WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com

Welcome to WellnessOne of Eastgate! We are excited to help you on the journey to your best health.

Please take the time to fill out this simple health questionnaire prior to your first appointment. Answering as completely as you can will help us to serve you better.

WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
First Name
Last Name
Address
City
Zip Code
Home Phone
Cell Phone
Other Phone
Email
Gender
SSN
Birthdate
Height
Weight
Shoe Size
Marital Status
Spouse
Names/Ages
Num. of Children
Emergency Contact
Relationship
Phone
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
How did you hear about us?
Family Physician
Physician Phone
Date of Last Visit
Work Status
Employer
Employer Phone
Occupation
Employer Address
Have you missed work due to this injury?
Missed work start date
Return or anticipated return date
Extend. Health Cov.

Primary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip Code
State
Employer
Emp. Phone
Secondary
Company
Policy #
Group #
Who Carries this Policy?
Insured's:
Name
Birth Date
Gender
Patient Address
Phone
Address
City
Zip Code
State
Employer
Emp. Phone
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
The symptoms that have prompted you to seek care today include:
Have you seen other doctor(s) for this condition?
Prior Interventions
What is the condition related to?
When did your problem first start?
Have you had this condition before?
Does the pain radiate or travel to other parts of the body?
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
Does anyone from your family suffer from the same condition?
What makes the condition worse?
What makes the condition better?
Does this condition affect employment?
Does this condition affect recreation?
Does this condition affect household?
Does this condition affect personal?
Does this condition affect sleep?
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
What else should we know about your current condition?
Rate the severity of your pain from 0 to 10

No Pain
Excruciating Pain
Pain Duration
Current Medications
Supplements
Sleep Position
Hours of sleep per night (1-24)
Have you had x-rays in the last six months?
I realize that x ray examinations may be hazardous to an unborn child. I certify to the best of my knowledge I am not pregnant.
Last Cycle:
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
Type of Pain
Front Head

Type of Pain
Front Face

Type of Pain
Front Left Jaw

Type of Pain
Front Right Jaw

Type of Pain
Front Right Neck

Type of Pain
Front Left Neck

Type of Pain
Front Left Chest

Type of Pain
Front Right Chest

Type of Pain
Front Right Ribs

Type of Pain
Front Left Ribs

Type of Pain
Front Abdomen

Type of Pain
Front Pelvis

Type of Pain
Front Right Hip

Type of Pain
Front Left Hip

Type of Pain
Front Right Thigh

Type of Pain
Front Left Thigh

Type of Pain
Front Right Knee

Type of Pain
Front Left Knee

Type of Pain
Front Right Lower Leg

Type of Pain
Front Left Lower Leg

Type of Pain
Front Right Ankle

Type of Pain
Front Left Ankle

Type of Pain
Top of Right Foot

Please specify specific areas

Type of Pain
Top of Left Foot

Please specify specific areas

Type of Pain
Front Right Shoulder

Type of Pain
Front Left Shoulder

Type of Pain
Front Right Upper Arm

Type of Pain
Front Left Upper Arm

Type of Pain
Front Right Elbow

Type of Pain
Front Left Elbow

Type of Pain
Front Right Forearm

Type of Pain
Front Left Forearm

Type of Pain
Front Right Hand

Please specify specific areas

Type of Pain
Front Left Hand

Please specify specific areas

Type of Pain
Front Right Wrist

Type of Pain
Front Left Wrist

Type of Pain
Back of Head

Type of Pain
Back Right Neck

Type of Pain
Back Left Neck

Type of Pain
Upper Back

Type of Pain
Back Right Shoulder

Type of Pain
Back Left Shoulder

Type of Pain
Mid-Back

Type of Pain
Back Right Ribs

Type of Pain
Back Left Ribs

Type of Pain
Lower Back

Type of Pain
Back Right Hip

Type of Pain
Back Left Hip

Type of Pain
Back Right Glute

Type of Pain
Back left Glute

Type of Pain
Back Right Thigh

Type of Pain
Back Left Thigh

Type of Pain
Back Right Knee

Type of Pain
Back Left Knee

Type of Pain
Back Right Lower Leg

Type of Pain
Back Left Lower Leg

Type of Pain
Back Right Ankle

Type of Pain
Back Left Ankle

Type of Pain
Bottom of Right Foot

Please specify specific areas

Type of Pain
Bottom of Left Foot

Please specify specific areas

Type of Pain
Back Right Upper Arm

Type of Pain
Back Left Upper Arm

Type of Pain
Back Right Elbow

Type of Pain
Back Left Elbow

Type of Pain
Back Right Forearm

Type of Pain
Back Left Forearm

Type of Pain
Back Right Hand

Please specify specific areas

Type of Pain
Back Left Hand

Please specify specific areas

Type of Pain
Back Right Wrist

Type of Pain
Back Left Wrist

WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
Sensory
Integumentary
Endocrine
Genitourinary
General
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
Personal Illness History
Surgery/Trauma History
WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
Social History
Family History
Mother
Age
Age at Death
Health
Illness
Father
Age
Age at Death
Health
Illness
Sister
Age
Age at Death
Health
Illness
Brother
Age
Age at Death
Health
Illness

WellnessOne of Eastgate
15100 SE 38th Street Suite 305B
Bellevue, WA 98006
(425) 289-0092
frontdesk@wellnessoneofeastgate.com
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?

