Patient Health History

Transcription

1 Patient Health History Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Last Name Work By providing my address, I authorize my doctor to contact me via the address(es) provided. Which address would you like us to use to communicate with you? (check one) Home Work Contact Method (check one) Primary Phone Secondary Phone Mobile Phone Home Work Date of Birth / / Age Gender (check one) Male Female Unspecified Marital Status (check one) Single Married Other SSN Employment Status (check one) Employed FT Student PT Student Other Retired Self Employed Race (check one) White Black/African American Hispanic American Indian/Alaskan Native Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Native Hawaiian or other Pacific Island Samoan Guamanian or Chamorro Other I choose not to specify Multi-Racial (check one) Yes No Unknown Ethnicity (check one) Hispanic or Latino Not Hispanic or Latino I choose not to specify Preferred Language (check one) English Spanish American Sign Language Chinese French German Tagalog Vietnamese Italian Korean Russian Polish Arabic Portuguese Japanese French Creole Greek Hindi Persian Urdu Gujarati Armenian I choose not to specify Verification Question (choose only one question by circling the question, then give the answer to that question) What is the name of your favorite pet? In what city were you born? What high school did you attend? What is your favorite movie? What is your mother s maiden name? On what street did you grow up? What was the make of your first car? When is your anniversary? Verification Answer to the Chosen question: Answers must be at least 6 characters.

2 Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoker If yes, how often do you smoke: Current every day smoker Current sometimes smoker If yes, what is your level of interest in quitting smoking? No interest Very Interested Current medications, including frequency and dosage if known. If there are no current medications, check here: Start Date 1) 5) 2) 6) 3) 7) 4) 8) Start Date List any known allergies you have had to any medications. If no allergies are known, check here: 1) 3) 2) 4) Briefly list your main health problems: Has any doctor diagnosed you with Hypertension presently? Yes No If yes, describe: Has any doctor diagnosed you with Diabetes presently? Yes No If yes, what kind? Type I Type II If yes to Diabetes, was your blood lab-work test for hemoglobin A1c > 9.0%? Yes No Not Sure If yes, other comments regarding Diabetes: Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes No To be performed by clinic staff: Height: inches Weight: pounds BP: /

3 New Patient Data Date: Title: Mr. Mrs. Ms Miss (check one) Who is your medical doctor? Tele# First Name: Middle Initial: Last Name: What do you prefer to be called? Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Date of Birth: / / Sex: Male Female Social Security Number: - - Marital Status: Single Married Other Employment Status: Employed Full Time Student Part Time Student Other (check one) Spouse Data Is your spouse a patient in the clinic? Yes No First Name: Middle Initial: Last Name: Home Phone: ( ) - Work Phone: ( ) - Employer Data Name: Address : City: State: Zip Code: Emergency Contact Contact Name: Contact Phone: ( ) - Attorney Information Who is your attorney? Telephone # Date of accident:

4 Is it okay to call you at work? Yes No How did you hear about our clinic? Or who referred you? Family member Attorney Internet web site Health class Friend Yellow Pages Billboard Brochure Physician Newspaper ad TV Commercial Direct mail ad Employer Sign on building Radio Other If you selected Yellow Pages please indicate which Yellow Pages: If you selected family member, friend, or physician please enter their name below: If you selected other please describe Medical Conditions: Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Surgeries: Appendectomy Cardiovascular procedure Cervical disc procedure Hysterectomy Joint replacement Laminectomies Radical prostatectomy Transuretheral prostate surgery Allergies: Eggs Fish and Shellfish Milk or Lactose Peanut Soy Sulfites Wheat/Gluten Social History: Caffeine used occasionally Caffeine used often Chew tobacco occasionally Chew tobacco often Drink alcohol occasionally Drink alcohol often Exercise not at all Exercise occasionally Exercise often Experience stress occasionally Experience stress often Smoke 1 pack or less per day Smoke more than 1 pack a day Wear seat belts always Wear seat belts never Wear seatbelts usually Family History: Arthritis (parent) Arthritis (sibling) Cancer (parent) Cancer (sibling) Cholesterol (parent) Cholesterol (sibling) Diabetes (parent) Diabetes (sibling) Heart problems (parent) Heart problems (sibling) High blood pressure (parent) High blood pressure (sibling) Psychiatric (parent) Psychiatric (sibling) Stroke (parent) Stroke (sibling) Thyroid (parent) Thyroid (sibling) Substance Use: Alcohol (past) Alcohol (present) Amphetamines (past) Amphetamines (present) Barbiturates (past) Barbiturates (present) Cocaine (past) Cocaine (present) Crystal Meth (past) Crystal Meth (present) Heroine (past) Heroine (Present) Marijuana (past) Marijuana (present) Male Children: Under 6 years Under 10 years Under 19 years Female Children: Under 6 years Under 10 years Under 19 years Occupational Activities: Administration Business owner Clerical/secretarial Computer user Construction Daycare/childcare Executive/legal Food service industry Health care Heavy equipment operator Heavy manual labor Home services Household Light manual labor Manufacturing Medium manual labor

