Patient Information Form

Transcription

1 Patient Infrmatin Frm Date Pat. ID Please print Name (First) (M.) (last) Address Scial Security # DOB AGE City/State/Zip Sex M F Marital Status S M D W Hme # Wrk # Cell # Occupatin Emplyer Address Spuse s name Emergency Cntact Phne # Insurance Infrmatin (circle ne) HMO PPO Majr Medical Aut Wrk Cmp Medicare Medicaid Name f plicyhlder Plicy # Insurance C Name Grup # Secndary Insurance (circle ne) HMO PPO Majr Medical Aut Wrk Cmp Medicare Medicaid Name f plicyhlder Plicy # Insurance C Name Grup # Is yur cnditin due t an: A) Aut Accident B) Wrk Injury C) Other Accident D) Unknwn Cause E) Illness F) Sprt Injury I understand and agree that health and accident insurance plicies are an arrangement between the insurance carrier and me. I authrized payment frm my insurance carrier directly t Dr. Steven J. Melilli with the understanding that all mnies will be credited t my accunt upn receipt. Hwever, I clearly understand and agree that all services rendered t me are charged directly t me and that I am persnally respnsible fr payment. I als understand that if I suspend r terminate my care and treatment, all fees fr prfessinal services rendered t me will be immediately due and payable. In the event f default, I prmise t pay legal interest n the indebtedness, tgether with such cllectin csts and reasnable attrney fees as may be required t affect cllectin. Patient Signature Date Melilli Chirpractic and Rehab Center, 2655 State Rad 580, Suite 204, Clearwater, FL 33761

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4 Patient Health Questinnaire ACN Grup, Inc. Frm PHQ-102 ACN Grup, Inc. Use Only rev 3/27/2003 Patient Name Date 1. When did yur symptms start: Describe yur symptms and hw they began: 2. Hw ften d yu experience yur symptms? Cnstantly (76-100% f the day) Frequently (51-75% f the day) Occasinally (26-50% f the day) Intermittently (0-25% f the day) Indicate where yu have pain r ther symptms 3. What describes the nature f yur symptms? Sharp Dull ache Numb Shting Burning Tingling 4. Hw are yur symptms changing? Getting Better Nt Changing Getting Wrse 5. Hw bad are yur symptms at their: a. wrst: b. best: Nne Unbearable 6. Hw d yur symptms affect yur ability t perfrm daily activities? N cmplaints Mild, frgtten Mderate, interferes Limiting, prevents Intense, preccupied Severe, n with activity with activity full activity with seeking relief activity pssible 7. What activities make yur symptms wrse: 8. What activities make yur symptms better: 9. Wh have yu seen fr yur symptms? N One Other Chirpractr a. When and what treatment? Medical Dctr Physical Therapist Other b. What tests have yu had fr yur symptms and when were they perfrmed? Xrays date: CT Scan date: MRI date: Other date: 10. Have yu had similar symptms in the past? Yes N a. If yu have received treatment in the past fr the same r similar symptms, wh did yu see? This Office Other Chirpractr Medical Dctr Physical Therapist Other 11. What is yur ccupatin? Prfessinal/Executive White Cllar/Secretarial Tradespersn Labrer Hmemaker FT Student Retired Other a. If yu are nt retired, a hmemaker, r a Full-time Self-emplyed Off wrk student, what is yur current wrk status? Part-time Unemplyed Other 12. What d yu hpe t get frm yur visit/treatment (select all that apply): Reduce symptms Resume/increase activity Patient Signature Explanatin f cnditin/treatment Learn hw t take care f this n my wn Hw t prevent this frm ccurring again Date

