MOMO Chiropractic
405 14th St. Ste. 208
Oakland, CA 94612
CONFIDENTIAL CASE HISTORY
Name: ____________________________Date: __________Sex: ☐M ☐F Age: _____ DOB (MM/DD/YYYY): __________
Address: _______________________________________________________ City __________________________
State ______ Zip __________
Home Phone: (_______)__________________ Business Phone: (_______)__________________
Mobile Phone: (_______)________________
Fax: (_______)_____________________ Email: __________________________________ I prefer contact via: ☐Phone ☐Email ☐Mail
Occupation: _____________________________________________________
Employer: ____________________________________________
Marital Status: ☐Single ☐Married ☐Divorced ☐Widowed
Name of Spouse: ____________________________________________
Spouse’s Employer: _____________________________________________
Name and Phone of Emergency Contact: __________________________________________________
Relationship: __________________________
Have you ever received chiropractic care? ☐Y ☐N If yes, which doctor? _________________________
Phone: _______________________
Do you have a primary care physician? ☐Y ☐N If yes, which doctor? __________________________
Phone: _______________________
Payment Information | Please indicate your preferred form of payment
☐Cash
☐Visa, MasterCard
☐Check
Current Health Concerns| Please list the 5 major health concerns in your order of importance, with a brief history on each
complaint
1.
2.
3.
4.
5.
Review of Symptoms | Pain Presentation
Using the diagram below, mark areas of your body where you currently feel pain or other abnormal sensation. Also indicate where
your pain travels (if appropriate). You can also write notes next to your markings if a description would be helpful. Then, please
answer the questions to the right by circling the number that best represents your pain, where 1 is no pain and 10 is the worst pain
you
can imagine.
Review of Systems | Please check the boxes for all conditions that you are currently experiencing (1st box) and/or have
experienced in the past (2nd box)
General
☐ ☐Blacking out
☐ ☐Bleeding gums
☐ ☐Nosebleeds
☐ ☐Coughing phlegm
☐ ☐Leg cramps
☐ ☐Weight loss
Eyes
☐ ☐Cold sores
☐ ☐Sinus problems
☐ ☐Coughing blood
☐ ☐Calf pain
☐ ☐Weight gain
☐ ☐Change in vision
☐ ☐Dentures
Lungs
☐ ☐Tuberculosis
☐ ☐Varicose veins
Head
☐ ☐Cataracts
☐ ☐Sore throat
☐ ☐Difficulty breathing
Vascular
☐ ☐Low blood pressure
☐ ☐Headache
☐ ☐Light sensitivity
☐ ☐Jaw pain
☐ ☐Asthma
☐ ☐Chest pain
☐ ☐High blood pressure
☐ ☐Dizziness
☐ ☐Flashes in vision
☐ ☐Changes in taste
☐ ☐Pneumonia
☐ ☐Palpitations
G-I System
☐ ☐Head trauma
☐ ☐Spots in vision
☐ ☐Hoarseness
☐ ☐Wheezing
☐ ☐Ankle swelling
☐ ☐Gas
☐ ☐Fainting
Mouth
Nose
☐ ☐Persistent cough
☐ ☐Cold feet/hands
☐ ☐Heartburn
☐ ☐Indigestion
☐ ☐Pain urinating
☐ ☐Numbness
☐ ☐Fractures
☐ ☐Diabetes
☐ ☐Anemia
☐ ☐Ulcers
☐ ☐Blood in urine
☐ ☐Weakness
☐ ☐Dislocations
☐ ☐Thyroid condition
☐ ☐Osteoporosis
☐ ☐Vomiting/Nausea
☐ ☐Incontinence
☐ ☐Difficulty walking
