Online Forms

Eisman Chiropractic Clinic offers our patient form(s) online so you can complete it in the convenience of your own home or office.

This let's us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

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Download the necessary form(s), print it out, and fill in the required information.
You are able to fill these forms out through your device and email them to jeismandc@gmail.com. Alternatively, please complete your forms and bring them in with you to your appointment.

New Patient Health History Form

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Preferred Method of Contact

HomeCell

Sex

Marital status

Soc Sec

Occupation

Employer

Emergency Contact Name

Emergency Contact Phone

Primary Care Physician

Primary Care Physician Phone

Referred From

FamilyFamily DoctorInternetLectureWebsite

PAST HISTORY

Have You Ever Had

TBCancerEpilepsyDiabetesArthritisAsthmaHeart DiseaseSinusKidneyHepatitisHIV-AidsPolioThyroid DiseaseAlcohol/Drug Dependency

Other:

Previous Chiropractic Care (Where And When)

Surgery

Previous Spine Injuries

Are You Pregnant?

YesNo

Last Menstrual Period

Alcohol

NeverOccasional (3x/Week)DailyFormer

Smoke

NeverOccasional (3x/Week)DailyFormer

List Vitamins/Medications

Race:

Black/AfricanWhiteHispanic Or LatinoAsianAmerican IndianPacific Islander

Ethnicity:

HispanicNon-Hispanic

INSURANCE

The Clinic Policy Requires Payment Arrangements Be Made on The First Visit. If you were involved in an Auto Accident or Work Comp Case, please inform The Eisman Clinic Team Member at the Front Desk.
INSURANCE INFORMATION-Please check below

NO INSURANCE/CASHPERSONAL INSURANCEAUTO INSURANCEWORK COMP

IF AUTO OR WORK COMP:

Insurance Company

Claim Number

Policy Holder

Adjuster

Adjuster’s Phone No.

Attorney

Attorney’s Phone No.

Date of Injury

IF WORK COMP:

Employer/Company Name

Company Address

Work Comp Ins Co.

Claim Number

Adjuster

Adjuster’s Phone No.

Attorney

Attorney’s Phone No.

IF PERSONAL MEDICAL INSURANCE:

Insurance Company

Policy Number

Secondary Ins.

Relationship

SelfSpouseMotherFather

Spouse's Birth Date

Spouse’s Soc Sec

Financial Policy-I understand and agree that my insurance policies are an arrangement between the insurance company and myself. The clinic, as a courtesy to you, will bill your insurance company. I authorize my insurance company to pay the Eisman Clinic, P.C. directly. All monies paid will be applied to my account. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will be immediately due and payable. Some plans may not cover the entire bill or may refuse to pay. You will be responsible to pay any unpaid balance. If you do not have insurance, then all services are paid per visit or in advance. Please speak to the doctor about payment/family plans. I authorize the Eisman Clinic, P.C. to release all records as needed for collecting bills for services that I may or will incur. Records may be sent via mail or electronically (fax or email) as deemed by the eisman clinic. I understand and agree to the financial policies of the Eisman Clinic, P.C.

Signature

Date

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HIPAA Consent Form

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I acknowledge that Eisman Clinic’s “Notice of Privacy Practices” has been provided to me.

I understand I have a right to review Eisman Clinic’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Eisman Clinic.

The Notice of Privacy Practices for Eisman Clinic is also provided on request at the main administration desk of this practice. This Notice of Privacy Practices also describes my rights and Eisman Clinic’s duties with respect to my protected health information.

Eisman Clinic reserves the right to change the privacy practices that are described in the Notice of Privacy Practice. I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, ask for one at the time of my next appointment or accessing Eisman Clinic.

I have the right to revoke this consent, in writing, except to the extent that Eisman Clinic has taken action in reliance on this consent.

PATIENT ACKNOWLEDGEMENT

By subscribing my name below, I acknowledge receipt of a copy of this notice, and my understanding and my agreement to its terms.

