Personal Information

Full Name *

Email *

Do we have your permission to send you information from the practice via email? *

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Phone *

Address

City

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Birth Date *

Current Age *

Biological Gender

Marital Status

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How did you first hear about our office?

Please list your top five health concerns or primary reasons for visiting our office. *

What would optimal health look like for you? ( ie: What would you be able to do, experience or feel differently ) *

What are the life goals that optimal health could assist you with? *

How much time have you spent with our website, Facebook page, YouTube channel or talking to friends about our office?

In helping you solve problems and reach optimal health we work thru HIDN®. HIDN® involves Hormonal balance, Immune strength, Detoxification efficiency and Neurological connection. We are proud that HIDN® is unique enough to be awarded a US trademark. The next slides will have questions related to these topics.

Hormonal balance:

Please describe the timing and ease with which you get to sleep and stay asleep, if you snore, if you wake feeling rested and if you use any sleep aids.

Does your energy fluctuate during the day and does it change with eating? When is it best and worst?

Ladies - Please describe any issues with hair loss or hair growth, low or excessive sex drive, temperatute changes ( cold, hot, hot flashes ), changes in breast tissue, changes in skin or vaginal dryness

Ladies please describe cycle regularity or lack thereof, any ovaries removed as well as current and past history of birth control.

Ladies : Please describe number of pregnancies ___, live births___ ages of children ________miscarriage or abortion history ____

Men - Please describe any prostate problems, erectile difficulties, increases in belly fat or decreases in muscle mass and increases or decreases in sex drive.

Please describe any heart palpitations, ringing of the ears, changes in pulse, skin, temperature or weight

Have you been diagnosed with any of the following?

Hypothyroidism

Hyperthyroidism

Type 1 Diabetes

Type 2 Diabetes

High Blood pressure

Kidney Disease

Addison's Disease

Cushing’s Disease?

All please list any hormone supplements, patches, creams, pellets or injections that you receive

When and where were your last set of labs completed?

Immune strength :

Is there any family history of autoimmune conditions? (thyroid disease, Hashimoto's or Graves, Celiac Disease, MS, Lupus, rheumatoid arthritis, type one diabetes etc.)

Please estimate antibiotic use in childhood and adulthood

Describe any recurrent infections or fevers

Describe any vaccine reactions

Describe any tick bites or other bites or diagnosis or suspicion of Lyme disease

Describe any possible or known exposures to mold

Describe any known or suspected environmental or dietary allergies or sensitivities

Describe any issues with bloating, burping, belching, indigestion, stomach or abdominal cramping, constipation or diarrhea or other digestive or abdominal concerns

Detoxification efficiency :

Please list all of your current medications and the reason for taking each

Please list all current supplements

Please list your current use of tobacco, alcohol, coffee, soda,energy drinks, artificial sweeteners, marijuana and recreational drugs

Please list past usage and time frames of alcohol, marijuana, and recreational drugs

Please list number of non tooth-colored fillings, number of root canals and any dental implants or fixtures both present and in the past

Describe any significant exposures to paint, polishes, bleaches, disinfectants, perfumes, hair sprays, cosmetics, exhausts, gas or diesel fumes

Describe any health changes after moving to a new home or taking a new job

Neurological connection:

Describe any sports, work or automobile injuries, your age at the time and any complications or lasting effects. Please list any confirmed or suspected concussions.

Describe all surgeries, your age at the time and any complications or lasting effects

Please describe the location of any scars, piercings or tattoos not associated with surgeries above as these can affect tissue pull and energy flow

Do you have any of the following?

neck pain

mid back pain

low back pain

tailbone / pelvic pain

left wrist

left elbow

left shoulder

left hip

left knee

left ankle/ foot

right wrist

right elbow

right shoulder

right hip

right knee

right ankle/ foot

Which of the items you selected is the most concern for you?

Which of the following are difficult for you?

