PATIENT INTRODUCTION FORM

Transcription

1 PATIENT INTRODUCTION FORM Name: Date: Have you been to our office before? If so, please check back with front desk before continuing. 1. Personal Information Address: Home Telephone: City / ZIP Code: Work Telephone: Birthday: Marital Status: Cell Phone: Height: Weight: Would you like text reminders? Occupation & Employer: If yes, Cell Carrier Company: Social Security Number: address: Attending physician name/phone number: 2. Contact person for emergencies Name: Telephone: Address: Relationship: 3. Visit Related to: Check-up only Non-injury symptoms Sports or recreational injury School/Employment Physical Car crash injury Work related injury Motorcycle/Bicycle injury Other: Accident date : State: Insurance company name: Claim Number Insurance phone number: Do you have an attorney? If so, who? 4. Is there any chance that you are currently pregnant? YES NO 5. Please allow us to make a copy of your insurance card for your file. Our office will provide insurance billing services for you if you so desire as a courtesy. Remember that you are ultimately responsible for any charges incurred in this office. It is your responsibility to pay any deductible amount, co-insurance, and or any other balances not paid by your insurance carrier. Your signature on this document indicates that you agree to pay for any outstanding bills incurred in this office. We need payment for the patient portion or copay at the time of visit. 6. How did you hear about our office: 7. Signature of responsible party (Patient or Parent): Date: * With your signature, you give consent for us to diagnose and treat your minor child. Page 1 of 9

2 Name: GENERAL HEALTH HISTORY 1. General Questions Check only those conditions that apply to you and indicate if you have had in the past or presently have. YES NO Condition Year I bruise easily I heal slowly My body temperature is normally low (feel cold)* Smoke cigarettes or use tobacco products Diabetic-Hypoglycemic or need to have dialysis. Do you have a heart pacemaker or neck or chest shunt? Heart Attack Do you have difficulties or intolerance to heat packs or ice packs on your skin? Dizziness, blacked out, or fainting spell history Epilepsy-Seizure-Convulsion history History of gout, lupus, psoriasis, temporary paralysis, or spinal meningitis Cancer history or treatment of any type Stroke history (Indicate any suspected strokes or transient ischemic attacks) Told that you have scoliosis, spondylolisthesis, disc degeneration, or herniated disc Told that you have spina bifida, abdominal aneurysm, or vascular conditions Have you ever been hospitalized? Why: Thyroid disorders Coma from head injury or other problem Told you have osteoporosis of your spine or osteopenia (weak bones) Told you have osteoarthritis or rheumatoid arthritis of your spine or joints Women only Check this box if you currently have any type of breast implants 2. Prior injury or musculoskeletal pain history Please check below. N/A Injury Year Injury/Pain Year Work injury Lifting injury Motorcycle/Bicycle injury Military injury Pedestrian injury Headaches/Migraines Car accident Neck pain or arm pain Sports injury Middle back pain Fall Low back or leg pain 3. Prior Fractures/Broken Bones Please check below. N/A Region Year Region Year Spinal vertebra Skull Collar bone (clavicle) Rib bone Arm or hand bone Leg or foot bone Pelvis bone Other: 4. Prior Surgeries If you have had any previous surgery, indicate type and when. N/A Surgery Year Surgery Year Spine Surgery (neck or back) Appendix Disc surgery in neck or back Gallbladder/Stomach/Kidney Heart Cancer (any type) Tonsillectomy Rib/Collar bone Head/Brain Hernia Shoulder/Arm/Leg Other: Page 2 of 9

