DR. MOSCOW & ASSOCIATES PATIENT INFORMATION

Transcription

1 DR. MOSCOW & ASSOCIATES PATIENT INFORMATION Name Date / / Sex: Male Female Date of Birth Age Cell Phone ( ) Home ( ) Work ( ) address Preferred Method of contact Social Security # Address City State Zip Occupation Employer Marital Status: Single Married Widowed Domestic partner Emergency contact and phone number Date of your accident Time of accident am pm Location Were you the Driver Passenger Pedestrian Did another car hit you or did you hit another car? Was the impact in the Front Back Left Right Did you go to the hospital? yes no Where you wearing your seatbelt? yes no Did the airbags deploy? yes no Please circle any of the symptoms that you have been experiencing since your accident Headache Lower Back Pain Chest Pain Dizziness Numbness/Tingling into Legs Difficulty Breathing Blurred Vision/Sensitivity to Light Shoulder Pain Abdominal Pain Ringing in the Ears Elbow Pain Diarrhea Nausea Wrist/Hand/Finger Pain Constipation Memory Loss Pelvic Pain Blood in Stool Difficulty Swallowing Hip Pain Difficulty Urinating Neck Pain Knee Pain Blood in Urine Numbness/tingling into Arms Ankle/Foot/Toe Pain Scrapes/Lacerations/Abrasions Upper Back Pain Rib Pain Difficulty Sleeping Please mark the areas of your pain in the diagram.

2 1. What words best describe your pain? Aching Sharp Stabbing Throbbing Tender Deep Unbearable Localized Burning Numb Exhausting Dull Heavy Sore Stiff Tender Tight 2. How often do you have pain? 100% of the time 75% 50% 25% 0% of the time 3. Is your pain worse during certain parts of the day? Morning Afternoon Evening Night 4. Please rate your pain at its worst Please rate your pain on average What makes your pain better? (ex: Sitting, standing, lying on back, lying on side, bending forward, etc.) 7. What makes your pain worse? (ex. Sitting, standing, bending, lifting, walking, working, etc.) 8. Have you missed work? Yes No Dates of missed work 9. Is your pain preventing you from participating in any activities that you would normally do? (ex: Playing with or participating in activities with your kids, friends, or spouse, work, sports, sex, etc.) 10. Is your condition causing you any psychological issues such as anxiety or depression? Yes No 11. Have you seen anyone else for this condition? Yes No What were the results? Name of Primary Doctor: Would you like us to contact him/her? Yes No Current Medication and Dosage: Please include all prescription, over-the-counter medications, vitamins, and supplements. (Types of medications may include Pain Killers, Muscle Relaxers, Blood Thinners, Stimulants, Insulin, Tranquilizers, etc. Types of supplements may include, Mulit-Vitamin, Glucosamine, Omega 3, Probiotics, Calcium, etc) Allergies (medication, lotion/cream, food, other): Please list and state the reaction you had: Surgeries, Hospitalization, Metal Implants (please list procedures and dates):

3 Previous Injuries (auto accidents, fractures, sprain/strains, head trauma, etc.) Do you wear orthotics, heel lifts, or arch supports? Yes No Please explain Have you ever had the following (please circle those that apply): Heart Attack Cancer Eye Disease/Glaucoma Stroke Leukemia Difficulty sleeping Congenital Heart defect Kidney Disease Artificial Joint Heart disease Lung Disease Rheumatic Fever Pacemaker Thyroid Disease Hernia High/low blood pressure Liver Disease/Hepatitis Skin Condition/Disorder Mitral Valve Prolapse Psychiatric Disorder Blood Transfusion Anemia Substance Abuse Enlarged Glands/Thyroid Heart Murmur Sinus Difficulties/Sinusitis Difficulty Hearing/Deafness Diabetes Headaches/Migraines Difficulty Swallowing Tuberculosis Difficulty Breathing/Asthma/Bronchitis Bladder Infection Fainting/Dizziness/Seizures/Epilepsy Ulcers/Crohn s/ulcerative Colitis Diarrhea HIV/AIDS/Venereal disease/std Hemorrhoids Constipation Tooth Decay Lumps in the skin Difficulty/Painful Urination Weight Gain/Loss Neurological Disorder Visual Problems How often and for how long do you exercise? (ex: 3x/week for 30 min). What type of exercise do you do? Do you take recreational drugs? Yes No Please explain Do you drink alcohol? Yes No How often and how much? Do you smoke or chew tobacco? Yes No How many cigarettes do you smoke per day? What is your stress level from 1-10? What causes stress? How is your diet? Would you like to discuss your dietary habits with your doctor? Yes No Please explain

4 Family History: Please check off if your relatives have had any of the following diseases. Relatives Arthritis Cancer Diabetes Heart Disease/ Stroke Kidney Disease Neurologica l Disease Thyroid Disease Father Mother Brothers/Sisters Grandparents Is your immediate family in good health? (Includes parents, brothers/sisters, children, and spouse). If anyone is deceased, what was their cause of death? WOMEN ONLY Is there any possibility that you are pregnant? Yes No Date of last period Do you have regular menstrual cycles? Yes No Do you have difficult periods? Yes No Number of Children Born: Have you ever had a Cesarean? Yes No Describe Pregnancy Complications (if applicable) Age at Menopause (if applicable): I, do hereby state to the best of my knowledge that I am not pregnant and give full permission to Dr. Moscow & Associates to x-ray me. Signature Date IF USING AUTOMOBILE INSURANCE Please notify your auto insurance carrier of your visit to our office immediately. You must notify our insurance department if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately. IMPORTANT INFORMATION- MUST READ Florida law requires that we furnish our patients with receipts after each visit. By signing below, you are waiving your right to a receipt for your visits to our office. Receipts will only be provided upon request. Signature Date 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. Signature Date OUM

5 Disclosure and consent for chiropractic adjustments and care You have a right as a patient to be informed about your condition and the recommended chiropractic adjustments and other physical procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the potential risks and hazards involved. This disclosure is not meant to scare or alarm you: it is simply an effort to make you better informed so you may give or withhold your consent to the procedure. I hereby request and consent to the performance of chiropractic adjustments and other procedures, including various modes of physical therapy and diagnostic X-rays, on me (or the patient named below, for whom I am legally responsible) by Dr. Moscow and/or other licensed Doctors of Chiropractic or those working at the clinic or office who now or in the future treat me while employed by, working or associated with, or serving as a backup for Dr. Moscow. I have had the opportunity to discuss with the doctor, my diagnosis, the nature and purpose of chiropractic adjustments and other procedures and alternatives. I understand and I am informed that, in the practice of chiropractic there are some risks to exam and treatment including, but not limited to, fractures, disc injuries, strokes, dislocations, sprains and increased symptoms and pain or no improvement of symptoms of pain. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I with to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Signature of patient Please print name & date or Patient s Representative s signature (eg. Patient is a minor or physically incapacitated). Please print name of Patient Representative & date