Neighborhood Chiropractic and Acupuncture LLC Registration and History
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- Antony Davidson
- 5 years ago
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1 PATIENT INFORMATION Registratin and Histry Last Name: Date: First Name Middle Initial: Address: City: State: Zip: Cell Phne Number: Hme Phne Number: May we send yu crrespndence? Yes N Sex: M F Prnun Preference: He She They Ze Single Married Dmestic Partnership Divrced Widwed Minr Birthdate: Age: Occupatin: Patient Emplyer and/r Schl: Wrk Phne Number: May we call yu at wrk? Yes N Wh is respnsible fr this accunt? Self Insurance Cmpany Guardian Name: Wh d we thank fr referring yu? In Case f Emergency, Cntact Name: Hme Phne: Primary Care Physician: Relatinship: Wrk Phne: Phne Number: ACCIDENT INFORMATION Is this cnditin due t an accident? Yes N Date f Accident: Type f Accident: Aut Wrk Hme Other: T whm have yu made reprt f yur accident? Aut Insurance: Emplyer Wrker Cmp. Other: Claim # (if applicable): Attrney Name (if applicable): PATIENT CONDITION Reasn fr yur visit When did yur symptms appear? Is this cnditin getting prgressively wrse? Yes N Dn t Knw Mark an X n the picture where yu have pain, numbness, r tingling. Areas f yur bdy that need special attentin? Yes N Describe: Rate the severity f pain frm 1 (least pain) t 10 (mst pain): Type f pain: Sharp Dull Thrbbing Numbness Aching Shting Burning Tingling Cramps Stiffness Swelling Other (describe): Lcatin f numbness r tingling: Hw ften d yu have these symptms? Is it cnstant r des it cme and g? Des it interfere with yur: Wrk Sleep Daily Rutine Recreatin Activities that are painful: Sitting Standing Walking Bending Lying Dwn Lvemaking Other Are yu experiencing any ther symptms in yur bdy? 6040 SE Belmnt Ste Prtland, OR (503)
2 HEALTH HISTORY What treatment have yu already had fr yur cnditin? Medicatins Surgery Physical Therapy Chirpractic Services Nne Other: Name f ther practitiners wh have treated yu fr this cnditin: Have yu ever had chirpractic care? Yes N Massage? Yes N Acupuncture? Yes N Date f Last: Physical Exam: X-ray (Area): Lab Wrk: Spinal Exam: MRI, CT-Scan r Bne Scan: Place a mark in the bx t indicate if yu have had any f the fllwing: AIDS/HIV Eating Disrder Allergies t ils/ Easy Bruising fragrance Emphysema Anemia Epilepsy/ seizures Arm/ Hand Pain Fainting Arthritis Fibrids Asthma Fibrmyalgia Bleeding Disrders Glaucma Bld clts Gnrrhea Cancer Headaches Cataracts Hearing Difficulty Chemical Dependency Heart Disease Chicken Px Hepatitis Cmmunicable disease Herniated Disc Cntacts Hernia Diabetes High Chlesterl Dizziness Jaw Prblems Other cnditin nt listed abve: Kidney Disease Leg/Ft Disease Liver Disease Lw Back Prblems Lw Bld Pressure Multiple Sclersis Neck Pain/ Stiffness Open cuts r sre Osteprsis Pacemaker Parkinsn s disease Pinched Nerve Pneumnia Pli Prsthesis Psychiatric Care Respiratry Prblems Exercise: Nne Mderate Daily Heavy Describe: Wrk Activity: Sitting Standing Light Labr Heavy Labr Habits: Smking: # Cigarettes r Packs/day? Hw many years? Were yu ever a smker? Yes N Alchl: # Drinks/week? Caffeine Drinks # Cups/Day? High Stress Level Reasn: Wmen: Are yu pregnant? Yes N Due Date: Number f children: Injuries/ Surgeries (Include a date and a descriptin): Falls: Head Injuries: Brken Bnes: Dislcatins: Surgeries: Car Accidents: Family Health Histry Has anyne in yur immediate family had the fllwing cnditins? (including grandparents): Heart Disease Strke Cancer Diabetes Other Describe any selected: Other Family Diseases: Rheumatid Arthritis Rheumatic Fever Sciatica Shulder Prblems Skin Disease Strke Thyrid Prblems Transient Ischemic Attack (TIA) Tuberculsis Tumrs/ Grwths Typhid Ulcers Varicse Veins Venereal Disease Medicatins: Fr what cnditin? Vitamins/Herbs/Supplements: Allergies: Is there anything else yu wuld like t share with yur dctr? T the best f my knwledge, this infrmatin is cmplete and crrect. I understand it is my respnsibility t infrm my dctr/clinic if there are any changes t my health r persnal infrmatin. Signature Printed Name Date 6040 SE Belmnt Ste Prtland, OR (503)
