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Hogan Chiropractic Services

.................................Wayne A Hogan DC................................. ............... And Standard Process Whole Food Supplements

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New Patient Documents
This page contains documents that we use to establish a new patient case.  They are in a downloadable PDF format.  Please feel free to download them and fill them out completely before your first visit.  There are five (5) forms to fill out, plus  our Financial Policy to be signed, HIPPA Privacy Information Forms, the Informed Consent To Treatment form (please bring this one with you) ,and a Welcome Letter that helps put things in perspective.
 
Welcome Letter 
Welcome to HOGAN CHIROPRACTIC SERVICES and chiropractic care using the diagnostic technique of Applied Kinesiology.In general, this approach allows us to make a very in-depth FUNCTIONAL evaluation of the human body.  We strive to help you understand the messages (symptoms) your body is sending you by, "reading" your BODY LANGUAGE in a way that you can understand, so that you can become an active part in your quest for BETTER HEALTH!
 
             Welcome Letter
 

                             Initial Incident Encounter Information

In this age of insurance scrutiny and electronic data availability, our office strives to collect the information that will be required to participate in these new, soon-to-be-globally-available digital health records.  Please try your best to give us this information as completely as possible.  In the long run, it will make your health care plan more precisely tailored to your individual needs.





                               Confidential Patient Case History

There are two pages to this case history form.  Please fill them out with careful attention to detail.  The more completely we understand your condition, the better we will be able to help you work your way back to health!
Even though some items may seem redundant, please strive to fill out each form completely.
            
 
 

 
Substance Survey Form

It is very important for us to know about the medications and supplements you take, as well as some of your bad habits as well:  how much coffee you drink, whether you drink soda or diet soda, eat chocolate...  We want to know about all the things you take in to your body!
 
       Substance Survey Form 

 

RAND Health Medical Outcomes Study:
                       36-Item Short Form Survey Instrument
  
Developed by the RAND Health Organization, this tool is a little tedious, but very important for us to determine your health status when you begin care, measure your improvements as you complete care, and map out the areas of continuing concern for your ongoing care.  Please take the time and trouble to complete this form as carefully and as accurately as you can.  This may be the most important form you fill out, after the Case History Form! 
 
                                  SF-36 Health Survey
 

 Standard Process 7 Day Diet Diary

One of the most important keys in our understanding of your overall health is to have a very clear picture of what fuel you're putting into your body.  And even more importantly, what food you're NOT putting in to your body.  Please write down EVERYTHING you put in your mouth for one week.  Also, in the margins, make a note of any symptoms you experience.  Sometimes we can see patterns of reactions that aren't obvious when we rely on our memory alone!  For your convenience, if you can, print it on two sides.
 
          Daily Record Of Food Intake (7 Day Diet Diary)
 

  
 
 
Financial Policy

We are committed to providing you with the best possible care, and affordable prices.  Your clear understanding of our Financial Policy is important to our professional relationship.  Please ask if you have any questions about our fees, Financial Policy, and your responsibilities. 
 
                                    Our Financial Policy
 
  
 HIPPA Privacy Information Form

In today's information overload culture, many protections to privacy have been incorporated into our lives.  This two page form is one more required bit of information that you must be aware of concerning our responsibilities in communicating with you and your rights in controlling who may have access to your Personal Health Information.
 

 
Informed Consent To Chiropractic Care 

 Our sincere goal is to help you have clear understanding of Chiropractic Health Care and the functional status of your health.  This standard form is to be signed once you feel confident that we have evaluated you and your condition thoroughly enough to administer chiropractic care with confidence, knowing that you have no Relative Contraindications or Absolute Contraindications to Chiropractic Manipulative Therapy.

Ion Cleanse Footbath Checklist


 We are pleased to offer a complimentary Ion Cleanse Footbath as the concluding experience in our New Patient intake prodedure.  Giving you a chance to see the kinds of sludge and toxins you accumulate in your body, the footbath helps to begin your journey towards a healthy, happy insides.

The advances in technology and materials mean that there are fewer and fewer reasons NOT to enjoy this fascinating technology.

 

       IonCleanse Contraindications Checklist


 


Functional Rating Index


 A New Valid and Reliable Instrument - The One Minute Index
Although chiropractors may continue their traditional emphasis on the structure of the body, it is vitally important for them to understand the everyday functioning and pain of the patient and to have a method of quantifying those items. Patient-centered outcome instruments are now widely recognized as valuable assessment tools for researchers, doctors, patients and payors. In fact, a patient’s self-evaluation may be more accurate than the clinical, biochemical, or physiological indexes that we have traditionally relied upon (Epstein 1990).

  

                                                                Functional Rating Index