OFFICE USE ONLY F/C: □ INS □ MC □ MD □ IO □ WC □ AA □ PI □ SP
TW
Included: □ insurance card copy □ employer claim form □ Referral/script
#:
Welcome to Tranquility Wellness!
Chiropractic ● Acupuncture ● Natural medicine
We are committed to providing the best, most comprehensive care possible. We encourage you to ask questions. Please assist us by providing
the following information. All information is confidential and is released only with your consent.
Please arrive 15 minutes prior to your scheduled appointment time to complete additional forms in our
Electronic Medical Records system.
Patient Name:_____________________________________________________ Birth Date:________________________
Is it OK to leave phone messages for you? □ Yes □ No
Marital Status: □ Single □ Married □ Divorced □ Widow(er)
Who can we thank for referring you to Tranquility Wellness? __________________________________________________
Who is your Primary Care Doctor? Name/Practice:__________________________________________________________
Address:_________________________________________________________Phone:____________________________
Emergency Contact
Last Name:
Relation to Patient:
First Name:
Home Phone:
Cell Phone:
Insurance Information Relation to Insured: □ Self □ Spouse □ Child □ Other
Insurance Company:
Subscriber’s Name (if different from patient):
Subscriber’s Birth Date:
Subscriber’s SS#:
Insurance ID #:
Secondary Insurance :
Insurance ID #:
Subscriber’s Name (if different from patient):
Subscriber’s Birth Date:
Subscriber’s SS#:
Group #:
Group #:
Relation to Insured:
Accident Patients
WORK COMP OR MEDPAY INFORMATION
Date of Injury:
Insurance Carrier Name:
Carrier Address:
City,State,Zip:
Adjuster’s Name:
Adjuster’s Phone: ( )
Claim Number:
ATTORNEY INFORMATION
□ Attorney Only–no WC or Medpay Info
Name:
Address:
City,State,Zip
Contact:
Phone: ( )
File No:
I, the undersigned, hereby authorize the staff to perform such services as deemed necessary by the physician to diagnose and treat my
condition(s). Further I authorize assignment of my insurance rights and benefits directly to this provider and also authorize the release of such
information as needed to process insurance claims by provider or agent. I designate this provider, practice, and agent as Authorized
Representative with Durable Power of Attorney in insurance related matters. I understand that I am responsible for all charges which may
include legal fees, collection fees or other expenses incurred by the provider in collection my account. I hereby order all parties to accept a copy
of this release and assignment in lieu of the original. This shall remain in effect until revoked by me in writing. I designate provider and agent
(here after referred to as my doctor), to the full extent permissible under the Employee Retirement Income Security Act of 1974 (“ERISA”) and
as provided in 29 CFR 2560-503-1(b)4 to act on my behalf to pursue claims and exercise all rights connected with my employee health care
benefit plan, with respect to any medical or other health care expense(s) incurred as a result of the services I received from my doctor. These
rights include the right to act on my behalf with respect to initial determinations of claims, to pursue appeals of benefits determinations under
the plan, to obtain records, and to claim on my behalf such medical or other health care service benefits, insurance or health care reimbursement
and to pursue any other applicable remedies, all in connection expenses as the result of doctor services.
Patient/Legal Guardian Signature: ____________________________________________Date:___________
REVIEW OF SYSTEMS and METABOLIC ASSESSMENT
Please circle the appropriate number “1 – 3” on all questions below.
0=never, 1=occasionally, 2=somewhat frequently 3=very frequently
Category I: Colon
Feeling that bowels do not empty completely
Lower abdominal pain relief by passing stool or gas
Alternating constipation and diarrhea
Diarrhea
Constipation
Hard dry or small stool
Coated tongue or “fuzzy” debris on tongue
Pass large amount of foul smelling gas
More than 3 bowel movements daily
Do you use laxatives frequently
Category II: Hypochlorydia
Excessive belching burping or bloating
Gas immediately following a meal
Offensive breath
Difficult bowel movements
Sense of fullness during and after meals
Difficulty digesting fruits and vegetable;
undigested foods found in stools
Category III: Hyperacidity (Ulcer)
Stomach pain, burning or aching 1-4 hrs after eating
Do you frequently use antacids?