5 Cmplaints Chart Head: (circle as many as apply) A) Headache 1) Mild 2) Mderate 3) Severe Frequency: ( ) times per (Day Week Mnth) Are they: 1) Sharp 2) Dull 3) Cnstant 4) Intermittent Lcatin: 1) back f head 2) frehead 3) right side 4) left side 5) behind eyes B) Light Headed C) Dizziness D) Lss f Balance E) Blurred Visin F) Ringing in Ears G) Fainting H) JAW Pain I) sensitivity t light Neck: (circle as many as apply) A) Pain: 1) Left Side 2) Right Side 3) Bth Pain Level: 1) Mild 2) Mderate 3) Severe Pain Increased by: 1) Frward bending 2) Backward Bending 3) rtating head t left 4) rtating Head t the right 5) bending neck left 6) bending neck right B) Stiffness C) Muscle Spasm D) Grinding Shulders: (circle as many as apply) A) Pain in Jint Left Right Bth B) Limitatin f Mtin Left Right Bth C) Tensin Left Right Bth D) Lcatin Frnt Back Arms and Hands: (circle as many as apply) A) Pain in upper arm Left Right Bth B) Pain in elbw Left Right Bth C) Pain in frearm Left Right Bth D) Pain in wrist Left Right Bth E) Numbness in arm Left Right Bth F) Numbness in frearm Left Right Bth G) Numbness- hand and fingers Left Right Bth Lw Back: (circle as many as apply) Mid Back: (circle as many as apply) A) Lumbar Pain Left Right Bth A) Pain Left Right Bth B) Sacriliac jint pain Left Right Bth B) Muscle spasm Left Right Bth C) muscle spasm Left Right Bth C) Rib pain Left Right Bth Pain Level: 1) Mild 2) Mderate 3) Severe Pain Level: 1) Mild 2) Mderate 3) Severe Hips and Legs: (circle as many as apply) A) Pain in Buttcks Left Right Bth B) Pain in Hips Left Right Bth C) Pain in Leg Left Right Bth Radiates t: 1) sle f ft 2) tp f ft 3) calf 4) back f leg 5) hamstring 6) thigh D) Numbness dwn Leg Left Right Bth E) Numbness in Ft/Tes Left Right Bth F) Knee pain Left Right Bth Ft and Ankle: (circle as many as apply) A) Ankle Pain Left Right Bth B) Swllen Ankle Left Right Bth C) Ft Pain Left Right Bth Name (Print) Signature Date Melilli Chirpractic and Rehab Center, 2655 State Rad 580, Suite 204, Clearwater, FL Rev. 9/12/2016

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7 Histry Chart Persnal Health Histry: (circle as many as apply) AIDS/HIV Cataracts Hernia Osteprsis Strke Alchlism Chemical Dependency Herniated Disc Pacemaker Suicide attempt Allergies Chickenpx Herpes Parkinsn's disease Thyrid Prblems Anemia Depressin High Bld Pressure Pinched Nerve Tnsillitis Anrexia Diabetes High Chlesterl Pneumnia Tuberculsis Appendicitis Emphysema Kidney Diseases Pli Tumrs Arthritis Epilepsy Liver Disease Prstate Prblems Ulcers Asthma Fractures Measles Prsthesis Vaginal Infectins Bleeding disrder Glaucma Migraines Psriasis Venereal disease Blcked arteries Giter Miscarriage Psychiatric Care Whping Cugh Breast lump Gut Mnnuclesis Rheumatid Arthritis Other Brnchitis Heart Disease Multiple Sclersis Rheumatic Fever Cancer Hepatitis Mumps Scarlet fever Name f Primary Care Physician Date f Last Exam Wmen: Are yu pregnant Y N Nursing? Y N Taking Birth Cntrl Pills? Y N List any surgeries yu have had and the dates: Family Health Histry: Assciated health prblems f relatives: Deaths in immediate family: Cause f parent s r sibling s death Age f Death Name (print) Signature Date Melilli Chirpractic and Rehab Center, 2655 State Rad 580, Suite 204, Clearwater, FL Rev. 9/12/2016

