DeLand Chiropractic logo
905 N. Stone St., DeLand, FL 32720

New Patient Application & Auto Accident Form

Patient Information

The information that you will provide on this form will play a key role in determining your ability to be accepted as a patient in this office. your qualification as a patient is determined by the nature of your injury, the doctor's ability to treat your condition, your commitment to getting well, your family and/or spousal support, your ability to pay for recommended care, and your willingness to make sacrifices to ensure your proper healing. Please be sure that you answer all questions.
Thank you - Dr. Gordon's Staff.

Sex
Current/Former Doctor
May we contact them?
Pregnant
Work Related?
Auto Accident Related?
Have you had chiropractic care before?
How about acupuncture?
Do you smoke cigarettes?
Currently
Formerly
Do you drink alcohol?
Do you use recreational drugs?

Family Health History



Personal Health History


Will you be filing through insurance?
When discussing possible treatment options, do you prefer:
Our team has four goals that drive our practice and quality of care. All are important to us, but out of these values, which would be your priority for today’s visit? Please select one.
Are you willing to do your part to help us achieve your goal?
Looking at this list, would any of these be a possible barrier to you when considering treatment?

Informed Consent, Financial Responsibility, and Assignment of Benefits

IF YOU HAVE ANY QUESTIONS OR CONCERNS WITH THE INFORMATION BELOW, IT IS YOUR RESPONSIBILITY TO ADDRESS THOSE CONCERNS WITH THE DOCTOR.

As with all medical or chiropractic treatments, I acknowledge and understand that there are inherent risks to receiving care including but not limited to sprains, strains, fractures, dislocations, muscle pain, bruising, and stroke. Statistically, these risks are extremely rare and uncommon (1 in 1 – 5 million in the case of strokes), especially when compared to those risks related with alternative treatment options for my condition including the use of over the counter analgesics, prescription drugs, and surgery. Due to that fact, I will not hold the physician or staff responsible for those risks listed above. In addition, I understand that the risk and danger of allowing my condition to go untreated may lead to further deterioration of my condition with possible serious and/or permanent consequences to my health. I acknowledge and understand that the use of certain prescription medications (i.e. birth control pills, hormone replacement, aspirin, Coumadin), illicit drug or alcohol use, and cigarette smoking may increase these risks and inhibit proper healing. I also understand that if I am accepted as a patient, and if I receive care, that I am the ultimate responsible party on my account regardless of the actions of any 3rd party carrier (insurance company). I agree that should my account become delinquent, I will be responsible for all collection costs, including but not limited to the outstanding balance, attorney fees, court costs, collection agency fees, and interest at the rate of 18% per annum(1.5% per month). By signing below, I also agree to allow the doctor to share any and all medial reports and findings with my primary care physician, and I allow the doctor to use my name and case history in monthly newsletters and/or patient testimonial booklets. Lastly I understand that any physician at DeLand Chiropractic & Spinal Decompression cannot evaluate, examine, x-ray, diagnose, or treat me for my presenting condition without my signature below. By signing below I acknowledge that I have weighed the risks versus benefits of treatment, and I give the doctor consent to treat me for my condition.

Pain Disability Questionnaire

Instructions: These questions ask your views about how your pain now affects how you function in every day activities. Please answer every question and mark the ONE number on EACH scale that best describes how you feel.

Pain scale reference
1. Does your pain interfere with your normal work inside and outside the home?
Work Normally Unable to work at all
2. Does your pain interfere with personal care (such as washing, dressing, etc.)?
Take care of myself completely Need help with all my personal care
3. Does your pain interfere with your traveling?
Travel anywhere I like Only travel to see doctors
4. Does your pain affect your ability to sit or stand?
No problems Can not sit/stand at all
5. Does your pain affect your ability to lift overhead, grasp objects or reach for things?
No problems Can not do at all
6. Does your pain affect your ability to lift objects off the floor, bend, stoop or squat?
No problems Can not do at all
7. Does your pain affect your ability to walk or run?
No problems Can not walk/run at all
8. Has your income declined since your pain began?
No decline Lost all income
9. Do you have to take pain medication every day to control your pain?
No medication needed Need medication throughout the day
10. Does your pain force you to see doctors much more often than before your pain began?
Never see doctors See doctors weekly
11. Does your pain interfere with your ability to see the people who are important to you?
No problem Never see them
12. Does your pain interfere with recreational activities and hobbies?
No interference Total interference
13. Do you need the help of your family and friends to complete everyday tasks?
Never need help Need help all the time
14. Do you now feel more depressed, tense, or anxious than before your pain began?
No depression/tension Severe depression/tension
15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities?
No problems Severe problems

Acknowledgment of Receipt of Notice of Privacy Practices
DeLand Chiropractic & Spinal Decompression

By checking the lines below I authorize being contacted for practice reminders, birthday greetings or promotions by:

THIS FORM WILL BE PLACED IN THE PATIENT’S CHART AND MAINTAINED FOR SIX YEARS.