5 By using the key below, indicate on the body diagram where you are experiencing the following symptoms: # = Numbness X = Burning / = Stabbing 0 = Pins & Needles + = Dull Ache Describe your symptoms: When did your symptoms start? Month Day Year How did your symptoms begin? How often do you experience your symptoms? Constantly Frequently (76-100% of the day) (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) What describes the nature of your symptoms? Sharp Dull ache Numb Shooting Burning Tingling Stabbing How are your symptoms changing? Getting better Not changing Getting worse During the past 4 weeks, indicate the average intensity of your symptoms: (0 = None to 10 = Unbearable) 0 None Unbearable During the past 4 weeks, how much has pain interfered with your normal work (including both work outside the home and housework): Not at all A little bit Moderately Quite a bit Extremely During the past 4 weeks, how much of the time has your condition interfered with your social activities? All of the time Most of the time Some of the time A little of the time None of the time In general, would you say your overall health right now is. Excellent Very good Good Fair Poor Who have you seen for your symptoms: No one Other Chiropractor Medical Doctor Physical Therapist Other

6 What treatment did you receive for your symptoms? Adjustments Physical Therapy Medication Surgery Other When did you receive this treatment? In the last month 2 3 months ago 3 6 months ago 6 months to 1 year ago 1 2 years ago 2 5 years ago 5 10 years ago What tests have you had for your symptoms? X-rays MRI CT Scan Other When were these tests done? In the last month 2 3 months ago 3 6 months ago 6 months to 1 year ago 1-2 years ago 2 5 years ago 5 10 years ago Have you had similar symptoms in the past? Yes No If you have seen treatment in the past for the same or similar symptoms, who did you see? This Office Other Chiropractor Medical Doctor Physical Therapist Other What is your occupation? Professional/Executive White Collar/Secretarial Tradesperson Laborer Homemaker Full-time Student Retired Other If you are not retired, a homemaker or a student, what is your work status? Full-time Part-time Self-employed Unemployed Off work Other

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10 Review of Systems: Have you had trouble with any of the following: Cardiovascular: No Respiratory: No Allergic/Immunologic: No Present Past No Present Past No Present Past No Poor Circulation Asthma Hives High Blood Pressure Tuberculosis Immune Disorder Aortic Aneurism Shortness of Breath HIV/AIDS Heart Disease Emphysema Allergy Shots Heart Attack Cold/Flu Cortisone Use Chest Pain Cough/Wheezing High Cholesterol Pace Maker Gastrointestinal: No Jaw Pain Ears/Nose/Throat: No Present Past No Irregular Heartbeat Present Past No Gallbladder Problems Swelling of Legs Dizziness Bowel Problems Hearing Loss Constipation Sinus Infection Liver Problems Genitourinary: No Nosebleed Ulcers Present Past No Sore Throat Diarrhea Kidney Disease Difficulty Swallowing Nausea/Vomiting Lower Side Pain Bleeding Gums Bloody Stools Burning Urination Poor Appetite Frequent Urination Blood in urine Eyes: No Kidney Stone Present Past No Musculoskeletal: No Glaucoma Present Past No Double Vision Hematologic/lymphatic: No Blurred Vision Gout Present Past No Arthritis Hepatitis Joint Stiffness Blood Clots Integumentary: No Muscle Weakness Cancer Present Past No Osteoporosis Easy Bruising Skin Ulcers Broken Bones Easy Bleeding Skin Disease Joints Replaced Fevers/Chills/Sweats Eczema Psoriasis Rashes Endocrine: No Neurologic: No Present Past No Present Past No Thyroid Disease Stroke Psychiatric: No Diabetes Seizures Present Past No Hair Loss Head Injury Depression Menopausal Brain Aneurysm Anxiety Disorder Menstrual Problems Numbness Unusual Stress Severe Headaches Pinched Nerves Parkinson's Disease Constitutional: No Carpal Tunnel Present Past No Spinning/Balance Weight Loss/Gain Energy Level Problem Difficulty Sleeping