8 Patient s Name: Number: Date: NECK DISABILITY INDEX This questinnaire has been designed t give the dctr infrmatin as t hur yur neck pain as affected yur ability t manage in everyday life. Please answer every sectin and mark in each sectin ONE bx which apples t yu. We realize yu may cnsider that tw f the statements in any ne sectin relate t yu, but please just mark the bx which MOST CLOSELY describes yur pain. Sectin 1 Pain Intensity I have n pain at the mment The pain is very mild at the mment The pain is mderate at the mment The pain is fairly severe at the mment The pain is very severe at the mment The pain is the wrst imaginable at the mment Sectin 2 Persnal Care (Washing, Dressing Etc.) I can lk after myself nrmally withut causing extra pain I can lk after myself nrmally but it causes extra pain It is painful t lk after myself and I am slw and careful I need sme help but manage mst f my persnal care I need help every day in mst aspects f self care I d nt get dressed, I was with difficulty and stay in bed Sectin 3 Lifting I can lift heavy weights withut extra pain I can lift heavy weights but it gives extra pain Pain prevents me frm lifting heavy weights, but I can manage light t medium weights if they are cnveniently psitined I can lift very light weights I cannt lift r carry anything at all Sectin 4 Reading I can read as much as I want t with n pain in my neck I can read as much as I want t with slight pain in my neck I can read as much as I want t with mderate pain I cannt read as much as I want because f mderate pain in my neck I can hardly read at all because f severe pain in my neck I cannt read at all Sectin 5 Headaches I have n headaches at all I have slight headaches which cme infrequently I have slight headaches with cme frequently I have mderate headaches which cme infrequently I have mderate headaches which cme frequently I have headaches almst all the time Signature: Fr Office Use Only: Scre: Sectin 6 Cncentratin I cannt cncentrate at all I can cncentrate fully when I want t with n difficulty I can cncentrate fully when I want t with slight difficulty I have a fair degree f difficulty in cncentrating when I want t I have a lt f difficulty in cncentrating when I want t I have a great deal f difficulty in cncentrating when I want t Sectin 7 Wrk I can d as much as I want t I can nly d my usual wrk, but n mre I can d mst f my usual wrk, but n mre I cannt d my usual wrk I can hardly d any wrk at all I cannt d any wrk at all Sectin 8 Driving I drive my car withut any neck pain I can drive my car as lng as I want with slight pain in my neck I can drive my car as lng as I want with mderate pain in my neck I cannt drive my car as lng as I want because f mderate pain in my neck I can hardly drive my car at all because f severe pain in my neck I cannt drive my care at all Sectin 9 Sleeping I have n truble sleeping My sleep is slightly disturbed (less than 1 hr. sleepless) My sleep is mderately disturbed (1-2 hrs. sleepless) My sleep is mderately disturbed (2-3 hrs. sleepless) My sleep is greatly disturbed (3-4 hrs. sleepless) My sleep is cmpletely disturbed (5-7 hrs. sleepless) Sectin 10 Recreatin I am able t engage in all my recreatin activities with n neck pain at all I am able t engage in all my recreatin activities, with sme pain in my neck I am able t engage in mst, but nt all f my usual recreatin activities because f pain in my neck I am able t engage in few f my usual recreating activities because f pain in my neck I can hardly d any recreatin activities because f pain in my neck I cannt d any recreatin activities at all Melilli Chirpractic & Rehab Center 2655 State Rad 580, Suite 204 Clearwater, FL 33761

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10 Patient s Name: Number: Date: Oswestry Lw Back Pain Disability Questinnaire This questinnaire has been designed t give us infrmatin as t hw yur back r leg pain is affecting yur ability t manage in everyday life. Please answer by checking ONE bx in each sectin fr the statement which best applies t yu. We realize yu may cnsider that tw r mre statements in any ne sectin apply, but please just mark the bx that indicates the statement which mst clearly describes yur prblem. Sectin 1 Pain Intensity I have n pain at the mment The pain is very mild at the mment The pain is mderate at the mment The pain is fairly severe at the mment The pain is very severe at the mment The pain is the wrst imaginable at the mment Sectin 2 Persnal Care (Washing, Dressing Etc.) I can lk after myself nrmally withut causing extra pain I can lk after myself nrmally but it causes extra pain It is painful t lk after myself and I am slw and careful I need sme help but manage mst f my persnal care I need help every day in mst aspects f self care I d nt get dressed, I wash with difficulty and stay in bed Sectin 3 Lifting I can lift heavy weights withut extra pain I can lift heavy weights but it gives extra pain Pain prevents me frm lifting heavy weights ff the flr, but I can manage if they are cnveniently placed n a table I can lift very light weights I cannt lift r carry anything at all Sectin 4 Walking Pain des nt prevent me walking any distance Pain prevents me frm walking mre than 1 mile Pain prevents me frm walking mre than ½ mile Pain prevents me frm walking mre than 100 yards I can nly walk using a stick r crutches I am in bed mst f the time Sectin 5 Sitting I can sit in any chair as lng as I like I can nly sit in my favrite chair as lng as I like Pain prevents me frm sitting mre than ne hur Pain prevents me frm sitting mre than 30 minutes Pain prevents me frm sitting mre than 10 minutes Pain prevents me frm sitting at all Signature: Sectin 6 Standing I can stand as lng as I want withut extra pain I can stand as lng as I want but it gives me extra pain Pain prevents me frm standing fr mre than 1 hur Pain prevents me frm standing fr mre than 30 minutes Pain prevents me frm standing fr mre than 10 minutes Pain prevents me frm standing at all Sectin 7 Sleeping My sleep is never disturbed by pain My sleep is ccasinally disturbed by pain Because f pain I have less than 6 hurs sleep Because f pain I have less than 4 hurs sleep Because f pain I have less than 2 hurs sleep Pain prevents me frm sleeping at all Sectin 8 Sex Life (If applicable) My sex life is nrmal and causes nt extra pain My sex life is nrmal but causes sme extra pain My sex life is nearly nrmal but is very painful My sex life is severely restricted by pain My sex life is nearly absent because f pain Pain prevents any sex life at all Sectin 9 Scial Life My scial life is nrmal and gives me nt extra pain My scial life is nrmal but increases the degree f pain Pain has n significant effect n my scial life apart frm limiting my mre energetic interests eg. sprts Pain has restricted my scial life and I d nt g ut as ften Pain has restricted my scial life t my hme I have n scial life because f pain Sectin 10 Traveling I can travel anywhere withut pain I can travel anywhere but it gives me extra pain Pain is bad but I manage jurneys ver tw hurs Pain restricts me t jurneys f less than ne hur Pain restricts me t shrt necessary jurneys under 30 minutes Pain prevents me frm traveling except t receive treatment Scre: Melilli Chirpractic & Rehab Center 2655 State Rad 580, Suite 204 Clearwater, FL

