Phone: (386) 337-3884

Corrective Chiropractic care for spinal misalignments, postural issues, and sports injuries.

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"I tell everybody about the program because it really works."

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A non-surgical, drug-free approach to severe neck and back pain.

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New Patient Application

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.

   Male   Female
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No
   Yes   No

   Yes   No   
  
Yes   No   
  
Yes   No    
Never

   Yes   No

   Yes   No

Family Health History

Personal Health History

   Yes   No

lot of details  
just the bottom line?

Reduce Pain  
Do Everyday Activities Normally
Improve Overall Appearance
Maintain Optimal Health & Wellness
   Yes   No

Fear
Time
Budget
Trust

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.

1. Does your pain interfere with your normal work inside and outside the home?
Work Normally
Unable to work at all
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9
10

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
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9
10

3. Does your pain interfere with your traveling?
Travel anywhere I like
Only travel to see doctors
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9
10

4. Does your pain affect your ability to sit or stand?
No problems
Can not sit/stand at all
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8
9
10

5. Does your pain affect your ability to lift overhead, grasp objects or reach for things?
No problems
Can not do at all
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10

6. Does your pain affect your ability to lift objects off the floor, bend, stoop or squat?
No problems
Can not do at all
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9
10

7. Does your pain affect your ability to walk or run?
No problems
Can not walk/run at all
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8
9
10

8. Has your income declined since your pain began?
No decline
Lost all income
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10

9. Do you have to take pain medication every day to control your pain?
No medication needed
Need medication throughout the day
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8
9
10

10. Does your pain force you to see doctors much more often than before your pain began?
Never see doctors
See doctors weekly
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11. Does your pain interfere with your ability to see the people who are important to you?
No problem
Never see them
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10

12. Does your pain interfere with recreational activities and hobbies?
No interference
Total interference
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9
10

13. Do you need the help of your family and friends to complete everyday tasks?
Never need help
Need help all the time
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2
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8
9
10

14. Do you now feel more depressed, tense, or anxious than before your pain began?
No depression/tension
Severe depression/tension
1
2
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9
10

15. Are there emotional problems caused by your pain that interfere with your family, social and or work activities?
No problems
Severe problems
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2
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9
10

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
DELAND CHIROPRACTIC & SPINAL DECOMPRESSION

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.

Mail
Email
Telephone
Text Message

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

HIPAA Compliant Authorization for Release of Patient Information

Section II: Authorization for Release of Patient Information: I, or my authorized representative, hereby authorize:


and their respective employees, agents and subcontractors to disclose my Personal Health Information (PHI) and Insurance Record to: Deland Chiropractic & Spinal Decompression.

Section III: Specific Information to be Released:

Please release my Medical Record from:
Please release my entire Medical Record, including patient histories, office notes (excluding psychotherapy notes; including test results, radiology studies, films, referrals, consults, billing records, insurance records sent by other health care providers.
Other:
Reason for release of information:
Include:

Alcohol/Drug Treatment
Mental Health Information
HIV-Related Information
At the request of the individual
Other:

Section IV: I understand that Section 460.413 (1) (m), Florida Statutes, and Board of Chiropractic Medicine Rule 64B2-17.006 require chiropractic physicians to retain records and xrays for at least four years. Therefore, a chiropractic physician receiving a request for a patient’s x-ray within that four-year period must retain the x-ray and provide a copy of it in lieu of the original x-ray. I, further, understand that Section 456.057 (18), Florida Section 457.057 (16), Florida Statutes, authorizes a health care practitioner or patient records owner furnishing copies of reports or records or making the reports or records available for digital scanning pursuant to this section to charge no more than the actual cost of copying, including reasonable staff time, or the amount specified in administrative rule by the appropriate board, or the department when there is no board. The Board of Chiropractic Medicine Rule 64B-17.0055, Florida Administrative Code, authorizes chiropractic physicians to charge patients $1.00 per page for the first 25 pages, and 25 cents for each page in excess of 25 pages. The Board of Chiropractic Medicine Rule defines the reasonable costs of reproducing x-rays, and such other special kinds of records as the actual costs. The phrase reasonable cost; means the cost of the material and supplies used to duplicate the record, as well as the labor costs and overhead costs associated with such duplication. The Board of Chiropractic Medicine Rule 64B-17.0055, Florida Administrative Code, authorizes chiropractic physicians to charge people who are not patients authorized to seek copies of my patient records $1.00 per page. I understand that the HIPAA regulations authorize the practice to charge the cost of labor and hardware onto which the records are electronically copied unless the Board of Chiropractic Medicine sets lower costs. I understand that there is no cost for transmitting the electronic records by email. This authorization will be in effect for five years from the date signed, unless you indicate a shorter period below:

If an authorized representative is making this request, please provide your information below and attach certifying documentation of your status as the authorized representative, such as a Power of Attorney or Guardianship papers.
AUTHORIZED REPRESENTATIVE

I am confirming that this form accurately reflects my wishes. In addition, I have kept a for my records.





Disclaimer

DeLand Chiropractic & Spinal Decompression complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. DeLand Chiropractic & Spinal Decompression does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.