3 Name: GENERAL HEALTH HISTORY (cont.) 5. Current Syptoms Please check all symptom regions and how long you have had them. Symptom How long Symptom How long Headaches/Migraines Upper back pain, soreness, or stiffness Neck pain, soreness, or stiffness Hip Pain Low back pain, soreness or stiffness Leg or foot pain, numbness or tingling Arm pain, numbness or tingling Other: How did your symptoms come on? Suddenly Gradually 6. Symptom/pain description Please check all words below that best describe how your symptoms currently feel to you. Pain Pinching Spreading Vicious Unbearable Ache Pricking Shooting Sickening Soreness Cutting Tingling Stabbing Miserable Pins and Needles Tearing Gnawing Dull Troublesome Radiating Crushing Nagging Bony Pressing Weakness Pulling Boring Terrifying Deep pain Falls asleep Irritating Burning-Hot Dreadful Superficial pain Suffocating Annoying Drill like Fearful Stinging Punishing Stiff or tight Heavy Unhappy Throbbing Crawling Exhausting Numbness Torturing Sharp Tender 7. Chiropractic care past experiences Have you ever been to a Chiropractor before for any condition? YES NO If so, Chiropractor s Name : Year: Problem seen for: Do you have any problems laying face down on an examination table? YES NO If yes, why: 8. Medications in use Please check below all that you are currently taking N/A Muscle Relaxants Blood pressure/stroke prevention Cortisone injections Pain/Anti-inflammatory Osteoporosis (bone strengthening) Other: 9. Pain level changes Please indicate what activities or at what time your pain level increases. Morning Bending your back Walking Afternoon or evening Lying down flat Standing During sleep hours Sitting Exercise/Stretching Standing up from sitting Poor posture Other: 10. Other symptoms Please check all other symptoms that your pain has been associated with. Excessive fatigue-malaise Bowel or bladder disorders Night pain or night time sweats Weight loss Ovarian pain Abdominal pain Low grade fever Kidney pain/painful urination Balance problems 11. Exercise Please check all of the following that best describe your Physical activities. I do not exercise regularly I exercise 1-2 times a week I exercise 3-5 times a week I stretch regularly I do weight lifting at gym/home I do cardiovascular work outs I am willing to do exercise I am not willing to do exercises I do regular sports activities Page 3 of 9

4 PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED INFORMATION I hereby give my consent for Allied Chiropractic to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Allied Chiropractic's Notice of Privacy Practices provides a more complete description of such uses and disclosures and is available in the lobby at all times. I have the right to review the Notice of Privacy Practices prior to signing this consent, Allied Chiropractic reserves the right to revise its Notice of Privacy Practices at anytime. With this consent, Allied Chiropractic may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care. With this consent, Allied Chiropractic has my persmission to text me appoitment reminders if I specifically signed up for the service. With this consent, Allied Chiropractic may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With this consent, Allied Chiropractic may to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Allied Chiropractic restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Allied Chiropractic's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Allied Chiropractic may decline to provide treatment to me. Signature of Patient, Parent or Legal Guardian Date Patient s Name Page 4 of 9

5 OSWESTRY DISABILITY INDEX (low back pain/dysfunction) Name: Date: PLEASE READ: This questionnaire is designed to enable us to understand how much your back pain has affected your ability to manage everyday activities. Please answer each section by checking the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, please just circle the one choice which closely describes your problem right now. Section 1 Pain Intensity A. Pain comes and goes and is mild. B. Pain is mild and does not vary. C. Pain comes and goes and does not vary much. D. Pain is moderate and does not vary much. E. Pain comes and goes and is severe. F. Pain is severe and does not vary much. Section 2 Personal Care (Washing, Dressing etc.) A. Does not change habits to avoid pain. B. Does not change habits/some pain. C. Does not change habits/increases pain D. Changes habits/increases Pain E. Unable to do some personal care without help. F. Unable to wash or dress without help. Section 3 Lifting A. Lifts heavy weights with no pain. B. Lifts heavy weights with pain. C. Cannot lift heavy weights off the floor. D. Can lift heavy weights from a table. E. Can lift light weights from a table. F. Can lift only very light weights. Section 4 Walking A. Pain does not prevent walking. B. Cannot walk more than one mile. C. Cannot walk more than ½ mile. D. Cannot walk more than ¼ mile. E. Can walk only with crutches. F. Bedridden and must crawl to the toilet. Section 5 Sitting A. Can sit in any chair as long as desired. B. Can sit only in the favorite chair as long as desired. C. Can sit no more than 1 hr. D. Can sit no more than ½ hr. E. Can sit no more than 10 minutes. F. Cannot sit at all due to pain. Page 5 of 9