Feeling hungry an hour or two after eating
Heartburn when lying down or bending forward
Temporary relief from antacids, food, milk,
carbonated beverages
Digestive problems subside with rest & relaxation
Heartburn due to spicy foods, chocolate, citrus
peppers, alcohol and caffeine
Category IV: Small Intestine (Pancreas)
Roughage and fiver cause constipation
Indigestion and fullness lasts 2-4 hrs after eating
Pain, tenderness, soreness on left side
under rib cage bloated
Excessive passage of gas
Nausea and/or vomiting
Stool undigested, foul smelling,
mucous-like, greasy or poorly formed
Frequent urination
Increased thirst and appetite
Difficulty losing weight
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
Category V: Biliary Insufficiency/Statis
Greasy or high fat foods cause distress
Lower bowel gas and or bloating
several hours after eating
Bitter metallic taste in mouth, esp. in the morning
Unexplained itchy skin
Yellowish cast to eyes
Stool color alternates from clay colored
to normal brown
Reddened skin, esp. palms
Dry or flaky skin and/or hair
History of gallbladder attacks or stones
Have you had your gallbladder removed?
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
Category VI: Hypoglycemia
Crave sweets during the day
Irritable if meals are missed
Depend on coffee to keep yourself going or started
Get lightheaded if meals are missed
Eating relieves fatigue
Feel shaky, jittery, tremors
Agitated, easily upset, nervous
Poor memory, forgetful
Blurred vision
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
Category VII: Insulin Resistance
Fatigue after meals
Crave sweets during the day
Eating sweets does not relieve cravings for sugar
Must have sweets after meals
Waist girth is equal or larger than hip girth
Frequent urination
Increased thirst & appetite
Difficulty losing weight
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Category VIII: Adrenal Hypofunction
Cannot stay asleep
Crave salt
Slow starter in the morning
Afternoon fatigue
Dizziness when standing up quickly
Afternoon headaches
Headaches with exertion or stress
Weak nails
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
Category IX: Adrenal Hyperfunction
Cannot fall asleep
Perspire easily
Under high amounts of stress
Wake up tired even after 6 or more hours of sleep
Excessive perspiration or perspiration with
little or no activity
2|Patient Name:
0 1 2 3
0 1 2 3
Category X: Hypothyroid
Tired, sluggish
Feel cold-hands, feet, all over
Require excessive amounts of
sleep to function properly
Increase in weight gain even with low-calorie diet
Gain weight easily
Difficult, infrequent bowel movements
Depression, lack of motivation
Morning headaches that wear off
as the day progresses
Outer third of eyebrow thins
Thinning of hair on scalp, face or genitals or
excessive falling hair
Dryness of skin and/or scalp
Mental sluggishness
0 1 2 3
0 1 2 3
0 1 2 3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0 1 2 3
0 1 2 3
0 1 2 3
0 1 2 3
Category XI: Thyroid Hyperfunction
Heart palpations
Inward trembling
Increased pulse even at rest
Nervous and emotional
Insomnia
Night sweats Difficulty gaining weight
0
0
0
0
0
0
Category XII: Pituitary Hypofunction
Diminished sex drive
Menstrual disorders or lack of menstruation
Increased ability to eat sugars without symptoms
0 1 2 3
0 1 2 3
0 1 2 3
Category XII: Pituitary Hyperfunction
Increased sex drive
Tolerance to sugars reduced
“Splitting” type headaches
0 1 2 3
0 1 2 3
0 1 2 3
Category XIV: MALE ONLY
Urination difficulty or dribbling
Urination frequent
Pain inside of legs or heels
Feeling of incomplete bowel evacuation
Leg nervousness at night
0
0
0
0
0
3|Patient Name:
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
Category XV: MALE Physiology MALE ONLY
Decrease in libido
0 1 2 3
Decrease in spontaneous morning erections
0 1 2 3
Decrease in fullness of erections
0 1 2 3
Difficulty in maintaining morning erection
0 1 2 3
Spells of mental fatigue
0 1 2 3
Inability to concentrate
0 1 2 3
Episodes of depression
0 1 2 3
Muscle soreness
0 1 2 3
Decrease in physical stamina
0 1 2 3
Unexplained weight gain
0 1 2 3
Increase in fat distribution around chest and hips
0 1 2 3
Sweating attacks
0 1 2 3
More emotional than in the past
0 1 2 3