Signature of Patient or Personal Representative

Name of Patient or Personal Representative

Description of Personal Representative’s Authority

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Consent to Treatment Form

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To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

The nature of the chiropractic adjustment.
The primary treatment we use as a Doctor of Chiropractic is spinal manipulative therapy or adjustments. We will use that procedure to treat you. The procedure may be by hand or with a mechanical instrument placed upon your body in such a way as to move your joints. That may cause an audible “pop” or “click”, much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis/Examination/Treatment
In addition to spinal manipulation, we may use a variety of other therapies and examination procedures. As a part of the analysis, examination, and treatment, you are consenting to any and all of the following procedures:

spinal manipulative therapy/adjustment instrument spinal/extremity adjustment
vital signs muscle strength testing
palpation trigger point therapy
orthopedic testing range of motion testing
basic neurological exam flexion distraction traction
postural analysis testing hot/cold therapy
x-ray/radiographic studies electric muscle stimulation
rehabilitation/core strengthening nutritional analysis/therapy
manual traction adjustment laser therapy
low level laser therapy ultrasound
spinal segmental traction neuromuscular re-education
mechanical massage

The material risks inherent in chiropractic adjustment.
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation (CMT) and therapy. However studies have shown that any observed association between vertebral artery dissection (VAD) and stroke with CMT is likely attributed to patients with an undiagnosed VAD who seek care for neck pain and headache before the onset of a stroke. As a result we examine our patients thoroughly before initiating any treatment to be sure that treatment is appropriate. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.

Chiropractic is a safe and comfortable form of health care for most people. If a potential risk is identified, you will be informed and offered either treatment or a referral to the appropriate health care specialist for evaluation and care.

Soreness: It is not uncommon to experience some localized soreness following a manipulation. This type of soreness is usually minor and occurs most often following the initial few visits. It is similar to the soreness you may experience after exercise.

Fracture: Fractures caused from spinal manipulation are extremely rare, so rare that an actual number of incidences per manipulation have never been determined. Patients suffering from bone weakening conditions like Osteoporosis are in a higher risk category. Alternative forms of spinal manipulation are utilized for this type of patient.

TIA/Stroke: Spinal manipulation is clearly one of the safest forms of treatment for cervical spine pain. The incidence of serious adverse events, stroke, or death is very rare. Researchers found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. The risk was as low as 1.46 adverse events per 10,000,000 manipulations. The risk of artery dissection was as low as 1 per 5,846,381 cervical manipulations.

What about NSAIDs and Tylenol? To put it in perspective, non-steroidal anti-inflammatory drugs (NSAIDs) kill approximately 16,500 people per year annually in the US. And Tylenol toxicity is now the leading cause of liver failure in the US. Spinal manipulation is safer than NSAIDs by a factor of several hundred times.

Note: Screening tests are performed when necessary to rule out high-risk patients. Alternative spinal adjusting is utilized when necessary to minimize potential risks.

Ruptured/Herniated Disc: include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns.

Other complications: There have been some reports of herniated or ruptured discs caused by spinal manipulation. Alternative spinal adjusting methods are often utilized to minimize the risk and help the patient recover from serious disc-related pain.

The availability and nature of other treatment options:

Other treatment options for your condition may include:
- Self-administered, over-the-counter may include:
- Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
- Hospitalization
- Surgery

If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

The risks and dangers attendant to remaining untreated or undertreated.
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Early intervention to restore normal function and compliance with the treatment program are both essential in an effort to prevent the condition from progressing to a chronic pain state.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Early intervention to restore normal function and compliance with the treatment program are both essential in an effort to prevent the condition from progressing to a chronic pain state.

I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. I have discussed it with the doctor(s) at the Eisman Clinic and/or
and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.

NOTE: This informed consent form exceeds the minimal requirements and standards in the chiropractic profession.

