Patient Signature (or guardian) Date · waiting list. If you cancel within 24 business hours you...

Welcome to Secoya Health. We are dedicated to providing you with personalized and preventive care to help you reach your health goals. Initial visits include: initial consultation; applied kinesiologic and chiropractic structural exam; body composition analysis, first treatment; and/or other necessary kinesiologic tests. This comprehensive appointment is $397. Additional costs may include: specialized lab testing; nutritional supplements and homeopathic remedies; Bio-Meridian Analysis; special programs; and/or orthopedic appliances. When you schedule an appointment for your healthcare needs, that time is set aside for you. Given the busy nature of our practice and the high demand for patients to receive care, we charge 1/3 of the exam cost to a credit card to hold your appointment. The 1/3 charged at the time of scheduling will be credited toward your initial exam fee on the day of your appointment. If you need to cancel or reschedule your initial appointment, we ask that you give a minimum of 72 business hours’ notice. If not cancelled within 72 business hours, you will forfeit your appointment reservation fee. All follow up appointments we require 24 business hours’ notice for any cancellation. This will allow us to contact another person on the waiting list. If you cancel within 24 business hours you will be charged for half the appointment. By signing below, you authorize that the card on file can be charged if this notice is not given.

Secoya Health is a “fee for service” practice and payment is due at the time of service. We accept cash, checks, Visa, Discover, and MasterCard. As a courtesy, we do provide our patients with an itemized bill to submit for insurance reimbursement. The following sheets are very important. Please answer all of the questions thoroughly at least three days before your appointment and bring them with you to your initial exam. Please wear comfortable clothing & shoes to your appointment.

IMPORTANT: Prior to your appointment please do not have any caffeine or alcohol 12 hours prior to your exam as well as refrain from exercising, saunaing, or taking any nutritional supplements on the day of your exam. We have all patients remove their shoes in our office so please bring a clean pair of shoes, slippers, or socks if you are uncomfortable with being barefoot. Also, we ask that you bring any medications and/or nutritional supplements (vitamins, herbs, oils, etc.) you deem a necessity in your health routine. Out of respect for those patients who are sensitive, we also ask that you refrain from wearing any perfumes or colognes for your appointments at Secoya Health.

We ask that you arrive 15 min. early to your initial appointment. Thank you for choosing Secoya Health for your healthcare needs.

Patient Signature ______________________________________________ (or guardian) Date ______________

Secoya Health – 7650 Currell Blvd – Woodbury, MN 55125 – 651-738-7800 2 SecoyaHealth.com

Mandatory Disclosures

Informed Consent for Chiropractic Treatment

Chiropractic adjustments are a conservative and very safe procedure. We are required by law to notify you of any risk involved. The only serious complication of a chiropractic adjustment is a vertebral artery injury, commonly known as a stroke. It is extremely rare – statistics show this may occur about once in a million to once in 10 million adjustments. Most importantly, there has never been a case of vertebral artery injury at this clinic. ______ I understand the remote possibility of injury from chiropractic treatment and elect to receive the recommended treatment.

Privacy Policies and Authorizations

THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED/DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

We have always been very concerned with protecting your privacy, but now the federal and state law requires us to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. This notice will remain in effect until further notice.

Uses and Disclosures of Health Information We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information within this clinic in connection with our healthcare operations. Healthcare operations include, but are not limited to, quality assessment and improvement activities such as reviewing office procedures and training staff. Patient information will be disclosed in hardcopy only. No fax or internet transmissions will be sent. We may also disclose your health information with your written consent. Your authorization may be revoked in writing at any time. Your revocation will take effect upon receipt. Any authorization you have signed that we receive from any other source will also be considered valid. Your Family and Persons Involved in Your Care: We ask that patients take responsibility to make and cancel their own appointments, except in the case of minors or disadvantaged adults. We confirm your appointment time by telephone and may leave a message on either a voicemail or with another person in your household if you are not available. We will also use our professional judgment when allowing another person to pick up supplements or requested information relayed on your behalf. You have the right to get a copy of your health record by giving us a written request. We reserve the right to charge for copying costs. You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. I authorize you to use or disclose my health information in the manner described above. I am also acknowledging I have received a copy of this authorization.

____________________________________ ______________________________ _______________________ Patient Name Patient Signature Date

______________________________________ ____________________________________ Personal Representative Personal Representative Signature


New Participant Evaluation Please complete the following questions carefully. This information will help us to build a personalized

wellness program for you. Information you provide is strictly confidential.