HIPAA Compliant Authorization for Release of Patient Information

You may use this form to allow limited access to your health information by certain persons for certain purposes. Your choice on whether to sign this form will not affect your ability to get medical treatment, payment for medical treatment, or health insurance enrollment or eligibility for benefits.

By signing/submitting this form, I voluntarily authorize, give my permission, and allow use and disclosure of, including paper, oral and electronic interchange:

, including information about sensitive conditions, if any. Health information includes, but is not limited to, all records and other information regarding my health history, treatment, hospitalization, test, and outpatient care, and also educational records that may contain information about my health.

This includes my specific permission to release any and all of the following information:

  1. Drug, alcohol, or substance abuse
  2. Psychological, psychiatric or other mental impairment(s) or developmental disabilities, excluding “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501
  3. Sickle cell anemia
  4. Birth control and family planning
  5. Records which may indicate the presence of a communicable disease or noncommunicable disease; and tests for or records of HIV/AIDS or sexually transmitted diseases or tuberculosis
  6. Genetic, inherited diseases or tests
  7. Copies of educational tests or evaluations, including Individualized Educational Programs, assessments, psychological and speech evaluations, immunizations, recorded health information such as height and weight, and information about injuries or treatment

. Check off all that you want disclosed.

Excluding “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501.

Date range of records: Information created before or after the date of this form may be disclosed, unless you specify a date range of records here.

From Whom:

All information sources, including but not limited to medical and clinical sources, including hospitals, clinics, labs, pharmacies, physicians, psychologist, etc.; mental health, correctional, addiction treatment, Veterans Affairs healthcare facilities, state registries and other state programs; all educational sources, including schools, records administrators, counselors, etc.; social workers, rehabilitation counselors, insurance companies, health plans, health maintenance organizations, employers, pharmacy benefit managers, worker’s compensation programs, state Medicaid, Medicare and other governmental program.

To Whom:

Purpose: Check all that apply.

Effective Period: This authorization/permission form will remain in effect until:

Revoking Your Permission:

I can revoke my permission at any time by giving written notice to the person or organization to whom I originally gave this form.

  • I authorized the use of a copy, including electronic copy, of this form for the disclosure of the information described above.
  • I understand that there are some circumstances in which this information may be disclosed to other parties.
  • I understand that refusing to sign this form does not stop disclosure of my health information that is otherwise permitted by law without my authorization or permission.
  • I have read all pages of this form and agree to the disclosures above from the types of sources listed.

Check one to describe the relationship of Legal Representative to Patient, if applicable:

Accident Details

Were you the
The time of day of the accident was
Road conditions at the time of the accident were
Were you wearing a seatbelt at the time of the accident?
Did an airbag deploy?
Was your head turned at the time of the accident?
If you were the driver, was your foot applied on the brake at the time of the accident?
Did you strike any part of the interior of the vehicle during the accident?
Did you lose consciousness as a result of the accident?
Was a police report made at the accident scene?
After the crash did you go
Have you seen any other physicians or received treatment for your injuries anywhere else?

Please use the figure and dropdown menus to select the affected areas, type of pain, and severity of the pain you are experiencing.

1 = least, 10 = greatest
1 = least, 10 = greatest
1 = least, 10 = greatest
1 = least, 10 = greatest
Body zones reference

Instrumental Activities of Daily Living Scale (I.A.D.L.)

Choose the option below that best describes your ability:

1. Ability to use the telephone
2. Laundry
3. Shopping
4. Mode of transportation
5. Food preparation
6. Responsibility for own medications
7. Housekeeping
8. Ability to handle finances

Katz Basic Activities of Daily Living (ADL) Scale

Check “yes” if you are able to do the task independently or “no” if you are unable.

1. Bathing – Able to bathe without assistance
2. Dressing – Able to dress without assistance
3. Toileting – Able to use toilet or urinal without assistance
4. Transferring – Moves in and out of bed or chair alone
5. Continence – Controls bowel and bladder completely by self
6. Feeding – Feeds self without assistance

Auto Accident Information Needed

Policy Type

Electronic Signature

By checking this box, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.