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases, or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect, or domestic violence. We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. There may sometimes be close proximity with other patients. We will try to speak quietly to you in a manner reasonably calculated to avoid disclosing your health information to others; however, complete privacy may not be possible.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative, or any other person that is responsible for the care of your location, general condition or death. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances. We may use or disclose your protected health information in an emergency treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.

Except as indicated above, your health information will not be used or disclosed to any other person or entity without your specific Authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental-health treatment, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without your written authorization.

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns. You will not be retaliated against for filing such a complaint. More information is available about complaints at the government’s web site, http://www.hhs.gov/ocr/hipaa.

Name of Patient

Date(Required)

MM slash DD slash YYYY

Patient or Patient Representative Signature(Required)

Part 1:

Please list your 5 major health concerns in order of importance:

1:(Required)

2:(Required)

3:(Required)

Part 2:

Please select the appropriate number on all questions below. 0 as the least/never to 3 as the most/always.

Category I

Feeling that bowels do not empty completely(Required)

Lower abdominal pain relieved by passing stool or gas(Required)

Alternating constipation and diarrhea(Required)

Diarrhea(Required)

Constipation(Required)

Hard, dry, or small stool(Required)

Coated tongue or "fuzzy" debris on tongue(Required)

Pass large amount of foul-smelling gas(Required)

More than 3 bowel movements daily(Required)

Use laxatives frequently(Required)

Category II

Increasing frequency of food reactions(Required)

Unpredictable food reactions(Required)

Aches, pains, and swelling throughout the body(Required)

Unpredictable abdominal swelling(Required)

Frequent bloating and distention after eating(Required)

Abdominal intolerance to sugars and starches(Required)

Category III

Intolerance to smells(Required)

Intolerance to jewelry(Required)

Intolerance to shampoo, lotion, detergents, etc(Required)

Multiple smell and chemical sensitivities(Required)

Constant skin outbreaks(Required)

Category IV

Excessive belching, burping, or bloating(Required)

Gas immediately following a meal(Required)

Offensive breath(Required)

Difficult bowel movements(Required)

Sense of fullness during and after meals(Required)

Difficulty digesting fruits and vegetables; undigested food found in stools(Required)

Category V

Stomach pain, burning, or aching 1-4 hours after eating(Required)

Use of antacids(Required)

Feel hungry an hour or two after eating(Required)

Heartburn when lying down or bending forward(Required)

Temporary relief by using antacids, food, milk, or carbonated beverages(Required)

Digestive problems subside with rest and relaxation(Required)

Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol, and caffeine(Required)

Category VI

Roughage and fiber cause constipation(Required)

Indigestion and fullness last 2-4 hours after eating(Required)

Pain, tenderness, soreness on left side under rib cage(Required)

Excessive passage of gas(Required)

Nausea and/or vomiting(Required)

Stool undigested, foul smelling, mucus like, greasy, or poorly formed(Required)

Frequent urination(Required)

Increased thirst and appetite(Required)

Category VII

Abdominal distention after consumption of fiber, starches, and sugar(Required)

Abdominal distention after certain probiotic or natural supplements(Required)

Lowered gastrointestinal motility, constipation(Required)

Raised gastrointestinal motility, diarrhea(Required)

Alternating constipation and diarrhea(Required)

Suspicion of nutritional malabsorption(Required)

Frequent use of antacid medication(Required)

Have you been diagnosed with Celiac Disease, Irritable Bowel Syndrome, Diverticulosis/ Diverticulitis, or Leaky Gut Syndrome?(Required)

Yes

Category VIII

Greasy or high-fat foods cause distress(Required)

Lower bowel gas and/or bloating several hours after eating(Required)

Bitter metallic taste in mouth, especially in the morning(Required)

Burpy, fishy taste after consuming fish oils(Required)

Difficulty losing weight(Required)

Unexplained itchy skin(Required)

Yellowish cast to eyes(Required)

Stool color alternates from clay colored to normal brown(Required)

Reddened skin, especially palms(Required)

Dry or flaky skin and/or hair(Required)