Patient Name (please print):

Patient Signature:

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Symptoms List Form

Download Form Digital Form

NECK PAIN

How often

ConstantFrequentIntermittentOccasional

Severity

MildMild to ModerateModerateModerate to SevereSevere

Movement

InflexibilityRestricted MovementStiffness

Sensation

CrawlingDeadNumbPins and NeedlesPricklyTingling

Pain Types

BurningDullExcruciatingNumb ache typePoundingPulsatingSharpShootingStabbingStingingThrobbingAchy

Area

Generalized InLocalized InMigrating ToRadiating ToShooting Into

Region

ShoulderArmForearmWristHandFingers

Aggravate

CoughingSneezingStraining at BMsLooking downLooking upRecliningRepetitious MovementSleepingTurning the head leftTurning the head rightEmotional UpsetStressFlashing Lights

Other

Relieve

Having AdjustmentsTaking AdvilTaking AspirinTaking Pain PillsTaking TylenolExercisingRecliningRestingSittingSleepingColdHeatThrobbing Heat LinimentNothingHot ShowersRubbing Mineral Ice

Other

MID BACK PAIN

How often

ConstantFrequentIntermittentOccasional

Severity

MildMild to ModerateModerateModerate to SevereSevere

Movement

InflexibilityRestricted MovementStiffnessSpasmCramps

Sensation

CrawlingDeadNumbPins and NeedlesPricklyTingling

Pain Types

BurningDullExcruciatingNumb ache typePoundingPulsatingSharpShootingStabbingStingingThrobbingElectric ShockHurtingExquisiteScaldedSoreAchy

Area

Generalized InLocalized InMigrating ToRadiating ToShooting Into

Region

Aggravate

CoughingSneezingStraining at BMsRecliningRepetitious MovementsSleepingEmotional UpsetStressFlashing LightsWalkingGetting Out of BedExercisingDrivingCarryingBreathing

Other

Relieve

Having Adjustments Taking AdvilTaking AspirinTaking Pain PillsTaking TylenolExercisingRecliningRestingSittingSleepingColdHeatThrobbing Heat LinimentNothingHot ShowersRubbing Mineral Ice

LOWER BACK PAIN

How often

ConstantFrequentIntermittentOccasional

Severity

MildMild to ModerateModerateModerate to SevereSevere

Movement

InflexibilityRestricted MovementStiffnessSpasmCramps

Sensation

CrawlingDeadNumbPins and NeedlesPricklyTingling

Pain Types

AchyBurningDullExcruciatingNumb ache typePoundingPulsatingSharpShootingStabbingStingingThrobbing

Area

Generalized InLocalized InMigrating ToRadiating ToShooting Into

Region

HipButtockThighKneeLegFootToes

Aggravate

Bowel MovementsCoughingSneezingStraining at BMsArising From A ChairBendingCarryingClimbing A LadderClimbing StairsDrivingExercisingGetting In and Out Of A CarGetting Out Of BedLiftingPullingPushingRecliningSittingStandingStoopingWalking UphillWalkingEmotional UpsetStress

Other

Relieve

Having AdjustmentsTaking AspirinTaking Pain PillsTaking TylenolExercisingRecliningRestingSittingSleepingColdHeatNothingMassaging by handMassaging with a vibratorTub soakingStretching

Other

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Tues	9:00 am-1:00 pm
Wed	9:00 am-1:00 pm 3:00 pm-6:00 pm
Thurs	9:00 am-1:00 pm 3:00 pm-6:00 pm
Fri	9:00 am-1:00 pm
Sat	By Appointment
Sun	Closed

New Patient Health History Form

PAST HISTORY

INSURANCE

IF AUTO OR WORK COMP:

IF WORK COMP:

IF PERSONAL MEDICAL INSURANCE:

HIPAA Consent Form

Consent to Treatment Form

Symptoms List Form

Office Hours

Get in Touch

Contact Info

Online Forms

New Patient Health History Form

PAST HISTORY

INSURANCE

IF AUTO OR WORK COMP:

IF WORK COMP:

IF PERSONAL MEDICAL INSURANCE:

HIPAA Consent Form

PATIENT ACKNOWLEDGEMENT

Consent to Treatment Form

Symptoms List Form

NECK PAIN

MID BACK PAIN

LOWER BACK PAIN

Office Hours

Get in Touch

Contact Info

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