11 VEHICLE ACCIDENT REPORT Name: Date: 1) Date f Accident / / 2) Time f Accident : (AM / PM) 3) Were yu: A) Driver B) Passenger (Frnt) C) Passenger (Rear) D) Pedestrian 4) Were yu wearing seatbelts? (Y / N) 5) Type f Vehicle: A) Aut B) Truck C) Van D) Mtrcycle E) Mtrhme F) Bicycle 6) Hw accident ccurred: A) Struck by anther vehicle B) Struck anther vehicle C) Struck a statinary bject D) Other 7) Where was yur vehicle hit? A) Frnt B) Rear C) Rt. Side D) Lft. Side E) Rt. Frnt F) Lft. Frnt G) Rt. Rear H) Lft. Rear 8) Where was ther vehicle hit? A) Frnt B) Rear C) Rt. Side D) Lft. Side E) Rt. Frnt F) Lft. Frnt G) Rt. Rear H) Lft. Rear 9) Yur apprximate speed MPH 10) Other vehicle apprximate speed MPH 11) What ccurred at the mment f impact? (Circle as many as apply) A) Tensed bdy BEFORE impact B) Neck whipped frward & back C) Spine trqued and twisted D) Thrwn ver seat E) Thrwn frm vehicle F) Pinned in vehicle G) Thrwn frm side t side H) Cut and bruised 12) Did yu strike yur: (Circle as many as apply) A) Head Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object B) Shulder (Lft./Rt.) - Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object C) Arm (Lft./Rt.) - Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object D) Elbw (Lft./Rt.) - Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object E) Wrist (Lft./Rt.) - Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object F) Hip (Lft./Rt.) - Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object G) Knee (Lft./Rt.) - Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object H) Ankle (Lft./Rt.) - Against the: 1) Dashbard 2) Windshield 3) Steering Wheel 4) Rt. Dr 5) Lft. Dr 6) Seat Frame 7) Unknwn Object 13) Were yu rendered uncnscius? (Y / N) 14) Did yu receive medical attentin at the scene f the accident? (Y / N) 15) Where did yu g immediately fllwing the accident? A) Hspital B) Hme C) Persnal Dctr D) T the ffice E) Resumed activities 16) Were yu: (Circle as many as apply) A) Shaken B) Disriented C) Cnfused Did yu have any physical cmplaints befre the accident? (Y / N) If YES please describe: In yur wn wrds, please describe accident: Hw did yu feel immediately after the accident? PATIENT SIGNATURE: DATE: Imprtant: This frm may be used in the determinatin f insurance benefits and/r litigatin fr cmpensatin. It is imperative that this frm be filled ut cmpletely. Melilli Chirpractic and Rehab Center, 2655 State Rad 580, Suite 204, Clearwater, FL 33761