History of gallbladder attacks or stones(Required)

Have you had your gallbladder removed?(Required)

Yes

Category IX

Acne and unhealthy skin(Required)

Excessive hair loss(Required)

Overall sense of bloating(Required)

Bodily swelling for no reason(Required)

Hormone imbalances(Required)

Weight gain(Required)

Poor bowel function(Required)

Excessively foul-smelling sweat(Required)

Category X

Crave sweets during the day(Required)

Irritable if meals are missed(Required)

Depend on coffee to keep going/get started(Required)

Get light-headed if meals are missed(Required)

Eating relieves fatigue(Required)

Feel shaky, jittery, or have tremors(Required)

Agitated, easily upset, nervous(Required)

Poor memory/forgetful(Required)

Blurred vision(Required)

Category XI

Fatigue after meals(Required)

Crave sweets during the day(Required)

Eating sweets does not relieve cravings for sugar(Required)

Must have sweets after meals(Required)

Waist girth is equal or larger than hip girth(Required)

Frequent urination(Required)

Increased thirst and appetite(Required)

Difficulty losing weight(Required)

Category XII

Cannot stay asleep(Required)

Crave salt(Required)

Slow starter in the morning(Required)

Afternoon fatigue(Required)

Dizziness when standing up quickly(Required)

Afternoon headaches(Required)

Headaches with exertion or stress(Required)

Weak nails(Required)

Category XIII

Cannot fall asleep(Required)

Perspire easily(Required)

Under a high amount of stress(Required)

Weight gain when under stress(Required)

Wake up tired even after 6 or more hours of sleep(Required)

Excessive perspiration or perspiration with little or no activity.(Required)

Category XIV

Edema and swelling in ankles and wrists(Required)

Muscle cramping(Required)

Poor muscle endurance(Required)

Frequent urination(Required)

Frequent thirst(Required)

Crave salt(Required)

Abnormal sweating from minimal activity(Required)

Alteration in bowel regularity(Required)

Inability to hold breath for long periods(Required)

Shallow rapid breathing(Required)

Category XV

Tired/sluggish(Required)

Feel cold—hands, feet. all over(Required)

Require excessive amounts of sleep to function properly(Required)

Increase in weight even with low-calorie diet(Required)

Gain weight easily(Required)

Difficult, infrequent bowel movements(Required)

Depression/lack of motivation(Required)

Morning headaches that wear off as the day progresses(Required)

Outer third of eyebrow thins(Required)

Thinning of hair on scalp, face, or genitals, or excessive hair loss(Required)

Dryness of skin and/or scalp(Required)

Mental sluggishness(Required)

Category XVI

Heart palpitations(Required)

Inward trembling(Required)

Increased pulse even at rest(Required)

Nervous and emotional(Required)

Insomnia(Required)

Night sweats(Required)

Difficulty gaining weight(Required)

Category XVII (Males Only)

Urination difficulty or dribbling

Frequent urination

Pain inside of legs or heels

Feeling of incomplete bowel emptying

Leg twitching at night

Category XVIII (Males Only)

Decreased libido

Decreased number of spontaneous morning erections

Decreased fullness of erections

Difficulty maintaining morning erections

Spells of mental fatigue

Inability to concentrate

Episodes of depression

Muscle soreness

Decreased physical stamina

Unexplained weight gain

Increase in fat distribution around chest and hips

Sweating attacks

More emotional than in the past

Category XIX (Menstruating Females Only)

Perimenopausal

Yes

Alternating menstrual cycle lengths

Yes

Extended menstrual cycle (greater than 32 days)

Yes

Shortened menstrual cycle (less than 24 days)

Yes

Pain and cramping during periods

Scanty blood flow

Heavy blood flow

Breast pain and swelling during menses

Pelvic pain during menses

Irritable and depressed during menses

Acne

Facial hair growth

Hair loss/thinning

Category XX (Menopausal Females Only)

How many years have you been menopausal?

Since menopause, do you ever have uterine bleeding?