DO NOT TAKE ANY NUTRITIONAL SUPPLEMENTS ON THE DAY OF YOUR EXAM

Initial visit date and time: ________________________________ Referred by: _________________________

Name: ______________________________________ Birth date: _____/_____/_____ Age: ______ M / F

Address: _____________________________________City: ___________________State: ____ Zip: _______

Phone (circle preferred): Home_________________Work___________________Cell__________________

Email: _______________________________________Would you like to receive our emails? YES / NO

Preferred Method of Contact (circle one): Email/Phone/Text/All Cell Phone Provider: _________________

Do you have Medicare benefits? YES / NO

Marital Status: Single Married Divorced Widowed No. of Children: __________________________

Occupation: ______________________________________________________________________________

1. Please list the current health conditions/symptoms that concern you and rate their severity on a

scale from (1 to 10) 10 being the most severe.

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2. What treatments have you tried for these conditions and has anything helped?

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3. What are your hopes and goals for your health in the next 6-12 months?

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4. Nutritional Supplements Please list any nutritional supplements/products you are currently using.

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5. Medications Please list any medications you are currently taking and how long you have taken them (including birth control pills, aspirin, pain medication, sleep aids, etc.)

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6. Surgeries

Have you ever had full-body anesthesia (wisdom teeth, to remove tonsils, etc.)? Y / N

Do you have breast implants? Y / N Other surgical implants or prostheses? Y / N

Have you had elective surgery (tummy tuck, face-lift, mole removal, etc)? Y / N

Do you have any internal metal or plastic (such as pins, clamps, plates, etc)? Y / N

Do you have body piercings or tattoos? Y / N

Explain:____________________________________________________________________________

___________________________________________________________________________________

7. Stress

Please rate your current stress level on a scale of (1 to 10) 10 being the highest stress:__________

Please list the 5 most stressful events in your life, from the most recent to the most distant. Are any of these situations continuing to impact your life or your health? a._________________________________________________________________________________

b._________________________________________________________________________________

c._________________________________________________________________________________

d._________________________________________________________________________________

e._________________________________________________________________________________

What step(s) are you taking to reduce your stress level? ___________________________________________________________________________________

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From birth to the age of thirteen, did you experience the absence of a parent, a parent’s sickness, divorce, witness substance abuse or experience any emotional, physical, or sexual abuse? If yes, please share at what age and the type of stress.

___________________________________________________________________________________

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___________________________________________________________________________________

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8. Sleep

How is your sleep? (check all that apply)

I sleep very well Restless Difficulty falling asleep Difficulty staying asleep

Bad dreams I wake feeling rested I wake feeling tired Other:________________________

How many times per night do you wake up? _________________

What time do you usually go to sleep? ______________________

How many hours of sleep do you get per night? _______________

How many times per night do you wake to urinate? ____________

9. Exercise

What kind of exercise do you enjoy on a frequent basis?

___________________________________________________________________________________

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How often? ______________________________________ For how long at a time? _______________


Please check all that you are currently experiencing: Muscular-Skeletal System

______ Neck pain ______ Pain between shoulders ______ Low back pain ______ Arm problems

______ Leg problems ______ Swollen joints ______ Painful joints ______ Stiff joints

______ Sore muscles ______ Weak muscles ______ Walking problems

Gastro-Intestinal System

______ Poor appetite ______ Excessive hunger ______ Difficulty chewing ______ Difficulty swallowing ______ Excessive thirst

______ Nausea ______ Vomiting food ______ Abdominal pain ______ Diarrhea ______ Constipation

______ Black stool ______ Bloody stool ______ Hemorrhoids ______ Heartburn

Cardio-Vascular-Respiratory

______ Chest pain ______ Pain over heart ______ Difficulty breathing ______ Persistent cough

______ Coughing phlegm ______ Coughing blood ______ Rapid heartbeat ______ High blood pressure

______ Low blood pressure ______ Heart problems ______ Varicose veins ______ High cholesterol

Nervous System

______ Numbness ______ Loss of feeling ______ Dizziness

______ Fainting ______ Headaches ______ Muscle jerking

______ Forgetfulness ______ Confusion ______ Depression

Urinary System

______ Excessive urination ______ Scanty urination

______ Painful urination ______ Discolored urine

______ Frequent UTI’s

Bowel Function

How many bowel movements do you average per day? _________


Food Choices

1. Meal Habits

Do you: Skip meals often? Have irregular eating times? Eat food past 9pm?