3 Acupuncture Health Histry Name: (first) (middle) (last) Date: / / Date f Birth: / / Age: Gender: M/F/X/ Prnun: Marital status: S M DP D W Successful health care and preventive medicine are nly pssible when the practitiner has a cmplete understanding f the patient physically, mentally and emtinally. Please cmplete this questinnaire as thrughly as pssible. Print all infrmatin and indicate areas f cnfusin with a questin mark. Thank yu. 1. When and where did yu last receive health care? Fr what reasn? 2. Please identify the health cncerns that have brught yu in rder f imprtance belw: Cnditin Past Treatment a. Hw des this cnditin affect yu? b. Hw des this cnditin affect yu? c. Hw des this cnditin affect yu? d. Hw des this cnditin affect yu? 3. If applicable, please list any fds, drugs, r medicatins yu are hypersensitive r allergic t (please include reactin): 4. Please list any medicatins (prescribed and ver-the-cunter), vitamins, herbs, and supplements yu are currently taking: 5. D yu have any reasn t believe yu may be pregnant? N Yes, hw far alng? 6. D yu have any infectius diseases? N Yes, please identify: Name: Date f Birth: Date: pg 1
4 Acupuncture Health Histry 7. Family Histry: Father Mther Brthers Sisters Spuse Children Check thse applicable: Age (if living) Health (G=Gd, P=Pr) Cancer Diabetes Heart Disease High Bld Pressure Strke Mental Illness Asthma/Hay fever/hives Kidney Disease Age (at death) Cause f Death 8. Height: Weight: Currently: Past Maximum: When? 9. Bld Pressure: What is yur mst recent bld pressure reading? / When was this reading taken? 10. Childhd Illness (please circle any that yu have had): Scarlet Fever Diphtheria Rheumatic Fever Mumps Measles German Measles Chicken Px 11. Immunizatins (please circle any that yu have had, r had reactins t): Pli Tetanus Rubella/Mumps/Rubella Pertussis Diphtheria Hib Hepatitis B Others: 12. Hspitalizatins and Surgeries: Reasn When Reasn When 13. X-Rays/CAT Scans/MRI s/nmr s/special Studies: Reasn When Reasn When 14. Emtinal/Mental (please circle any that yu experience nw and underline any that yu have experienced in the past): Md Swings Nervusness Mental Tensin Pr Cncentratin Memry Prblems Seasnal Depressin 15. Energy and Immunity (please circle any that yu experience nw and underline any that yu have experienced in the past): Fatigue Slw Wund Healing Chrnic Infectins Chrnic Fatigue Syndrme Chrnic Swllen Glands 16. Head, Eye, Ear, Nse, & Thrat (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Impaired Visin Eye Pain/Strain Glaucma Glasses/Cntacts Tearing/Dryness Dizziness Impaired Hearing Ear Ringing Stuffiness Lss f Smell Earaches Headaches/Migraines Sinus Prblems Nse Bleeds Frequent Sre Thrats Teeth Grinding TMJ/Jaw Prblems Hay Fever Head Trauma Name: Date f Birth: Date: pg 2
5 Acupuncture Health Histry 17. Respiratry (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Pneumnia Frequent Cmmn Clds Difficulty Breathing Emphysema Persistent Cugh Pleurisy Brnchitis Asthma Tuberculsis Wheezing Shrtness f Breath Other: 18. Cardivascular (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Heart Disease Chest Pain Swelling f Ankles High/Lw Bld Pressure Palpitatins/Fluttering Strke Heart Murmurs Rheumatic Fever Varicse Veins 19. Gastrintestinal (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Ulcers Changes in Appetite Nausea/Vmiting Cnstipatin Diarrhea Epigastric Pain Passing Gas Heartburn Belching Gall Bladder Disease Liver Disease Hepatitis B r C Hemrrhids Abdminal Pain 20. Genit-Urinary Tract (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Kidney Disease Painful Urinatin Frequent UTI Frequent Urinatin Kidney Stnes Impaired Urinatin Bld in Urine Frequent Urinatin at Night 22. Female Reprductive/Breasts (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Irregular Cycles Breast Lumps/Tenderness Nipple Discharge Heavy Flw Vaginal Discharge Premenstrual Prblems Cltting Bleeding Between Cycles Menpausal Symptms Difficulty Cnceiving Painful Perids Pain with Intercurse Date f last annual exam Was it nrmal? Yes N Have yu had an abnrmal pap? N Yes, when? Have yu been diagnsed with Ovarian Cysts, Endmetrisis, PCOS, Fibrids, r