Yes

Hot flashes

Mental fogginess

Disinterest in sex

Mood swings

Depression

Painful intercourse

Shrinking breasts

Facial hair growth

Acne

Increased vaginal pain, dryness. or itching

PART III

How many alcoholic beverages do you consume per week?(Required)

Rate your stress level on a scale of 1-10 during the average week:(Required)

How many caffeinated beverages do you consume per day?(Required)

How many times do you eat fish per week?(Required)

How many times do you eat out per week?(Required)

How many times do you work out per week?(Required)

How many times do you eat raw nuts or seeds per week?(Required)

List the three worst foods you eat during the average week:

1(Required)

List the three healthiest foods you eat during the average week:

1(Required)

2(Required)

3(Required)

Please list any medications you currently take and for what conditions:(Required)

Please list any natural supplements you currently take and for what conditions:(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

I understand that Dr. Joshua Redd, Dr. Brinton Andersen, Dr. Jeremy Swindlehurst, Dr. Paul Stadler, Dr. Justin Jenkins, Dr. Loren Grover, Dr. Daniel Torres, and Dr. Justin Maia are chiropractic physicians.

I understand that I am receiving a consultation, and that I am not currently under the care of a RedRiver chiropractic physician.

I understand that if I am accepted into a care plan, the doctors at RedRiver Health and Wellness will teach me valuable tools and lifestyle changes that can help me manage my condition.

I understand that once I am under the care of a RedRiver chiropractic physician, I will still be required to see my primary care physician and/or my endocrinologist or other specialist for prescription maintenance and changes.

RedRiver chiropractic physicians are great advocates for prescribing physicians and endocrinologists. We do not replace our patients’ primary care physicians and specialists, but complement their care by providing our patients with nutrition and lifestyle support.

We have developed rewarding relationships with many prescribing physicians across the country, and we strive to continue to build relationships with MD’s, DO’s, NP’s, and NMD’s. We believe that by working together, the patient will benefit and have a more favorable outcome.

I understand that if I request copies of my medical records, I must do so in writing.

Welcome! We look forward to working with you as you embark on your journey to optimal health.

Date(Required)

MM slash DD slash YYYY

Signature(Required)

I request and authorize RedRiver Health and Wellness Center and/or RedRock Accident and Injury to release my healthcare information to:

Name

Relationship

Address

Street Address City State ZIP Code

Name

Relationship

Address

Street Address City State ZIP Code

Name

Relationship

Address

Street Address City State ZIP Code

I authorize the release of the following information:

Complete Record (includes all listed)

Progress Notes

Imaging Reports

Laboratory Results

Financial Agreements

Appointment Information

Prescription/Nutritional Supplement History

Other

List Other(Required)

I understand that the medical records released pursuant to this authorization could contain information concerning drug-related conditions, alcoholism, psychological conditions, psychiatric conditions, and/or blood-borne infectious disease which are subject to federal and/or state disclosure restrictions. By my signature below, I specifically authorize the disclosure of those records. I also understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations.

This permission to disclose my protected health information is valid for a period of ONE (1) YEAR, or until October 20, 2022, whichever occurs first. I understand that I can change my mind and cancel or revoke this permission at any time by sending a letter to RedRiver Health and Wellness Center/ RedRock Accident and Injury at the address given above. That revocation shall include all but the information which has already been disclosed or released pursuant to this authorization and prior receipt of the revocation, I hereby affirm that I have read and fully understand the statements above and consent to the disclosure of the protected health information for the purpose and extent stated.

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Relation to the Patient(Required)

Name

This field is for validation purposes and should be left unchanged.

Due To Your Main Problem.....

List ANY surgeries that you have had and the corresponding dates

Notice of Privacy Practices

Part 1:

Part 2:

Category I

Category II

Category III

Category IV

Category V

Category VI

Category VII

Category VIII

Category IX

Category X

Category XI

Category XII

Category XIII

Category XIV

Category XV

Category XVI

Category XVII (Males Only)

Category XVIII (Males Only)

Category XIX (Menstruating Females Only)

Category XX (Menopausal Females Only)

PART III

Request a Consultation