Grosse Ile Family Chiropractic Bertie R.

Synowiec, MS, DC

Welcome to Grosse Ile Family Chiropractic!

New Patient History Date of Initial Visit / / 2010 _________

Name (Please Print)_____________________________________________ Date of birth__________________ Age_________

Address______________________________________________________ State ______________ Zip____________________

Phone ________________________ Cell Phone _____________________ Marital status: S _____M ____ # of Children _____

Occupation___________________________________________________ Employer_________________________________

Primary Insurance Plan__________________________________________ Patient ID #_______________________________

Secondary Insurance __________________________________________ Secondary ID#_____________________________

Spouse’s name________________________________________________ Date of birth ______________________________

Referred by___________________________________________________ Primary MD ______________________________

Kindly circle your level of pain: (No Pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst Possible)

Please explain your reason for coming into chiropractic care today: Please mark areas of discomfort below:

Major area of concern_______________________________________________

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Pain/Problem started on_____________________ Check the type of pain you are feeling:

Sharp _____ Dull Ache _____ Constant _____Intermittent _____Other ______

Does this pain shoot, radiate, or travel in your body?__________ Where?_____________

Are you experiencing numbness or tingling anywhere? ________ Where? ____________

Since it began, is it: Same _____ Better _____Worse at certain times _______

What activities aggravate your condition? _____________________________________

Is the pain interfering with work______ sleep ______activities of daily living ________

What other doctors have you seen for this condition___________ Diagnosis? _________

Are you under medical care for any condition at this time? _______ How long? ________ Have they taken X-rays_________ MRI ________

CT Scan _______ Are you able to obtain a copy for this office? _____ Location where they were taken? _______________________

Have you had any spinal surgery? ____ When ____________ What level? ____ Neck (C/S) ____ Mid Back (T/S) ____ Low Back (L/S) ____

What side effects have you experienced from the drugs and surgery? ___________________________________________________________

Medications/ Vitamins: List any vitamins or medications are you now taking? _________________________________________________

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Grosse Ile Family Chiropractic Bertie R. Synowiec, MS, DC
Early Childhood: Describe any challenges that you may know of? _______________________________________________________
Ear infections/colic/asthma ___________Attention Deficit ___________ Antibiotics ___________ Broken bones _______________________
Any traumas? _____________________ Car accidents ______________ Chair pulled from under you________________________________

Current Health Habits: Did/do you smoke? ____ Drink alcohol? ____Do you eat healthy foods? ____ Do you exercise regularly? ________
Do you have dental/eye/hearing problems? _____ Did/do you have occupational stress?________ Physical/ emotional/mental stress? ________
Do you sleep well______________ Hours of sleep/ night____ Sleeping posture: Side ____ Stomach ____ Back ____ Arms over head _______

In your adult life have you ever been in a car accident of fallen?_______ Please explain ____________________________________________

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Please mark any of the following conditions or symptoms that you have now or have experienced:
O Headaches O Pain in Hands or Arms O Chest Pains O Loss of Balance
O Neck Pain O Numbness in Hands or Arms O Heart Attack O Ringing in Ears
O Sleeping Problems O Pain in Legs or Feet O High Blood Pressure O Jaw/TMJ Problems
O Low Back Pain O Numbness in Legs or Feet O Stroke O Menstrual Cramps
O Nervousness O Fatigue O Cancer O Menopause
O Tension O Depression O Painful Urination O Cold Hands
O Irritability O Lights Bother Eyes O Diabetes O Cold Feet
O Dizziness O Loss of Memory O Diarrhea O Weight Loss
O Pain Between Shoulders O Shoulder Pain O Constipation O Loss of Smell or Taste
O Stiff Neck O Sinus O Stomach Upset O Fever
O Joint Swelling O Shortness of Breath O Heartburn/Reflux O Asthma O Allergies

Please list any other conditions diagnosed by your medical doctors in the past or present that you would like us to include. _____

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Mark with an “X” any condition listed below that has affected your family history:

Heart disease Lung disease Arthritis Cancer Diabetes ___________

Father’s side O O O O O O
Mother’s side O O O O O O

Please sign below: I hereby certify that the statements and answers given on this form are accurate to the best of my
knowledge. I do understand that it is my responsibility to inform this office of any changes in my health as they occur.
I agree to allow the doctor to examine me for further evaluation and acceptability into chiropractic care.

