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Patient Health History and Application for Treatment

Would you like email and text message appointment reminders?
Gender
Employment
Marital Status*
Please select one option
Are you pregnant?

List of Current Medications/Supplements:

(You may submit a list on a separate piece of paper)

What is your approximate height and weight?

Musculoskeletal Case History

Fill in the bubble closest to your problem area. Please fill out a new box for each complaint. Circle answers below.If additional diagrams are needed for more complaints, please ask the front desk for another sheet.

Draw over image
At its worst, how would you rate your level of pain?
How often does it bother you?
What does it feel like?
Was this the result of an auto accident?
Does it radiate/travel down your arm/leg?
Draw over image
At its worst, how would you rate your level of pain?
How often does it bother you?
What does it feel like?
Was this the result of an auto accident?
Does it radiate/travel down your arm/leg?

Past Medical History and Review of Systems

Please mark what you have now and in the past

General
Skin
Head
Ears
Nose
Mouth
Throat
Neck
Breasts
Lungs
Heart
Blood
Endocrine
Gastrointestinal
Genitourinary
GYN/OB
Menstrual Flow
Neurologic
Psychiatric
Immunization/Vaccination
Musculoskeletal
Blood Type
Past Medical History (Check only ones you have had in the past)
Family History - List any of the diseases listed above which run in your family

Father

Mother

Brother(s)
Sister(s)

Grandfather (maternal)
Grandfather (paternal)
Grandmother (paternal)
Grandmother (maternal)
Social History
Smoking
Alcohol
Caffeine (Coffee, Tea, Cola)
Exercise
Mental Work
Physical Work

Consent to Treat, Fees, and HIPAA Information


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.

Professional Services and Release of Information. I voluntarily hereby authorize the doctor and whomever he may designate as his assistants to administer treatment, physical examination, X-ray studies, laboratory procedures, chiropractic care, medical care, or any clinic services that he/she deems necessary in my case; and I further authorize him/her to disclose all or any part of my (patient's) record to any person or corporation which is or may be liable under a contract to the clinic or to the patient or to a family member or employer of the patient for all or part of the clinic's charge, including, and not limited to, hospital or medical services complaints, insurance companies, worker compensation carriers, welfare funds, or the patient's employer. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

Insurance Payment Authorization & Agreement. I authorize payment of insurance benefits directly to this clinic or doctors. I understand that I am responsible for all costs of healthcare services, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable. If your insurance policy is not presented to us at the time of service, you have 30 days to submit it to our office. If your insurance policy, that is effective at the time of service, is not given to our office within 30 days from your date of service, we will not bill your insurance company and you will be responsible for all the charges from your care. If you have more than one insurance policy, please makes sure to give our staff ALL effective insurance cards. If you have a Medicaid and a primary insurance, please make sure we receive both cards to have your claims processed properly by both insurance companies.

Timely Payment and Fee Agreement. Fees are payable at the time examination, X-rays, or any other treatments are received, unless other arrangements are made in advance. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform the office of any changes to the information provided.

Consent for Treatment. As with all health services, there may be risks involved with receiving treatment in this or any other office. Please rest assured that all precautionary and indicated measures, diagnostic

tests, and relevant orthopedic testing will be performed, with your permission, to minimize this risk. By signing below you authorize treatment and acknowledge that you understand these inherent risks, with the understanding of the information offered above, and consent to allow necessary services and treatment according to the doctor's recommendations.

The nature of the manipulative therapy or adjustment. A treatment that may be used by a Doctor of Chiropractic or Physical Therapist is spinal and extremity manipulative therapy. The Doctor will use that procedure to treat you. The Doctor may use their hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible "pop" or "click," and you may feel a sense of movement. As a part of the analysis, examination, and treatment, you are consenting to spinal and extremity manipulative therapy, palpation, range of motion testing, orthopedic testing, basic neurological testing, muscle strength testing, postural analysis, and physiotherapy procedures.

The material risks inherent in chiropractic adjustment. As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, rib strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The Doctor 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 the Doctor's attention, it is your responsibility to inform the Doctor.

The probability of those risks occurring. Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination. Stroke and/or vertebral artery dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of a vertebral artery stroke. Other complications are also generally described as rare.