Category XVI Menstruating FEMALES ONLY
Are you perimenopausal
YES NO
Alternating menstrual cycle lengths
YES NO
Extending menstrual cycle lengths
more than 32 days
YES NO
Shortened menses, less than every 24 days
YES NO
Pain and cramping during periods
0 1 2 3
Scanty blood flow
0 1 2 3
Heavy blood flow
0 1 2 3
Breast pain and swelling during menses
0 1 2 3
Pelvic pain during menses
0 1 2 3
Irritable and depressed during menses
0 1 2 3
Acne break outs
0 1 2 3
Facial hair growth
0 1 2 3
Hair loss/thinning
0 1 2 3
Date of last menstrual period:
Date of last PAP:
_________________________
______________
Category XVII: Menopausal FEMALES ONLY
How many years have you been menopausal? ____________
Do you ever have uterine bleeding since menopause YES NO
Hot flashes
0 1 2 3
Mental fogginess
0 1 2 3
Disinterest in sex
0 1 2 3
Mood swings
0 1 2 3
Depression
0 1 2 3
Painful intercourse
0 1 2 3
Shrinking breasts
0 1 2 3
Facial hair growth
0 1 2 3
Acne
0 1 2 3
Increased vaginal pain, dryness or itching
0 1 2 3
Date of last menstrual period:
Date of last PAP:
_________________________
______________
Tranquility Wellness Responsibility Agreement & Financial Policy
FINANCIAL RESPONSIBILTY
Insurance Payment: This office will process insurance forms for both in and out of network health insurance
companies for any chiropractic care, excluding maintenance/preventative care, non-medical treatments or noncovered services. Patients are responsible for and will pay for any co-payments, co-insurance, deductible, denied,
and/or non-covered services, according to their health insurance plan.
Cash/Self pay: Patients will pay for services at the time of service. They may request a bill to submit to their own
insurance, health savings account or flex spending plan if applicable for possible reimbursement.
Auto Accident/Personal Injury Payment: Patients involved in an automobile accident/personal injury can have claims
submitted to the designated claims department. The patient will sign all liens necessary to protect our office. If the first
insurance payment is not received within 45 days of the first date of service, the patient agrees to pay $100.00 per month while
our office awaits final payment. The patient will be promptly reimbursed should any overpayment occur. Regardless of
payment arrangements, the patient is personally responsible for the entire balance within 90 days of completion of treatment.
Missed/Cancelled appointments: Patients will be charged a $25.00 fee for missed appointments or cancelling
with less than 24 hours notice.
Assignment of Benefits: I hereby request that payment of authorized Medicare and all other third party
insurance/payor benefits be made directly to Tranquility Wellness for any services furnished to me by that supplier.
I hereby assign payment for services provided to me by Tranquility Wellness are made directly to Tranquility
Wellness. I understand that I am financially responsible for any co-payments, deductibles and non-covered services.
Tranquility Wellness assignment on all Medicare/pay or covered services/supplies unless otherwise notified. I
further acknowledge that any benefits paid directly to the beneficiary for services provided by Tranquility Wellness
will be endorsed and delivered/mailed to Tranquility Wellness within 10 days of receipt.
If, for any reason, you have an account in arrears with our office and we are not to establish a repayment plan, your
account will be sent to collections. This is used only as a last resort by this office. If this option must be used, a
20% fee will be added to your account to help with the fees incurred by this office. We will always work with you
to get your account paid in full. If collections procedures fail to produce payment on your account, further action
will be pursued in Small Claims Court, and any court and/or attorneys fees will be your responsibility. Any
returned checks will be assessed a fee of $25.00 or 5% of the check amount, whichever is greater, in accordance
with State of Illinois regulations. If payment arrangements are not established with our office within a reasonable
amount of time (within 12 days of notice sent by our office), further action will be pursued through the Prosecutors’
Office to recoup our cost.