Skin
☐ ☐Heart condition
☐ ☐Osteoarthritis
☐ ☐Abdominal Pain
☐ ☐Foul odor of urine
☐ ☐Poor coordination
☐ ☐Rash
☐ ☐Rheumatic arthritis
☐ ☐High cholesterol
☐ ☐Diarrhea
☐ ☐Increased urination
☐ ☐Bruising
☐ ☐Rheumatic fever
☐ ☐Migraines
☐ ☐Constipation
☐ ☐Decreased urination
☐ ☐Brittle nails
☐ ☐TIAs
☐ ☐Blood in stool
☐ ☐Urinary infection
Muscle/Bone
☐ ☐Glaucoma
☐ ☐Alcoholism
☐ ☐Headache unlike any
☐ ☐Genital infection
☐ ☐Joint pain
☐ ☐Changes in moles
☐ ☐Hemorrhoids
☐ ☐Itching
previously experienced
☐ ☐Gall bladder disease
Neurologic
☐ ☐Stiffness
☐ ☐Cancer/Tumor
☐ ☐Muscle ache
☐ ☐Peeling
☐ ☐Polio
☐ ☐Liver disease
☐ ☐Seizures /Epilepsy/
G-U System
☐ ☐Arthritis
Conditions
Strokes
☐ ☐Bone pain
☐ ☐Hypertension
☐ ☐Difficulty urinating
☐ ☐Tingling sensation
☐ ☐Parkinson’s
☐ ☐Multiple Sclerosis
☐ ☐Gout
Family History | Please list (and specify if necessary) any conditions that you or a member of your family has experienced.
PATERNAL
SELF
FATHER/
BROTHER/
GRANDFATHER/
MOTHER
SISTER
GRANDMOTHE
R
Alcohol/Drug
Abuse
Allergies/
Sinus
Anemia/
Blood
Disorder
Arthritis
Birth Defect
Cancer/Type
Diabetes
Depression/
Anxiety
Mental Health
Disorder
High
Cholesterol
Heart
Disease
MATERNAL
GRANDFATHER/
GRANDMOTHER
CHILD
High Blood
Pressure
Obesity
Thyroid
Disorder
Stroke
Other
Surgeries/Hospitalizations | Please list any hospitalizations, surgeries, operations, fractures, car accidents, or major trauma you
have experienced:
☐Appendectomy
☐C-Section
☐Fracture
☐Implants/Prostheses
☐Arthroscopy
☐Cholecystectomy
☐Gallstones
☐Kidney Stones
☐Biopsies
☐Dental Surgery
☐Hernia
☐Laparoscopy
☐Breast Implants
☐Eye Surgery
☐Hysterectomy
☐Other:
Briefly list details including date, outcome, etc.:
Medications | Please list any medications you are taking, or have taken, and for how long
MEDICATION
PURPOSE
DATE STARTED/STOPPED
DOSAGE
Please list any medications you are allergic to:
Energy Level | List on a scale from 1 to 10 (10 being the highest) what your energy levels are during the following times:
Morning: 1 2 3 4 5 6 7 8 9 10
Afternoon: 1 2 3 4 5 6 7 8 9 10
Evening: 1 2 3 4 5 6 7 8 9 10
Late Evening: 1 2 3 4 5 6 7 8 9 10
After Meals: 1 2 3 4 5 6 7 8 9 10
Overall: 1 2 3 4 5 6 7 8 9 10
Stress Level | Rate your current stress level on a scale from 1 to 10 (10 being the highest): Note that stress can come in forms
such as overwork, relationships, health concerns, tiresome family or work responsibilities, trauma, excessive fear, worry, anxiety,
insomnia, road rage, not happy with life, etc.
Current Stress Level: 1 2 3 4 5 6 7 8 9 10
Average Stress Level: 1 2 3 4 5 6 7 8 9 10
Sleep | Rate your sleep quality. Check all that apply:
☐Restful sleep
☐Bruxing
☐Restless Sleep
☐Snoring
☐Difficulty falling asleep
☐Wake up during the night (usual time of waking:
☐Sleep Apnea
☐Wake up tired
☐Vivid Dreams
☐Wake up rested
☐Nightmares
☐Restless Legs
Exercise | Please check all boxes pertaining your exercise regimen and specify details if necessary:
Do you exercise? ☐Yes ☐No
If yes, what type of exercise?