What percentage of the meat you purchase is organic? ______________ What percentage of the produce you purchase is organic? ____________

Please indicate how many days per week you consume the following:

Do you eat at restaurants? Y / N If yes, how often?_______________________________________

Do you prepare meals at home? Y / N If yes, how often? ________________________________

How many times per week do you cook or reheat your food in a microwave? _____________________

2. Water

Do you drink tap water? Y / N

Do you use a water filter at home? Y / N If yes, what brand? _________________________

Do you buy purified drinking water? Y / N If yes, what brand? _________________________

3. Food Stressors Please indicate how many days per week you consume the following foods:

Stimulants Toxic Oils Commercial Dairy Highly Heated Foods

___Coffee ___Fried foods ___Cow’s milk ___Bread

___Black tea ___Fast food ___Yogurt ___Crackers

___Soft drinks ___Potato chips ___Ice cream ___Bagels

___NutraSweet drinks ___Roasted nuts ___Cottage cheese ___Muffins

___Alcohol ___Mayonnaise ___Sour cream ___Cookies - pastries

___Chocolate ___Margarine ___Cheese

___Candy or sweets ___Peanut butter

____ Frozen dinners

____ Red meat

____ Chicken or turkey

____ Fish

____ Pork

____ Fresh vegetables

____ Fresh fruit

____ Frozen or canned fruit

____ Frozen or canned vegetables

____ Wild game

____ Eggs

____ Pasta

____ Rice

____ Boxed cereals


4. Food Chart Please list everything you eat and drink for 2 days:

Breakfast Snack Lunch Snack Dinner Snack

Day 1

Day 2


Toxic Exposure

1. Smoking

Do you currently smoke? Y / N If yes, how much?_______________________________

How long have you smoked (currently or in the past)? _______________________________

2. Drugs

Do you currently use recreational drugs (ex. marijuana, cocaine, uppers, downers)? Y / N

If yes, which ones, and how often? Reminder: This is strictly confidential information.

____________________________________________________________________________

____________________________________________________________________________

3. Personal Care and Home Products Please check all that you use:

___Hair Perm ___Antiperspirant ___Facial make-up ___Hair spray ___Air fresheners (spray) ___Air fresheners (plug-ins) ___Hair gel

___Dryer sheets ___Roach/ant spray (in home) ___Hair color – semi or permanent ___Toilet freshener ___Fingernail polish ___Perfume/Cologne ___Lawn fertilizer (non-organic)

What type of mattress do you sleep on?

______________________________________________________________________________

Do you work with or near chemicals? Y / N Explain:________________________________________________________________________

Do you have any metal fillings? Y / N How many?________________________________

4. Appliances Please check all that you use:

____Gas stove ____Water bed ____Electric stove ____Microwave oven ____Electric heater ____Non-stick cookware ____Electric blanket ____Air purifier - What Brand?_______________________________

5. Pets

Do you have a pet? Y / N If yes, what kind and how many?_________________

Is the pet allowed in the house? Y / N On your bed? Y / N

6. Electromagnetic Exposure

Do you live or work near high voltage power lines? Y / N

How many hours do you spend daily: ____Watching TV ____Wearing a pager ____In a car ____Working on a computer ____Wearing a wrist watch ____Near electrical equip. ____Talking on a phone ____Wearing a hearing aid ____Near a clock radio


Scar/Trauma Chart

Name:

Date:

Directions

All Scars. Please draw a red line on the drawing where you have scars, even if they are

very old. Don’t forget C-sections, vaccination scars, episiotomies, surgeries, earring

puncture holes, tattoos, facelift scars, vasectomies, etc.

All Trauma Areas. Please put a red “X” where you have had trauma even if it is very old.

Don’t forget previous sprains, burns, falls, whiplash (from auto accidents), radiation, etc.

Internal Metal: Please draw a circle on the drawing if you have any type of internal metal

objects, such a surgical steel pin, metal plate, hip replacement, surgical wire mesh, etc.

Date of injury and type of injury. Draw a line from each of the above injury areas and print the type of injury and approximate date of injury. (For example, draw a line from a shoulder trauma area and print “car accident, 1988”)

Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score ra hbr 10 24 06

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often …

Swear at you, insult you, put you down, or humiliate you?

or Act in a way that made you afraid that you might be physically hurt?

Yes No If yes enter 1 ________

2. Did a parent or other adult in the household often …

Push, grab, slap, or throw something at you?

or Ever hit you so hard that you had marks or were injured?