any STD s? (please circle any that apply) D yu d regular breast exams? Yes N 24. Menstrual/Birthing Histry: a. Age f First/Last Menses: d. Birth Cntrl Type: g. # f Abrtins: b. # f Days f Menses: e. # f Pregnancies: h. # f Live Births: c. Length f Cycle: f. # f Miscarriages: 25. Male Reprductive (please circle any that yu experience nw and underline any that yu have experienced in the past): Sexual Difficulties Prstrate Prblems Testicular Pain/Swelling Penile Discharge Hernias STD s 26. Musculskeletal (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Neck/Shulder Pain Muscle Spasms/Cramps Arthritis Arm Pain Upper Back Pain Mid Back Pain Lw Back Pain Leg Pain Jint Pain (if s, where?): 27. Neurlgic (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Vertig/Dizziness ParalysisNumbness/Tingling Lss f Balance Seizures/Epilepsy 28. Endcrine (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Hypthyrid Hypglycemia Hyperthyrid Diabetes Mellitus Night Sweats Feeling Ht r Cld Fatigue 29. Other (Please circle any that yu experience nw. Underline any that yu have experienced in the past): Anemia Cancer Rashes Eczema/Hives Cld Hands/Feet Acne General Itchiness Is there anything else we shuld knw? Name: Date f Birth: Date: pg 3
6 Acupuncture Health Histry 30. Lifestyle: What des yur typical diet cnsist f? a. D yu typically eat at least three meals per day? Yes N, hw many? b. Exercise rutine: c. Spiritual practice: d. Hw many hurs per night d yu sleep? D yu wake rested? Yes N e. Level f educatin cmpleted: High Schl Bachelrs Masters Dctrate Other f. Occupatin: Emplyer: Hurs/Week: D yu enjy wrk? Yes N Why/Why nt? g. Nictine/Alchl/Caffeine Use: h. Have yu experienced any majr traumas? N Yes, explain: i. Hw many glasses f water d yu drink per day? j. D yu take vacatins? Yes N D yu spend time utdrs? k. D yu eat refined sugar? D yu add salt? D yu eat ut ften? D yu g n diets ften? l. Have yu ever been treated fr drug r alchl addictin? m. Televisin habits: Reading habits: n. D yu have supprtive relatinships in yur life?. Interests and hbbies: Name: Date f Birth: Date: pg 4
7 Neighbrhd Chirpractic and Acupuncture LLC 6040 SE Belmnt Street Suite 1230 Prtland, Oregn (P) (F) HIPAA Plicy Acknwledge f Receipt f Ntice f Privacy Practices I acknwledge that I have received, reviewed, understand and agree t the Ntice f Privacy Practice f Neighbrhd Chirpractic and Acupuncture which describes the Practice plicies and prcedures regarding the use and disclsure f any f my Prtected Health infrmatin created, received, r maintain by the Practice. Missed/Cancellatin Plicy When yu make an appintment, yu re paying fr the practitiner s time. Appintments require a 24- hur business day cancellatin ntice. Fr Saturday, Sunday, and Mnday appintments, cancellatin must ccur prir t Friday at nn. If we d nt receive 24-hur business day ntice, yu will be charged a $25 appintment cancellatin fee. We are unable t bill insurance cmpanies fr missed appintments. Thank yu fr yur understanding f this matter. Cmmunicatin Cnsent We are adding different cmmunicatin ptins t prvide yu with mre persnalized and integrative ways t infrm yu abut yur care. In rder t cmmunicate infrmatin regarding yur care, accunt, appintments, and the clinic, we need permissin t d s. We will never sell any f yur infrmatin, nr use it fr unslicited marketing purpses. By signing this, yu authrize Neighbrhd Chirpractic and/r ur autmated third-party reminder service t cntact yu and/r named authrized persn(s) and t cnvey Persnal Health Infrmatin by the fllwing methds and assume respnsibility t ntify Neighbrhd Chirpractic whenever this infrmatin changes. Text Message: Yes Text: N, prvider may nt cntact me by text message. Detailed Vic Detailed Yes Phne: N, Prvider may nly leave a name and phne number. Yes N, prvider may nt cntact me by . Please list names & relatinships f ther peple authrized t receive infrmatin abut yur care: I hereby attest the abve infrmatin is crrect, and that I have read and understd the abve plicies. Print Name: Date: Signature: HIPAA Plicy, Cmmunicatin Cnsent, and Cancellatin Plicy
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