11 PATIENT RESPONSIBILITY SHEET INSURANCE: Kinnard Chiropractic verifies each patient s benefit coverage however we do not guarantee payment from your insurance company. In the event that the carrier has provided Kinnard Chiropractic with incorrect information you will be responsible for any services you have received. Please note that in the event your account is placed in collections, you will be charged 40% service charge on the balance at the time the account is turned over to collections. BY YOUR SIGNATURE BELOW YOU ARE ACKNOWLEDGING THAT YOU HAVE READ AND UNDERSTAND THE TERMS AS STATED. (Signature of Client) (Date) (Signature of Kinnard Chiropractic Rep) (Date) Patient s or Authorized Person s Signature: I authorize the release of any medical or other information necessary to process my insurance claim. This is to serve as a long-term authorization card. Signed Date Insured s Or Authorized Person s Signature: I authorize payment of medical benefits to Dr. Jeffery Kinnard for the services described on the insurance form. This authorization is to apply to all occasions of service until it is revoked in writing. Signed Date CASH: I agree and understand that I am Responsible to pay Kinnard Chiropractic for all services rendered to me by Kinnard Chiropractic. I will pay at the time of services unless other arrangements have been made in advance between Kinnard Chiropractic and myself. Please note that in the event your account is placed in collections, you will be charged 40% service charge on the balance at the time the account is turned over to collections. Signed Date ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years. Print Name Date Parent, Guardian or Parent s legal representative Signed I give Kinnard Chiropractic permission to discuss and release my medical history and information with the following individuals. Relationship Date Relationship Date Signature Date

12 I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures, including examination test, diagnostic x-ray(s) and physical therapy techniques, on me (or on the patient named below for which I am legally responsible) which are recommended by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working for, or serving as back-up for the doctor of chiropractic named below. I understand that, as with any health care procedure there are certain complications, which may arise during a chiropractic adjustment. Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, Homer's syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some type 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. I do not expect the doctor to be able to anticipate all risk and complications and I wish to rely on the doctor to exercise judgment during the course of procedure(s) which the doctor feels, based upon the facts then known, are in my best interest. I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed. I have read ( ) or have had read to me ( ) the above explanation of the chiropractic adjustments and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest to undergo the chiropractic treatment recommended. Having been informed of the risks, I hereby give my consent to the treatment. I intend this consent for to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Facility Name of Doctor Treating this Patient Kinnard Chiropractic Jeffery Kinnard, D.C Hwy 44 W Christian Grause, D.C. Inverness, Fl DO NOT SIGN UNTIL YOU HAVE READ ABD UNDERSTAND THE ABOVE Printed Name: Signature of Patient: Signature of Patients' Representative: Date: Date: Date: Tel Fax 2611 Hwy 44 W. Inverness, Fl 34453

13 Patient: AUTHORIZATION AND ASSIGNMENT KINNARD CHIROPRACTIC Authorization to Release Information You are authorized to release any information concerning my physical condition to any insurance company, physician or my attorney in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequences thereof. Assignment of Cause of Action I hereby assign and transfer to you all benefits, causes of action and rights to file a lawsuit that exist in my favor against any insurance company, including all automobile policies that provide No-Fault/PIP benefits, and I authorize you to prosecute said action either in my name or your name. It is understood that in consideration of this assignment, you will restrain from attempts and efforts to collect the amounts owed directly from me, until after reasonable efforts have been made to collect the sums due from the insurance company (or companies) contractually obligated, and I understand that whatever amounts you do not collect from insurance proceeds, I personally owe you, and agree to pay in a current manner. If any portion of this assignment is deemed inconsistent with F.S , said portion shall be rewritten in order to conform with Florida law and to full effect to the intended purpose of this agreement. Authorization to Pay Directly to Doctor In consideration of the chiropractic services rendered and to be rendered, I authorize and direct payment to Kinnard Chiropractic, any sum I now or hereafter owe him out of the proceeds of any settlement of my case, and/or by any insurance company benefits obligated to reimburse me for the charges for his services or otherwise obligated to make payment to me or him based in whole or in part upon the charges made for his services. If my current policy prohibits direct payment to the doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows: Payee: Kinnard Chiropractic.2611 Hwy 44W, Inverness, FL Acknowledgement and Understanding I hereby acknowledge that I am receiving or about to receive health care services at Kinnard Chiropractic, and that I have been advised that the doctor(s) providing the services is/are willing to wait for Payment for these services, provided that there continues to be a reasonable chance that payment will be made either by insurance proceeds or out of the settlement of a liability claim. I understand that if it is determined either: (a) That there is no insurance company obligated to pay for the services, or if the insurance company involved refuses to acknowledge an assignment to the doctor(s) or make other provisions for the protection of the interest of the doctor(s) or; (b) If a liability claim exists, and my attorney refuses to agree to protect the interest of the doctor(s), or if I have not engaged the services of an attorney, then payment for services rendered by the doctor(s) at Kinnard Chiropractic will be made on a current basis and my bill paid in full as soon as my liability claim it settled or the passage of three month from my last treatment, whichever occurs first. Signature of Patient/Responsible Party Date