Dressing

Bending

Lifting

Exercise

Standing

Walking

computer work

Driving

getting in / out of a vehicle

Pushing

Pulling

arms overhead

sexual intercourse

Are there any additional restricted activities beyond those listed? Also, do you have any comments about the items you selected above?

Please describe any issues with mood, memory, concentration or decision making

Please note: if you have any issues with mood, memory, anxiety, attention, concentration, or decision making, please print and complete our Brain Localization form on the New Patients page and bring it with you to your visit or email it to info@WintersWellness.com. Also it is suggested you discuss with my staff how a " brain map " or qEEG can help us help you.

List any past emotional traumas or stress as well as any ongoing stress you feel could be affecting your health

HIPAA Notification

Pursuant to HIPAA regulation, for any of our patients over the age of 18, we are unable to give any information, whether medical or financial, to any family member. This includes information about your spouse or your child, 18 years of age or older. Please read below and consider carefully who you want to have access to your medical/billing information.

I give Winters Wellness Center permission to leave phone messages regarding my medical care and/or lab results at the following numbers. My medical care/billing account may be discussed with the person(s) listed below.

We will not leave messages with anyone except the patient or legal guardian. We will not leave any information on an answering machine. We will not leave messages on a voicemail unless we have your written permission to do so.

1. How We Leave Messages: I give permission to leave phone messages on (check all that apply):

a. My cellular phone voice mail

b. My home phone answering machine

c. My office/work voicemail

2. I give permission for the following people to have access to my records: (please type their name, relationship to you, and contact number)

Patient’s Responsibilities Policy

1. If you have any updated information since your last visit (such as, change in name, address, phone number, or insurance) please notify the front desk staff when you arrive for your appointment.

2. Self-pay patients are required to make payment arrangements or pay in full on the day of your office visit.

3. If you have a previous balance on your account, you must pay this amount or make payment arrangements before your office visit.

4. You agree, in order for us to serve your account, notify you of information pertaining to your account, or for the purposes of collection, that we may contact you by telephone at any number provided by you including wireless telephone numbers. Methods of contact may include the use of pre-recorded and artificial voice messages, text messaging and/or use of an automated dialing service.

5. Any appointments that are not cancelled before 24 hours of appointment time, will be billed to patient account at 50% of the service fee. If you miss an appointment and do not contact us prior to that appointment, you will be billed at 100% of the service fee.

6. Medicare is the only insurance company Dr. Winters is in network with and Medicare only pays on acute spinal care. For non Medicare patients no insurance is filed or reports written. However, Health Savings Accounts can be used for payment. The only services which are eligible for a super bill to file yourself are exams and standard chiropractic adjustments that do not fall under the maintenance definition from Medicare and which applies to all insurance companies. That definition is : “Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.” (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A)

Notice of Privacy Practices

I have read, understand, and agree to the Notice of Privacy Practices for protected health information that was provided to me by Winters Wellness Center.

MEDICARE/INSURANCE uniform of assignment, release of information and financial disclosure

MEDICARE ASSIGNMENT OF BENEFITS: I hereby assign or transfer payment benefits made to me and my behalf to Winters Wellness Center for any services furnished to me by this facility. I further agree that I am responsible for payment or charges incurred by me that are not covered by my insurance or for which my insurance has paid me.

RELEASE OF INFORMATION: I hereby authorize Winters Wellness Center to release information acquired during the course of my examination or treatment to my primary care doctor or to an appropriate insurance carrier. If Medicare patients, I further authorize release, of the Center of Medicare Services and its agents, any information needed to determine benefits payable for related charges.

PERMISSION TO CONTACT: I hereby authorize Winters Wellness Center to use the provided contact information to send me personal messages and messages intended for all patients, current and previous to the practice, including - but not limited to - upcoming event announcements, practice closure alerts, and other information.

I, the undersigned, agree to all of the policies provided to me at this time.

New Patient Acceptance Signature *

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