Patient/Legal Guardian Signature:____________________________________________Date:_______________
4|Patient Name:
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
We are very concerned with protecting your privacy. While the law requires that you give us this disclosure, please
understand that we have, and always will, respect the privacy of your health information.
There are several circumstances in which we may have to use or disclose your health information.
We may have to disclose your health information to another health care provider or a hospital if
it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health
condition.
We may have to disclose your health information and billing records to another party if they are
potentially responsible for the payment of your services.
We may need to use your health information within our practice for quality control or other
operational purposes.
We have a more complete notice that provides a detailed description of how your health information may be used
or disclosed. You have the right to review that notice before you sign this consent form (§ 164.520). We reserve the
right to change our privacy practices as described in that notice. Please feel free to call us at any time for a copy for
our privacy notices.
I agree to the HIPPA policy in place by this office. I am aware that a copy of this policy is available for me
to review at any time.
Patient/Legal Guardian Signature:____________________________________________Date:_______________
5|Patient Name:
CONSENT TO TREATMENT
I hereby consent to chiropractic treatments, acupuncture, natural medicine, laboratory services and/or related holistic
treatments and evaluations rendered to me (or my child if a minor) by all Tranquility Wellness practitioners and staff. I have
not been guaranteed any success concerning the uses and effects of chiropractic, acupuncture and/or natural medicine. I
understand that I am free to discontinue treatment at any time.
Chiropractic Treatment is conservative non invasive treatment to the joints and soft tissues. I understand that the
procedures may consist of manipulation/adjustments involving movement of the joints and soft tissues. 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:
 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.
 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 disk, or other abnormality is detected, this office will proceed with extra caution.
 Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are
exceedingly rare. I am aware that nerve or brain damage including stroke is reported to occur once in one million to
once in ten million treatments. Once in a million is about the same chance as getting hit by lightening. Once in ten
million is about the same chance as a normal dose of aspirin or Tylenol causing death.
Acupuncture Treatments is a healing therapy involving the insertion of fine needles into specific points along meridians on
the body. In addition to the use of needles, the scope of acupuncture includes the use of electrical, mechanical or magnetic
devices to stimulate acupuncture points, moxibustion, acupressure, cupping, Gua Sha, Tui-Na (Chinese massage), Chinese
herbal medicine, and nutritional counseling. Acupuncture side effects may include some pain following treatment in the
insertion area, temporary aggravation of symptoms existing prior to treatment, minor bruising, slight bleeding, dizziness,
infection or needle sickness (fainting). Acupuncture treatment is a complement to and not a substitute for Western medical
care. Certain conditions may best be addressed in partnership with other health care providers. I understand that my
acupuncture practitioner follows universally prescribed precautions to guard against the spread of infection by using only
sterilized, prepackaged, disposable needles. These needles will only be used on me and are inserted according to clean
procedures based on nationally prescribed standards.
Natural Medicine is the use of dietary modifications, supplementation, and/or laboratory study recommendations as part of
a wellness plan. I understand that disease claims made for supplements have not been evaluated by the Food and Drug
Administration and they are not intended to diagnose, treat, cure or prevent any disease or Cancer. Supplementation therapy
are suggestions, therefore it is my responsibility to read all labels and warning information. Laboratory studies, such as
drawing of blood samples, urine, stool, or saliva samples are for the purpose of diagnostic testing, determining cause of illness
and/or monitoring of treatment progress. With blood draws, I understand that I may experience some bruising at the site
where the needle entered my body and/or irritation may occur from the bandage adhesive.
If I am pregnant or shall become pregnant, experience symptoms, obtain a diagnosis from another
medical provider, or begin or have alterations in prescription medications per my Medical Doctor while
receiving treatment at Tranquility Wellness, I will inform my Tranquility Wellness provider.
I have read or have had read to me the above information. Any questions I have had regarding these
procedures and policies have been answered to my satisfaction PRIOR TO MY SIGNING THE
CONSENT FORM. I have made my decision voluntarily and freely.
Patient Name (printed):_______________________________________________________________________
Patient/Legal Guardian Signature:____________________________________________Date:_______________
6|Patient Name: