PATIENT INFORMATION. Name Last First Middle. Address Number Street Name Apt# Home Phone Work Phone Cell Phone. Date of Birth / / Age Sex: Male Female

Transcription

1 Today s Date PATIENT INFORMATION Name Last First Middle Address Number Street Name Apt# City State Zip Home Phone Work Phone Cell Phone Date of Birth / / Age Sex: Male Female Employed Full-Time Student Part-Time Student None Occupation Employer Your Referred by: Check this box if you wish to NOT be put on the marketing list, and therefore only contacted e- mail regarding any medical necessity only. If Patient is a Minor, Please List Names of Consenting Parents or Guardians In Case of Emergency Contact Name Phone # Marital Status: Single Married Significant Other Widowed Spouse Name Spouse Phone Number Spouse Occupation 1-NCP-E

2 HEALTH HISTORY Today s Date Patient s Name Mark one or both Past and/or Present to indicate if you had or have any of the following: Past Present Neck pain Upper back pain Mid back pain Low back pain Shoulder pain Elbow/arm pain Wrist/hand pain Hip/leg pain Knee/calf pain Ankle/foot pain Swelling/stiffness Fractures Fusion Headaches Migraines Jaw Pain/TMJ Arthritis Fibromyalgia Neuropathy Stroke Epilepsy Muscular Incoordination Multiple Sclerosis AIDS/HIV Cancer Tumor/Growth Breast Lump Parkinson s Disease Heart Disease Pacemaker Gout Goiter Osteoporosis Past Present Kidney Stones Kidney Disease Diabetes Excessive thirst Ulcer Abdominal pain Hernia Bladder Infection Prostate Problems Loss of bladder Control Trouble urinating Anemia Bleeding Disorders Thyroid Problem Dermatological Problems/Acne Allergies/sinus Allergy Shots Trouble smelling Trouble tasting Asthma Bronchitis Emphysema Tuberculosis Typhoid Fever Whooping Cough Abnormal Weight Gain/Loss Loss of appetite Anorexia Bulimia Liver/gall bladder Disorder Appendicitis Chemical Dependency Past Present Try to quit Smoking Alcoholism Attempting to Conceive Fertility Therapy Miscarriage Cataracts Chicken Pox Hepatitis Measles Mononucleosis Mumps Pneumonia Polio Rheumatic Fever Scarlet Fever Sexually Transmitted Disease Tonsillitis High Blood Pressure High Cholesterol Dieting Unwanted Graying Hair Fatigue Depression Suicide Attempt Psychiatric Care Visual Disturbance Glaucoma Dizziness Anxiety/trouble Relaxing Diarrhea Constipation HABITS: Smoking -Packs/Day Coffee/Caffeine Drinks -Cups/Day Alcohol -Drinks/Week Are you pregnant? Yes: Due Date No: Date of Last Menstrual Cycle 2-NCP-E

3 INFORMED CONSENT FOR CARE To ensure you are fully informed regarding your care; to that purpose we are providing the following information. We also invite and encourage you to discuss with us any questions regarding your treatment and/or our services. The best health serves are based on a friendly, mutual understanding between provider and patient. Our practice objective is to eliminate major interference to the expression of the body s innate wisdom. We may use procedures other than specific adjusting to correct vertebral subluxation in order to help your body hold the adjustments, including acupuncture treatments. An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. A vertebral subluxation is a misalignment of one or more of the 24 vertebra in the spinal column which cause an alteration of the nerve function and interference to the transmission of mental impulses. Various modes of physical therapy and diagnostics may be utilized by the doctor in order to determine the best course of treatment. Care and treatment may be delivered by our licensed doctor of chiropractic and/or the associates working at the facility. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to dislocations, strains or disk impairment. I understand the doctor cannot anticipate nor explain all risks, and I wish to rely on the doctor to exercise judgment during the course of the procedure based on known facts and my best interest. Office policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If an account is submitted for insurance payment and payment is discounted or denied, I understand I am fully responsible for all outstanding charges. If account is not paid within 90 days of the date of service and no financial arrangements have been made, I will be responsible for legal fees, collection agency fees, and any other expenses incurred in collecting on my account. I also understand that if I suspend or terminate care and treatment, any fees for services will be immediately due and payable. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand that if I do not give at least 24-hours notice when canceling an appointment, I may be responsible for a cancellation charge, not to exceed $25, to cover any lost costs and wages for my therapist. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my medical status. I have read or have had read to me the above consent and I accept care on this basis. X X Patient s Signature Date X Patient s Name Printed [IF PATIENT IS UNDER 18 YEARS OF AGE] PARENT OR GUARDIAN AUTHORIZATION: I, being the parent/legal guardian of have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive care at My Sport Chiropractic & Acupuncture. X X Parent s Signature Date 3-NCP-E

4 REASON FOR YOUR VISIT Today s Date Patient s Name 1. Describe your symptoms: 2. When did your symptoms begin: 3. How often do you experience your symptoms? Mark an X to describe your pain symptoms: Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) 4. How have your symptoms/pain changed? Sharp Dull Ache Numbing Neck Mid- Back Low- Back Shoulder/Arms Legs/Feet Getting Better Not Changing Getting Worse Shooting Burning 5. Rate your general pain level: Tingling 6. Have you had similar symptoms in the past? Yes No 7. Does your neck pain radiate to your hands? Yes No No Neck Pain 8. Does your shoulder pain radiate to your hands? Yes No No Shoulder Pain 9. Does your low-back pain radiate to your legs? Yes No No Low-Back Pain 10. Does your low-back pain radiate past your knees? Yes No No Low-Back Pain 11. What tests have been performed in regards to your current symptoms? X-Ray body parts: MRI body parts: CT Scan body parts: Other 4-NCP-E

5 HEATLH & PAIN QUESTIONNAIRE Today s Date Patient s Name DATE OF LAST: Physical Exam: Spinal X-Ray: Blood Test: Spinal Exam: Chest X-Ray: Urine Test: MRI, CT-Scan, Bone Scan: MEDICATIONS YOU ARE TAKING (INCLUDING VITAMINS): ALLERGIES: What do you hope to get from your visit/treatment? (select all that apply): Reduce symptoms Explanation of condition/treatment Learn how to take care of Resume/increase activity How to prevent this from occurring in the future this on my own FOR OFFICE USE ONLY BP / Weight RHB 5-NCP-E

6 HIPPA Authorization Form ACKNOWLEDGEMENT OF RECEIPT OF NOTICE PLEASE REVIEW THIS ACKNOWLEDGEMENT AND SIGN BELOW AFTER YOU HAVE READ THE PRIVACY NOTICE THAT HAS BEEN PRESENTED Patient Name: Date: ACKNOWLEDGEMENT X I acknowledge that I have received and/or read and been offered a copy of the Initial following: NOTICE OF PRIVACY PRACTICES AND RIGHTS I have read the notice and I understand my privacy rights and the privacy office s policies. PATIENT RIGHTS I have read the notice and I understand my patient rights. PATIENT AUTHORIZATION & RESPONSIBILITY FORM If the patient is a minor or represented by a personal representative; the authorized guardian/representative has signed below. I AGREE to have the following person(s) receive(s) my medical information in my absence: Relationship: Name of person that can call or receive information regarding my medical details If no one is available to answer my phone, it is OK to leave a message regarding appointments or medical information on the answering machine at my: HOME WORK CELL DO NOT LEAVE MESSAGE SIGNATURE: X DATE: X Privacy Officer Contact Information: NCP-E