6 OSWESTRY DISABILITY INDEX (cont.) Name: Section 6 Standing A. Can stand for an unlimited time without pain. B. Some pain standing/ doesn t increase with time. C. Cannot stand for more than 1 hr. D. Cannot stand for more than ½ hr. E. Cannot stand more than 10 minutes. F. Cannot stand at all. Section 7 - Sleeping A. No pain in bed. B. Gets pain in bed, but sleeps well. C. Normal sleep reduced by ¼. D. Normal night s sleep reduced by ½. E. Normal night s sleep reduced by ¾. F. Cannot sleep at all due to pain. Section 8 Traveling A. Travel without pain B. Travel causes some pain, but not made worse. C. Causes extra pain/ no change in form. D. Causes pain/ uses alternate travel. E. Pain restricts all forms of travel. F. Pain restricts travel exept lying down. Section 9 Social Life A. Normal and causes no pain. B. Normal but causes extra pain. C. Limits energetic interests. D. Pain limits/doesn t go out as often. E. Pain restricted social life to home. F. Pain restrics all social life. Section 10 Changing Degree of Pain A. Pain is rapidly improving. B. Pain fluctuates but is improving. C. Improvement is slow. D. Pain level is unchanged. E. Pain is gradually worsening. F. Pain is rapidly worsening. Page 6 of 9

7 NECK DISABILITY INDEX Name: Date: PLEASE READ: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. Please answer each Section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, please just circle the one choice which closely describes your problem right now. Section 1 Pain Intensity A. No pain at the moment. B. Mild pain at the moment. C. Moderate pain at the moment. D. Fairly severe at the moment. E. Very severe pain the moment. F. Worst imaginable at the moment. Section 2 Personal Care (Washing, Dressing etc.) A. Personal care is normal without extra pain. B. Personal care normal with extra pain. C. Pesonal care painful/ slow and careful. D. Manage most personal care with some help. E. Needs help everyday in most aspects care care. F. Difficulty dressing and washing/stays in bed. Section 3 Lifting A.Lifts heavy weights with no pain. B. Lifts heavy weights with pain. C. Can lift heavy weights from a table. D. Can lift light weights from a table. E. Can lift only very light weights. F. Cannot lift or carry anything. Section 4 Reading A. No pain while reading. B. Slight pain while reading. C. Moderate pain while reading. D. Moderate pain prevents reading. E. Severe pain prevents reading. F. Cannot read at all. Section 5 Headache A. No headaches. B. Slight, infrequent headaches. C. Moderate, infrequent headaches. D. Moderate, frequent headaches. E. Severe, frequent headaches. F. Constant headaches. Page 7 of 9

8 NECK DISABILITY INDEX (cont.) Name: Section 6 Concentration A. Can concentrate without diffuculty. B. Can concentrate with slight difficulty. C. Can concentrate with fair difficulty. D. Can concentrate with a lot of difficulty. E. Can concentrate with extreme difficulty. F. Cannot concentrate at all. Section 7 Work A. Work is unrestricted. B. Can only do usual work, but no more. C. Can do most usual work, but no more. D. Cannot do usual work. E. Can hardly do any work. F. Cannot do any work. Section 8 Driving A. Can drive without pain. B. Driving causes slight neck pain. C. Driving causes moderate neck pain. D. Cannot drive long due to moderate pain. E. Can hardly drive due to severe pain. F. Pain prevents driving. Section 9 Sleeping A.No difficulties sleeping. B. Sleep is mildly disturbed. C. 1-2 hours loss of sleep. D. 2-3 hours loss of sleep. E. 3-5 hours loss of sleep. F. 5-7 hours loss of sleep. Section 10 Recreation A. Recreation is not affected. B. Some neck pain, but does not affect activity. C. Some activity is affected by pain. D. Most activity is affected by pain. E. Activity severely restricted by pain. F. Cannot do any activity. Page 8 of 9

9 MISSED APPOINTMENT POLICY We understand that circumstances arise that prevent us keeping appointment which are out of our control. However, our professionals commit to the time scheduled with patients and ask for the same commitment in return. We do our best to assure all patients are reminded of upcoming appointments to prevent them from being missed. notifications, text notifications, reminder cards and phone call reminders are available to all patients per their request. If you are unable to keep your appointment, we request that you contact our office at least 24 hours in advance. Notifying our office in advance prevents us from enforcing our missed appointment policy. Our missed appointment policy is as follows: 1. If you miss an appointment without notice, you will be billed $25.00 on your next visit. 2. Insurance companies DO NOT pay missed appointment fees, therefore the fee will be your responsibility. 3. You will be billed each time you miss an appointment. If you miss an appointment 3 times, you will not be re-scheduled at this office. By signing below you acknowledge you have read and understand our missed appointment policy. Patient Name Signature Date Page 9 of 9