3. Did an adult or person at least 5 years older than you ever…

Touch or fondle you or have you touch their body in a sexual way?

or

Try to or actually have oral, anal, or vaginal sex with you?


4. Did you often feel that …

No one in your family loved you or thought you were important or special?

or Your family didn’t look out for each other, feel close to each other, or support each other?


5. Did you often feel that …

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

or

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?


6. Were your parents ever separated or divorced?


7. Was your mother or stepmother:

Often pushed, grabbed, slapped, or had something thrown at her?

or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?

or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?


8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?


9. Was a household member depressed or mentally ill or did a household member attempt suicide?


10. Did a household member go to prison?


Now add up your “Yes” answers: _______ This is your ACE Score


WOMEN’S HEALTH SCREEN

Are you pregnant? Y / N Are you nursing? Y / N Have you had a hysterectomy? Y / N If yes, when? _________ Do you have monthly periods? Y / N Date of last menstrual cycle (1st day of flow) ______ Number of C-sections ______ Number of episiotomies or muscle tears ______

Check the symptoms you experience regularly one to two weeks before your period:

___ Anxiety ___ Abdominal Bloating ___ Fatigue ___ Irritability ___ Tender, swollen and /or ___ Headaches ___ Nervous Tension painful breast ___ Shaky or clumsy ___ Aggressive or hostile toward ___ Breast lumps increase in ___ Depressed family/friends size and tenderness ___ Withdrawn ___ Engage in self destructive ___ Discharge from nipples ___ Confused behavior ___ Craving for sweets ___ Forgetful ___ Weight gain ___ Increased appetite ___ Insomnia/difficulty sleeping ___ Water retention ___ Heart palpitations

Check the symptoms and or behaviors that occur during your period:

___ Cramping in the lower ___ Low back aches ___ Painful and /or swollen breasts abdomen or pelvic area ___ Headaches ___ Irritability ___ Sharp intermittent pain ___ Difficulty concentrating ___ Mood swings ___ Dull aching pain ___ Accident prone ___ Depression ___ Upset stomach ___ Unusual fatigue ___ Painful intercourse ___ Diarrhea ___ Decrease productivity ___ Nausea or vomiting ___ Weight gain

Check any of the following statements that describe your menstrual cycle, energy level or reproductive function:

___ Heavy prolonged menstrual bleeding/clotting ___ Unusually light or heavy periods ___ Menstrual bleeding that last longer than 5 days ___ Unusually light menstrual flow ___ Absence of periods for 3 months or more ___ Menses last three days and are light ___ Vaginal itching, burning, dryness ___ Bleeding or spotting between periods ___ Menstruation that occurs too frequently ___ Bleeding or spotting between periods is light (21 days or less) ___ Bleeding or spotting between periods is heavy ___ Irregular periods (once every 3-6 months) ___ Abnormal vaginal discharge ___ Frequently skip periods ___ Frequent urination ___ Menstrual cycle every 36 days or longer

Check any of the following symptoms if they occur throughout the month:

___ Decline of vital energy and sense of well-being ___ Urinary problems ___ Hot flashes ___ Vaginal problems ___ Night sweats ___ Dry skin ___ Spontaneous sweating ___ Bleeding between periods ___ Chills ___ Irregular periods ___ Depressed ___ Stopped menstruating ___ Irritable ___ Joint and muscle pain ___ Anxiety ___ Change in sexual desire ___ Anger ___ Difficulty with orgasm ___ Mood swings ___ Painful intercourse ___ Headaches ___ Loss of muscle tone ___ Forgetful ___ Vaginal bleeding any time ___ Difficulty concentrating ___ Vaginal bleeding after sex ___ Difficulty sleeping ___ Vaginal discharge


A. Notifier: Secoya Health

B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn’t pay for D. below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have

good reason to think you need. We expect Medicare may not pay for the D. below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

98940-GA

Maintenance/Wellness Care

WHAT YOU NEED TO DO NOW: • Read this notice, so you can make an informed decision about your care. • Ask us any questions that you may have after you finish reading. • Choose an option below about whether to receive the D. listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.

☐ OPTION 1. I want the D. listed above. Secoya Health may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, I will receive reimbursement directly.

☐ OPTION 2. I want the D. listed above, but do not bill Medicare. Secoya Health may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

☐ OPTION 3. I don’t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature: J. Date:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/11) Form Approved OMB No. 0938-0566

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