☐Walking
☐Running
☐Dancing
)
☐Spinning
☐Kettle Bell Training
☐Team sports (please specify:
☐Aerobics
☐Triathlon
_________________________)
☐Biking
☐General Cardio
☐Other: ___________________
☐Weightlifting
☐Marathon (full / half / frequency per
☐CrossFit
year: _____________)
How long is your average exercise session? ☐30min ☐60min ☐90min ☐over 90min
How often do you exercise? ☐1-2 times per week ☐3-4 times per week ☐5 or more times per week
Do you train for any competitions? If yes, please explain:
MOMO Chiropractic
405 14th St. Ste. 208
Oakland, CA 94612
INFORMED PATIENT CONSENT
I, _______________________________, do hereby give my consent to the performance of conservative noninvasive treatment to the
joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the
joints and soft tissues. Physical therapy, home exercises, nutritional supplements/dietary recommendations may also be used.
Although spinal manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal
problems, I am aware that there are possible risks and complications associated with these procedures as follows:
Risk from Treatment
Soreness: I am aware that like exercise it is common to experience muscle soreness in the first few treatments.
Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. Please inform Dr. Sara Chong if you
experience these symptoms.
Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies like weak
bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc or other abnormality
is detected, this office will proceed with extra caution.
Stroke: Although strokes happen with some frequency in our world, stroke from chiropractic adjustments are rare. I am aware
that nerve or brain damage including stroke is reported to occur one in a million to one in ten million treatments. One in a million
is about the same chance as getting hit by lightning. One in ten million is about the same chance as a normal dose of aspirin or
Tylenol causing death.
Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite
precautions, if a burn is obtained, there will be a temporary increase of pain and possible blistering. This should be reported to the
doctor.
A thorough health history and exam will be performed on me to minimize any risk of complication from treatment and I freely
assume these risks.
Treatment Results
I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved
mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits.
I realize that the practice of medicine as well as chiropractic, is not an exact science and I acknowledge that no guarantee has
been made to me regarding the outcome of these procedures.
I agree to the performance of these procedures by my doctor and such other persons of the doctor’s choosing.
Alternative Available Treatments
Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription
or over-the-counter medications, exercises and possible surgery.
Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use of overuse of mediation is
always a cause for concern. Drugs may ask pathology, produce inadequate or short-term relief, undesirable side effects, physical
or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks.
Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce
inflammation and pain. The same is true of ice, heat, or other home therapy. Prolonged bed rest contributes to weakened bones
and joint stiffness. Exercises are of limited value but are not corrective of injured nerve and joint tissues.
Surgery: Surgery may be necessary for conditions such as joint instability or serious disc rupture, among others. Surgical risks
may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery.
Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion
formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may
complicate treatment making future recovery and rehabilitation more difficult and lengthy.
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 above-named procedures. I have made my decision voluntarily and freely. 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
Doctor Signature
Date
MOMO Chiropractic
405 14th St. Ste. 208
Oakland, CA 94612
FINANCIAL POLICY
Payment:
Payment for initial consultation, examination and visits, are due in full at the time of service. If, at any time, payment issues
interfere with your ability to receive chiropractic care, please arrange a time to speak privately with the doctor to discuss further
options to continue care.
Insurance/Medicare:
Being a non-participating provider allows for reasonable pricing and simple payment processing. Insurance policies vary widely in
coverage of services, deductible amounts, copay amounts, and network policies and procedures. By collecting payment in full at
the time of service, there is never a misunderstanding between the doctor and the patient about the cost of the service.
Missed Appointment:
We reserve the right to charge in full for the allotted time scheduled if an appointment is missed without prior notification. We ask
that patients please cancel or reschedule their appointment at least 24 hours in advance to avoid such fees. If patients are late for
their appointment, we will still need to end the appointment on time in order to respect our other patients’ appointment.
Responsibility for Payment:
The patient is responsible for all services rendered by the office.
BY SIGNING THIS STATEMENT, I ACKNOWLEDGE THE REGULATIONS OF THIS POLICY AND AM FULLY RESPONSIBLE
FOR THE CHARGES INCURRED.
