Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone

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Lambert Thornton
5 years ago
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1 Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn t Cntact in case f Emergency: Phne #: Insurance Cmpany: Subscriber Number: Grup #: If plicy is in Parent r Spuse s name please give his r her Name & birth date: Address f Insured if different frm abve: Emplyer Occupatin: Have yu ever received Chirpractic Care? Yes N If yes, when? Name f mst recent Chirpractr: 1. Reasns fr seeking chirpractic care: Primary reasn: Secndary reasn: 2. Previus interventins, treatments, medicatins, surgery, r care yu ve sught fr yur cmplaint: 3. Past Health Histry: A. Previus illnesses yu ve had in yur life: B. Previus Injury r Trauma: Have yu ever brken any bnes? Which? C. Allergies: D. Medicatins: Medicatin Reasn fr taking 1

2 E. Surgeries: Date Type f Surgery F. Females/ Pregnancies and utcmes: Pregnancies/Date f Delivery Outcme 4. Family Health Histry: Assciated health prblems f relatives: Deaths in immediate family: Cause f parents r siblings death Age at death 5. Scial and Occupatinal Histry: A. Jb descriptin: B. Wrk schedule: C. Recreatinal activities: D. Lifestyle (hbbies, level f exercise, alchl, tbacc and drug use, diet): I have read the abve infrmatin and certify it t be true and crrect t the best f my knwledge, and hereby authrize this ffice f Chirpractic t prvide me with chirpractic care, in accrdance with this state's statutes. If my insurance will be billed, I authrize payment f medical benefits t fr services perfrmed. I further understand that I am financially respnsible fr all charges whether r nt paid by insurance, and in the event any amunt due remains unpaid after a bill is rendered, I agree t pay a cllectin penalty f 25% f the then principle balance and any ther fees, including reasnable attrney fees. I hereby authrize the dctr t release all infrmatin necessary t secure payment as wed. Patient r Guardian Signature Date 2

3 HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Ntice f Privacy describes hw we may use and disclse yur prtected health infrmatin (PHI) t carry ur treatment, payment r health care peratins (TPO) fr ther purpses that are permitted r required by law. Prtected Health Infrmatin is infrmatin abut yu, including demgraphic infrmatin that may identify yu and that related t yur past, present, r future physical r mental health r cnditin and related care services. Use and Disclsures f Prtected Health Infrmatin: Yur prtected health infrmatin may be used and disclsed by yur physician, ur staff and thers utside f ur ffice that are invlved in yur care and treatment fr the purpse f prviding health care services t yu, pay yur health care bills, t supprt the peratins f the physician s practice, and any ther use required by law. Treatment: We will use and disclse yur prtected health infrmatin t prvide, crdinate, r manage yur health care and any related services. This includes the crdinatin r management f yur health care with a third party. Fr example, we wuld disclse yur prtected health infrmatin, as necessary, t a hme health agency that prvides care t yu. Fr example, yur health care infrmatin may be prvided t a physician t whm yu have been referred t ensure that the physician has the necessary infrmatin t diagnse r treat yu. Payment: Yur prtected health infrmatin will be used, as needed, t btain payment fr yur health care services. Fr example, btaining apprval fr a hspital stay may require that yur relevant prtected health infrmatin be disclsed t the health plan t btain apprval fr the hspital admissin. Healthcare Operatins: We may disclse, as needed, yur prtected health infrmatin in rder t supprt the business activities f yur physician s practice. These activities include, but are nt limited t, emplyee review activities and training f medical students. In additin, we may use a sign-in sheet at the registratin desk where yu may be asked t sign yur name and indicate yur physician. We may als call yu by name in the waiting rm when yur physician is ready t see yu. We may use r disclse yur prtected health infrmatin, as necessary, t cntact yu t remind yu f yur appintment. We may use r disclse yur prtected health infrmatin in the fllwing situatins withut yur authrizatin. These situatins included as required by law, public health issues, cmmunicable diseases, health versight, abuse r neglect, fd and drug administratin requirements, legal prceedings, law enfrcement, crners, funeral directrs, and rgan dnatin. Required uses and disclsures under the law, we must make disclsures t yu when required by the Secretary f the Department f Health and Human Services t investigate r determine ur cmpliance with the requirements f Sectin NO SHOW Appintment Fees, Cancellatin Plicy and what yu shuld knw abut yur insurance: Yu must cancel within 4 hurs f yur scheduled appintment. Any cancellatin that is less than 4 hurs until scheduled appintment, will be charged $ A NO SHOW appintment fee f $25.00 will be charged if patient des nt call t cancel appintment. An additinal $25.00 will be billed fr each additinal 15 minutes set aside fr yur appintment whether at yur request r as agreed upn as part f yur treatment plan. Yu are respnsible fr understanding yur insurance. C-pays are always due at the time f treatment. Any balance due after c-pays and/r insurance rate adjustments are the respnsibility f the patient r guardian theref. We will attempt t bill yur insurance as a curtesy t yu, ur patient; but yu the patient r the guardian theref are always the respnsible party. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW. With yur signature belw yu authrize us, ur successrs r assigns, t call yu r send a text message t yu at any number yu prvide r at any number at which we reasnably believe we can cntact yu, including calls t mbile, cellular, r similar devices, and including calls using autmatic telephne dialing systems and/r prerecrded messages, fr any lawful purpse, including but nt limited t: (1) suspected fraud r identity theft; (2) btaining infrmatin necessary r desirable; (3) yur accunt transactins r servicing; and (4) cllectin n yur accunt. Numbers yu prvide include numbers yu give us and/r numbers frm which yu call us, ur successrs r assigns. Yu agree t pay any fee(s) r charge(s) that yu may incur fr incming calls frm us, and/r utging calls t us, t r frm any such number, withut reimbursement frm us. Yur signature als states that yu have read and understand the abve HIPPA plicy and ffice guidelines regarding N Shw appintments, yur insurance, and appintment cancellatin plicy. Yu may revke this authrizatin, at any time, in writing, except t the extent that yur physician r the physician s practice has taken an actin in reliance n the use r disclsure indicated in the authrizatin; therwise this frm remains in effect frthwith. Signature f Patient r Guardian Date Privacy Office Signature Printed Name 3

4 PATIENT HISTORY FORM Symptm 1 Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 2 Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 4

5 Symptm 3 Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 4 Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 5

6 Symptm 5 Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 6 Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 6

Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Occupation Employer

Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Occupation Employer Milham Family Chirpractic Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex M F Marital Status M S D W Date f Birth Age Occupatin Emplyer Referred by: Have yu ever received Chirpractic