The availability and nature of other treatment options. Other treatment options for your condition may include: Self-administered over-the-counter analgesics and rest; Medical care and prescription drugs such as antiinflammatories, muscle relaxants and pain-killers; Physical Therapy; Hospitalization; Surgery. If you chose to use any of these 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. Potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. This may complicate treatment making future recovery and rehabilitation more difficult and lengthy.


I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment. I have discussed it with my treatment provider 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. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING.  By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms").  Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein.  Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

  1. THE E-SIGNATURE SERVICE.
    • Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy.  The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
    • Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law.  The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18.  In order to use the Services, you must be identified by a unique email address.  Two or more natural persons may not use the Services using the same set of credentials.
    • Appropriate Conduct. You agree not to use the Services for any illegal or unauthorized purpose and agree to comply with all applicable domestic and international laws, statutes, ordinances, and regulations relating thereto.  You further warrant and agree that your use of the Services does not violate any relevant laws, regulations, legislation, or other applicable rules of any applicable authority.  You are solely responsible for determining the suitability of the Services for your particular purpose.

You agree not to (attempt to) modify, adapt, or hack the Services.  You agree not to engage in any activities that would create a false association with the Services.  You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

  • Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.
  1. WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
    • Warranty Disclaimer. The Services are provided to you without warranty of any kind, whether express or implied.  REVIEW WAVE SPECIFICALLY EXCLUDES AND DISCLAIMS WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUIET ENJOYMENT, NON-INRFINGEMENT, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE OF TRADE.

USE OF THE SERVICES IS DONE AT YOUR OWN RISK.  REVIEW WAVE ASSUMES NO RESPONSIBILITY FOR ANY LOSS OF YOUR DATA OR CONTENT OR ANY ERRORS OR OMISSIONS IN ANY CONTENT, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRECT AS A RESULT OF THE USE OF THE SERVICE.

  • Damages Limitation. REVIEW WAVE SHALL NOT BE LIABLE FOR ANY INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA, LOSS OF GOODWILL, THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS ARISING OUT OF OR IN CONNECTION WITH THESE TERMS, OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT REVIEW WAVE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, EVEN IF A LIMITED REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.
  • Limitation of Liability. IN NO EVENT WILL REVIEW WAVE'S AGGREGATE LIABILITY ARISING OUT OF OR IN CONNECTION WITH THESE TERMS AND YOUR USE OF THE SERVICES EXCEED THE AMOUNT RECEIVED BY REVIEW WAVE FROM YOU IN THE SIX (6) MONTH PERIOD PRECEDING THE ACTION GIVING RISE TO THE CLAIM.  THE LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BARGAIN BETWEEN REVIEW WAVE AND YOU.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
  • German Customers. Review Wave's liability to you if you are domiciled in Germany is limited as follows:
    • Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
    • If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.
  1. CUSTOMER OBLIGATIONS.
    • Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations.  You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
    • Customer Acknowledgements and Warranties. By using the Service you consent to do business electronically.  You hereby represent and warrant to Review Wave that: a.) you have all requisite rights and authority to use the Services under these Terms and to grant all applicable rights herein; b.) you are solely responsible for all use of the Services associated with your credentials; c.) you are solely responsible for maintaining the confidentiality of your account credentials; d.) your agrees to immediately notify Review Wave of any unauthorized use of your account of which it becomes aware; e.) you agrees that Review Wave will not be liable for any losses incurred as a result of a third party's use of your Account, regardless of whether such use is with or without its knowledge and consent; f.) you will use the Services for lawful purposes only and subject to these Terms; g.) any information you submits to Review Wave is true, accurate, and correct; and h.) you will not attempt to gain unauthorized access to the Services, other accounts, computer systems, or networks under the control or responsibility of Review Wave through hacking, cracking, password mining, or any other unauthorized means.

Review Wave is not a party to any Document executed via the Services.


Review Wave has no control over the contents of any Document.  Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.


Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.


Review Wave is not responsible for determining how long any contracts, documents, and other records are required to be retained or stored under any applicable laws, regulations, or legal or administrative agency processes. Further, Review Wave is not responsible for or liable to produce any of your Documents or other documents to any third parties.


With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements.  You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.


You agree that you are solely responsible for the accuracy and appropriateness of instructions given by you and your personnel in relation to the Services.


