Child Form

1Case History

2HIPPA Privacy Policy

3Child Neurotransmitter & Nutrition

4Records Release Authorization

5Advance Beneficiary Notice

Location(Required)

Email(Required)

Date(Required)

Name(Required)

Age(Required)

Birthday(Required)

Gender(Required)

Gender at Birth(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Home Phone

Work Phone

Cell(Required)

Best Place to Reach You(Required)

Emergency Contact(Required)

Relationship(Required)

Phone(Required)

Do you have Medicare?(Required)

Do you have Medicaid?(Required)

How did you hear about RedRiver?

Radio

Internet Search

Instagram

Podcast

Facebook

Physician

Staff Member

Patient

Friend/Family

Other

Name of TV channel/show(Required)

Name of physician(Required)

Patient's name(Required)

Name of radio station(Required)

Staff member's name(Required)

Name of Family/Friend(Required)

Primary Care Physician:(Required)

Phone(Required)

Current Specialist, if applicable:

Phone

How serious do you think your problem is?(Required)

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

Would you consider this problem...

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 you other symptoms?

When did your symptoms begin?

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 reals problem is?

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

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

When?

Have you ever been diagnosed with a Thyroid problem?

When?

What condition?

Have you ever been diagnosed with any other disease?

Dates:

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

Please list them

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

Have you been seen by any specialist for your condition/symptoms?

What are you hoping the Dr. tells you today?

Describe what you hope or think he might be able to do for you:

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

Due to your main problem...

Have you lost any time from work?

Yes

How much time and what tasks have been limited?

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

Yes

How much time and what tasks have been limited?

Have you lost any time from your family?

Yes

How much time and what tasks have been limited?

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

Yes

How much time and what tasks have been limited?

On a scale of 0-10 (10 being the most motivation possible, 0 being no motivation at all) please rate your motivation to achieve your health goals.

List ANY surgeries that you have had and the corresponding dates

Surgery #1

Surgery #2

Surgery #3

Surgery #4

Surgery #5

Surgery #6

Date

Signature(Required)

Signature of patient, or signature of guardian if patient is under 18 years of age

Does your child have any food sensitivities or allergies? (please list)

List your child's 4 healthiest foods eaten regularly.

List your child's 4 unhealthiest foods eaten regularly.

How many times a week does your child eat candy?

How many times a week does your child drink soda pop?

Please list the top 4 foods your child craves regularly?

List the medication(s) your child is currently prescribed and over the counter.

Do you find it difficult as a parent to have your child on a special diet?

Part 2:

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

SECTION: A (K52)

Does your child eat pasta, breads, and breaded foods?

Does your child have symptoms (fatigue, hyperactivity, etc.) after eating wheat foods?

Does your child eat dairy products?

Does your child have symptoms (fatigue, hyperactivity, etc.) after eating dairy products?

SECTION: B (K53)

Does your child eat fried fish?

Does your child eat roasted nuts or seeds?

Is your child missing essential fatty acid rich foods in his/her diet? (For example: avocados, flax seeds, olives)(mark "0" if present, "3" if missing)

Does your child eat fried foods?

SECTION: C (K34)

Is your child's mental speed slow?

Does your child have difficulty with learning or memory?

Does your child have difficulty with balance and coordination?

SECTION: D (K16)

Does your child have stress?

Does your child not have enough sleep and rest? (mark "3" if not enough)

Does your child not have regular exercise? (mark "3" if no exercise)

Does your child feel overly worried and scared?

SECTION: E (K16, K51)

Does your child have temper tantrums?

Does your child exhibit wild behavior?

Does your child frequently yell or scream for unnecessary reasons?

Does your child have an inability to nap or sleep when physically exhausted? (mark "3" if unable)

Is your child overly talkative?

Does your child fidget and squirm when seated?

Does your child run and climb excessively when it is inappropriate?

Does your child have difficulty playing quietly or engaging in leisure activities?

SECTION: F (K51)

Does your child get excited easily?

Does your child have anxiousness and panic for minor reasons?

Does your child feel overwhelmed for minor reasons?

Does your child find it difficult to relax when she/he is awake?

Does your child have disorganized attention?

SECTION: G (K50)

Does your child seem depressed?

Does your child have mood changes with overcast weather?

Does your child have symptoms of inner rage?

Does your child seem uninterested in games or hobbies?

Does your child have difficulty falling into deep restful sleep?

Does your child seem uninterested in friendships?

Does your child have symptoms of unprovoked anger?

Does your child seem uninterested in eating?

SECTION: H (K49)

Does your child have difficulty handling stress?

Does your child have anger and aggression while being challenged?

Does your child feel tired even after long sleeps?

Does your child tend to isolate from others?

Does your child get distracted easily?

Does your child have constant need and desire for candy and sugar?

Does your child have disorganized attention?

SECTION: I (K48)

Does your child have difficulty with visual memory?

Does your child have difficulty remembering locations?

Does your child have fatigue or low endurance for learning activities?

Does your child have difficulty with attention or low attention span or endurance?

Does your child have slow or difficult speech?

Does your child have uncoordinated or slow movement?

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)

Signature(Required)

Signature of patient or signature of guardian if patient is under 18 years of age.

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.

Name of Patient

Date(Required)

Signature(Required)

Signature of patient, or signature of guardian if patient is under 18 years of age.

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

Name

Relationship

Address

City

State

Zip code:

Name

Relationship

Address

City

State

Zip code:

Name

Relationship

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

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 November 16, 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)

Signature(Required)
Signature of patient, or signature of guardian if patient is below 18 years of age.

Relationship to the Patient

Due to your main problem...

List ANY surgeries that you have had and the corresponding dates

Part 2:

SECTION: A (K52)

SECTION: B (K53)

SECTION: C (K34)

SECTION: D (K16)

SECTION: E (K16, K51)

SECTION: F (K51)

SECTION: G (K50)

SECTION: H (K49)

SECTION: I (K48)

Request a Consultation