Patient Signature
Date
MOMO Chiropractic
405 14th St. Ste. 208
Oakland, CA 94612
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND INFORMED PATIENT
CONSENT (HIPAA)
1. I have been informed a privacy notice may be provided to me prior to my signing this Consent form. The privacy notice
includes a complete description of use and/or disclosures of my protected health information (PHI) necessary for the
Practice to provide me treatment, and necessary for the Practice to explain to me that the Privacy Notice will be available
to me in the future at my request. The Practice explained my right to obtain a copy of the privacy Notice, and has
encouraged me to read the privacy Notice carefully prior to my signing this Consent.
2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with
applicable law.
3. I understand that, and consent to the following communication that will be used by the Practice: a) a card, letter or other
written information mailed to me at the address provided by me; and b) telephoning and leaving a message on my
answering machine or with the individual answering the phone; and c) sending an electronic mail to the address provided
by me.
4. The Practice may maintain a directory of and sign-in log for individuals seeking care and treatment in the office. This
information may be seen by, and is accessible to, others who are seeking care of services in the Practice’s offices.
5. The Practice may use and/or disclose my PHI in order for the Practice to treat me and obtain payment for that treatment,
and as necessary for the Practice to conduct its specific health care operations.
6. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out
treatment, payment and/or healthcare operations. However, the Practice is not required to agree to any restrictions that I
have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.
7. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in
writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent
that the Practice has already taken action in reliance on this consent.
8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to my above
and contained in the Privacy Notice, then the Practice has the right to choose to treat me. I further understand that if I
revoke this consent at any time, the Practice has the right to refuse to treat me.
I acknowledge that I may receive a copy of the Practice’s Notice of Privacy Practices at anytime. I further acknowledge that a copy
of the current notice is posted at the front desk with the Practice’s Privacy Policies Manual, which outlines all of the ways in which
the Practice handles my PHI.
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, please ask to speak with our HIPAA
Compliance Officer, Dr. Sara Chong, D.C., by phone at (510)842-6069. Signature below is acknowledgment that you have
received this Notice of Privacy Practice and that you have read and understand the foregoing notice, Notice of Privacy Practices,
and all of your questions have been answered to your full satisfaction in a way that you can understand.
Patient Signature
Date
MOMO Chiropractic
405 14th St. Ste. 208
Oakland, CA 94612
PATIENT AUTHORIZATION REGARDING CHIROPRACTIC CARE BEING PROVIDED IN AN “OPEN
ADJUSTING” ENVIRONMENT
It is the practice of this office to provide chiropractic care in an “open adjusting” environment. “Open adjusting” involves several
patients being seen in the same adjusting room at the same time. Patients are within sight of one another and some ongoing
routine details of care are discussed within earshot of other patients and staff. Patients also use a public sign in sheet located on
the front desk to record their visits.
This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations
or presenting reports of findings. These procedures are complete in a private, confidential setting.
We are requesting this authorization of you due to various interpretations under federal law with respect to what is known as an
“incidental disclosures” of health information. It is our view that the kinds of matters related in an “open adjusting” environment are
incidental matters; in the event you or someone else would not agree with us we are providing this disclosure.
The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance
your access to quality health care and health information. If you choose not to adjusted in an “open adjusting” environment, other
arrangements will be made for you. Your decisions will have no adverse effect on your care from MOMO Chiropractic or on your
relationships with the staff.
You may revoke this authorization at any time. Revocation may be accomplished by advising us in writing of your desire to
withdraw your authorization. Please allow a reasonable processing time for the change in our procedures to be completed.
MOMO Chiropractic takes patient privacy very seriously. All visits are recorded with a HIPAA complaint and secure
clearinghouse. Our staff uses a secure calendar, separate passwords and will not share your medial records without expressed
written permission. We do not sell or release patient information to any other facility or company.
YOUR SIGNATURE INDICATES YOUR AUTHORIZATION OF THIS ACTIVITY
Patient Signature
Date