You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

  1. TERM AND TERMINATION.
    • Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased.  Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason.  Review Wave may notify you prior to any such termination or suspension at its discretion.
    • Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.
  1. INDEMNIFICATION.
    • Indemnity. You agree to release, defend, indemnify, and hold Review Wave, affiliates, and subsidiaries, and their officers, directors, employees, and agents, harmless from and against any claims, liabilities, damages, losses, and expenses, including, without limitation, reasonable legal and accounting fees, arising out of or in any way connected with your access to or use of the Service, or your violation of any term or warranty contained within these Terms.
  1. DOCUMENT RETENTION AND DATA PROTECTION.
    • Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so.  Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
    • Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

  • Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services.  Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.
  1. GENERAL.
    • Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
    • Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
    • Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion.  Your use of the Service signifies your agreement to these changes.  You will be notified of material changes by notice on the website or via e-mail.
    • Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave.  Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion.  These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
    • Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

 

  • Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email:  support (at) reviewwave.com

Business Information

Multicare Health Clinic

Schedule Now

3930 Stadium Dr
Sioux City, IA 51106
Phone Number: (712) 276-4325

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Location

Email Us

Office Hours

Our Regular Schedule

Primary Location

Monday:

8:00 am-6:00 pm

Tuesday:

8:00 am-6:00 pm

Wednesday:

8:00 am-6:00 pm

Thursday:

8:00 am-6:00 pm

Friday:

8:30 am-2:00 pm

Saturday:

Closed

Sunday:

Closed

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Testimonials

Testimonials

  • "My shoulder and neck feel so much better. I now have the knowledge, motivation, desire and tools to keep up the exercises."
    Barb B.
  • "Dr. Sneller helped. I haven't been feeling dizzy anymore."
    Belinda B
  • "My company encouraged all of us employees to get screened at Multicare. I didn't know what to expect. It was easy and I learned so much. The orthotics they prescribed really help me to feel more stable and confident at work."
    Jim J.
  • "I'm a runner. When I wasn't able to run due to leg problems, I was devastated. But a consultation at Multicare Health Clinic identified the problem and after some adjustments, stimulation treatments and therapy, I'm running again!"
    Lisa L.
  • "Not only is my pain level down to zero, but what I'm really thrilled with, is that I have normal feeling in my hands."
    Jill L.
  • "There couldn't be a better physical therapy team in Siouxland! Not only did my knee feel so much better after six weeks, but I feel like I made new friends."
    Karla K.
  • "At night my right hand would go painfully numb at least 2-3 times where I could not sleep. Now, I don't have that pain and can get a full night sleep."
    Janet D.
  • "After an accident at work I didn't think I'd ever get relief from my aching shoulder. But, the doctors at Multicare gave me adjustments and physical therapy and now I feel normal again."
    Cliff C.
  • "I'm so glad my sister referred me to Multicare! My elbow hasn't felt this good in a long time. Thanks to the great physical therapy team there."
    Ellen E.
  • "After my consultatin with the doctors at Multicare Health Clinic, I understand how to address my balance issues."
    Anna A.
  • "I wasn't able to use my hand the way I should. After working with Dr. Sneller and the physical therapy team, I can use my hand again."
    Ivy I.
  • "I'm now a believer now! I didn't think chiropractic could help my foot problems. But after meeting with Dr. Pistello and Dr. Dave for a few weeks, I'm feeling so much better!"
    Gino G.
  • "I wasn't able to use my hand the way I should. After working with Dr. Sneller and the physical therapy team, I can use my hand again."
    Henry H.
  • "After my knee surgery I was asked where I wanted to do my physical therapy, I chose Multicare Health Clinic and I'm so glad I did! Dr. Steve and the therapy assistants (Sara and Megan) are fabulous! They know what they're doing and they all really seemed to care about my recovery. I'm feeling fantastic! I'll definitely go back again whenever I need therapy or adjustments."
    Sheri J.
  • "I now can go a full week without pain and headaches."
    Luke W.
  • "I leave here feeling confident that I have the resources to manage my pain and live normally, and that's priceless."
    Alycen V.
  • "Being able to present my back pain to three different professions in one place and knowing that they are working together to make me better is very comforting."
    Charlie P.