Not Interested
Very Interested
How do you want us to handle your problem?
Please read the following carefully before signing.

PRIVACY POLICIES

 

It is our desire to communicate to you that we take the Federal HIPAA (Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your personal health information seriously. We want you to know about our policies and procedures that we have developed in order to make sure your health information will not be shared with anyone who does not require it. We will use and communicate your health information only for the purposes of providing your treatment, obtaining payment, and conducting health care operations. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

HOW YOUR HEALTH INFORMATION MAY BE USED

To Provide Treatment: We will use your health information within our office for clinical office procedures to optimize scheduling and coordination of care between the doctors of this clinic and any other clinician you may be seeing at the same time.

 

To Obtain Payment: We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forums filed for you in the mail or sent electronically. We will be sure only to work with companies with a similar commitment to the security of your health information.

 

To Conduct Health Care Operations: Your health care information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. Health information may be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews.

 

For Patient Reminders: Because we believe regular care is very important to your general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up with your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventative and curative care. They may be postcards, folding postcards, letters, telephone or text reminders, or electronic reminders such as e-mail (unless you inform us you do not wish to receive these reminders).

 

Abuse or Neglect: We will notify government authorities if we believe a patient is the victim of abuse, neglect, or domestic violence. We will make this disclosure only when we are compelled by our ethical judgement, when we believe we are specifically required or authorized by law, or with the patient's agreement.

 

Public Health and National Security: We may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security.

 

For Law Enforcement: As permitted by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including under certain circumstances, if you are a victim of a crime or in order to report a crime.

 

Family, Friends, and Caregivers: We may share your health information with those you tell us will be hel[ing you with your home hygiene, treatment, medications, or payment. We will be sure to ask your permission first. In the case of an emergency where you are unable to tell us what you want, we will use our very best judgement when sharing your health information only when it will be important to those participating in your care.

 

To Coroners, Funeral Directors, and Medical Examiners: We may be required by law to provide information to coroners, funeral directors, and medical examiners for the purposes of determining a cause of death and preparing for a funeral.

 

Health Care Research: Advancing health care knowledge often involves learning from the careful study of the medical history of prior patients. Formal review and study of health history as a part of a research study will happen only under the ethical guidance, requirements, and approval of an institutional review board.

 

Authorization to Use or Disclose Health Information: Other than is stated above or where Federal, State, or local law requires use, we will not disclose your health information other than with your written authorization. You may revoke said authorization in writing at any time.

YOUR RIGHTS AS A PATIENT

Restrictions: You have the right to require restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.

 

Confidential Communications: You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present, or through mailed communications that are sealed. We will make every effort to honor your reasonable requestes for confidential communications.

 

Inspect and Copy Your Health Information: You have the right to read, review, and copy your health information, including your complete chart and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.

 

Amend Your Health Information: You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. Please provide us with your request in writing and describe your reason for the change. Your request may be denied if the health information records in question were not created by our office, are not part of our records, or if the records containing your health information are determined to be accurate and complete.

 

Documentation of Health Information: You have the right to ask us for a description of how and where your health information was used by our office for any reason other than for treatment, payments, or health operations. Please let us know in writing the time period for which you are interested. We may need to charge you a reasonable fee for your request.

 

Request a Paper Copy of This Notice: You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time. We are required by law to maintain the privacy of your health information and to provide you and your representative this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice, but we do reserve the right to change the terms of our Notice. If we change our privacy practice, we will be sure all of our patients receive a copy of the revised Notice. You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised.

 

INFORMED CONSENT TO CHIROPRACTIC CARE

 

I hereby authorize physicians and staff at WellnessOne to treat my condition as deemed appropriate. The doctor will not be held responsible for any pre-existing, medically diagnosed condition(s).

 

I certify that the information included in this new patient paperwork is correct to the best of my knowledge. I will not hold my doctor or any staff member of WellnessOne responsible for any errors or omissions that I may have made in the completion of this form.

* Please read and agree to the terms
Signature
Today's Date: 20 Mar 2019