Patient Signature______________________________ Date ____________ E-Mail ___________________________________

Cell phone # _________________________________ Emergency Contact _______________________Phone______________

- - - Doctor’s Notes ---

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Doctor’s Signature Roberta R Synowiec, DC Date / / 2010

Grosse Ile Family Chiropractic Bertie R. Synowiec, MS, DC

HIPAA Notice of Privacy Practices - Please read carefully

This Notice of Privacy Practices describes how we may use/disclose your protected health information (PHI) to carry out treatment,
payment or health care options and for other purposes that are permitted or required by law. It also describes your rights to access and
control your protected health information. Protected health information is information about you, including demographic information
that may identify you and that relates to your past, present or future physical or mental health or condition and related health services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your
physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing
health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use
required by law.

• Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services
including the coordination or management of your health care with a third party such as a home health agency, or to your
physician in the case of a referral, to ensure that the physician has the necessary information to diagnose or treat you.
• Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, to obtain
approval from your provider for services rendered.
• Healthcare Operations: We may use your PHI for employee review and quality assessment activities within our
chiropractic business. In addition we may utilize a sign-in sheet at the front desk where you will be asked to sign your name
that we will call from the waiting room when your physician becomes available.

We may use or disclose your PHI, to occasionally, contact you, to set up or confirm an appointment. Your cell phone number
at the bottom of this form would be helpful in this regard.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: those
Required by Law, Public Health issues, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements,
Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, if applicable, Research data, Criminal Activity, Military
Activity and National Security, Workers’ Compensation, Inmates and required uses and disclosures to the Department of Health and Human
Services, that oversee HIPAA compliance of our office.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object
unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the
physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Patient Rights:
• You may send us a request in writing to see or have a copy of your information we have on file, unless otherwise
restricted by law. You may notify us of any incomplete or inaccurate personal information that your wish amended. We
reserve the right to disagree with your changes. In the event of a disagreement, we will provide you with information about
our denial of your changes and the means with which you may appeal it.
• You have the right to request additional restrictions on how we may use, and to whom we may disclose your PHI.
However, we are not legally required to agree to your request, in particular, instances where it may be prohibited by law or
not in your best interest. Your request must be specific and include to whom you want the restriction to apply.
• You may request us to use reasonable alternative means of contacting you regarding health matters such as by cell
phone or e-mail or direct us to an alternate address when appropriate.
• You may request an accounting of any disclosures concerning your PHI, except when these are made for treatment,
payment or health care operations, or the law otherwise restricts the accounting.
• You have the right to a copy of this notice upon request.

Additional Information: We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal
duties and privacy practices with respect to protected health information. If you have any objections to this form or have any questions
about your rights to privacy or how these rights have been handled by this office, please contact our HIPAA Compliance Officer in
person or by phone at (734)-671-1740.

Your signature below acknowledges that you have received this Notice of Privacy Practices.

Signature________________________________________ Printed Name____________________________________

Cell Phone number where we can leave a message: _(_______)__________________ Date __________________

E-mail address ( used for this office only) ______________________________________________________________

 Grosse Ile Family Chiropractic
Informed Concent
I hereby request and consent to the performance of chiropractic adjustments and other
chiropractic procedures, including various modes of soft tissue manipulation and diagnostic X-
rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of
chiropractic named below and/or other licensed doctors of chiropractic who now or in the future
work at the clinic or office listed below or any other office or clinic. I have had an opportunity to
discuss with the doctor of chiropractic named below and/or with other office or clinic personnel
the nature and purpose of chiropractic adjustments and other procedures. I understand that results
are not guaranteed.
I understand and am informed that, as in the practice of medicine, in the practice of
chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries,
strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all
risks and complications, and I wish to rely upon the doctor to exercise judgment during the course
of the procedure which the doctor feels at the time, based upon the facts then known to him or
her, is in my best interest.
I have read, or have had read to me, the above consent. I have also had an opportunity to
ask questions about its content, and by signing below I agree to the named procedures used to
correct subluxations. I intend this consent form to cover the entire course of treatment for my
present condition and for any future condition(s) for which I seek treatment.

Patient Signature ___________________________________ Date _________________

Grosse Ile Family Chiropractic/Griswold Chiropractic

Signature on File Authorization

I request that payment of authorized Medicare or other health insurance benefits be made either to
me, or on my behalf to Grosse Ile Family Chiropractic or services furnished to me by the
provider. I authorize any holder of medical information about me to release to the Centers for
Medicare & Medicaid Services and its agents, or other insurance claims agents, any information
needed to determine these benefits or the benefits payable for related service.

Patient Signature ___________________________________ Date _________________

Financial Responsibility

I agree to be financially responsible for all my charges for services rendered at this clinic,
including my insurance deductible, co-payment and any services rejected by my insurance
company. (Medicare sets the standard for Covered and Non-Covered Services. See attached
explanation of Non-Covered Services).

Patient Signature ________________________________Date ____________________

Contact cell phone number where we can leave a message________________________

Witness Signature _______________________________Date ____________________

Bertie R. Synowiec, DC