Neighborhood Chiropractic and Acupuncture LLC Registration and History

Transcription

1 PATIENT INFORMATION Neighbrhd Chirpractic and Acupuncture LLC 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 Single Married 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 INFROMATION 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? Neighbrhd Chirpractic and Acupuncture LLC 6040 SE Belmnt Ste Prtland, OR (503)

2 HEALTH HISTORY Name: 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: Date: 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 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 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: Medicatins: Fr what cnditin? Vitamins/Herbs/Supplements: Allergies: Is there anything else yu wuld like t share with yur dctr? Neighbrhd Chirpractic and Acupuncture LLC 6040 SE Belmnt Ste Prtland, OR (503)

3 Last Name: First Name: Neighbrhd Chirpractic and Acupuncture LLC Wrkman s Cmp Accident Intake Date: Middle Initial: Age: Occupatin: Date f Accident: Claim #: Insurance C: Time f Accident: am pm Please describe the accident in yur wn wrds: AT THE SCENE Did medical persnal (ambulance, fire) cme t the scene? n yes If yes, were yu treated at the scene? n yes, please explain: HOSPITAL / EMERGENCY DEPARTMENT Did yu g t the Emergency Rm? n yes If yes, what was the name f the Hspital? What was yur dctr s name (if knwn)? Did yu g by: ambulance smene drve me I drve myself When did yu g the emergency rm? Immediately after the accident The next day Tw r mre days later ( )# hurs after the accident Were x-rays taken? n yes I had x-rays, but I am nt sure what was x-rayed. If yes, what x-rays were taken? neck upper back mid back lw back LEFT: shulder upper arm elbw frearm wrist hand fingers hip thigh knee calf ankle ft tes RIGHT: shulder upper arm elbw frearm wrist hand fingers hip thigh knee calf ankle ft tes Additinal x-rays nt marked abve: D yu knw the results yur x-rays? n yes, please explain: Were any additinal tests perfrmed? n yes unsure If yes, d yu knw what tests were perfrmed? n yes If yes, check all that apply: bld CAT/CT scan MRI Other: D yu knw the results f any f these tests? n yes, please explain Did yu receive a diagnsis? n yes, please explain: Please explain treatment given in the emergency rm: Upn leaving, what treatment plan were yu given? What prescriptins (and dsing) were yu given? Name: DOB: Date: pg 1

4 Neighbrhd Chirpractic and Acupuncture LLC Wrkman s Cmp Accident Intake AFTER THE ACCIDENT Have yu seen any ther dctr since the accident? n yes If yes, what was the name f the physician? Was this dctr yur primary care physician? n yes What date(s) did yu see this dctr? If yes, what x-rays were taken? neck upper back mid back lw back LEFT: shulder upper arm elbw frearm wrist hand fingers hip thigh knee calf ankle ft tes RIGHT: shulder upper arm elbw frearm wrist hand fingers hip thigh knee calf ankle ft tes Additinal x-rays nt marked abve: D yu knw the results yur x-rays? n yes, please explain: Were any additinal tests perfrmed? n yes unsure If yes, d yu knw what tests were perfrmed? n yes If yes, please check all that apply: bld CAT/CT scan MRI Other: D yu knw the results f any f these tests? n yes, please explain Did yu receive a diagnsis? n yes, please explain: Please explain treatment given in the dctr s ffice: Upn leaving, what treatment plan were yu given? What prescriptins (and dsing) were yu given? Have yu been able t wrk since the injury? yes n, hw many days have yu missed? Prir t the injury, were yu able t wrk n an equal basis with thers yur age? yes n If n, what has changed? Have yu had any f the fllwing symptms since yur injury? (Check all that apply.) arm / shulder pain back pain back stiffness chest pain dizziness ear buzzing ear ringing fatigue feet / te numbness hand / finger numbness r stiffness headaches irritability jaw prblems leg pain memry lss nausea neck pain neck stiffness shrtness f breath sleep difficulty stmach upset tensin visin blurred Is the cnditin getting prgressively wrse? n yes unsure Mvements that are painful: sitting standing walking bending lying dwn Rate the severity f yur pain frm 1 (least pain) t 10 (severe pain): Type f pain (check all that apply): sharp dull thrbbing numbness aching shting burning tingling cramps stiffness swelling ther: Hw ften d yu get this pain? Is the pain: cnstant cme and g Des it interfere with yur: wrk sleep daily rutine recreatin Name: DOB: Date: pg 2

5 Place an X n the picture here yu have cntinued pain, numbness, tingling. Neighbrhd Chirpractic and Acupuncture LLC Wrkman s Cmp Accident Intake Is there anything else yu wuld like us t knw? Have yu received any additinal treatment ther than what is listed abve? n yes If yes, please fill in the infrmatin. Use the bttm and back side f this frm if mre space is needed. Dates Name f Practitiner Type f Practitiner Treatment MD ND LAc LMT PT DC DO ther: MD ND LAc LMT PT DC DO ther: T the best f my knwledge, the abve infrmatin is cmplete and crrect. I understand it is my respnsibility t infrm my dctr if I r my minr child have any changes t my health. Signature f patient (r parent/ guardian r persnal representative f patient) Relatinship t patient: self parent guardian representative Date Name: DOB: Date: pg 3

6 Back Index Frm BI100 ACN Grup, Inc. Use Only rev 3/27/2003 Patient Name Date This questinnaire will give yur prvider infrmatin abut hw yur back cnditin affects yur everyday life. Please answer every sectin by marking the ne statement that applies t yu. If tw r mre statements in ne sectin apply, please mark the ne statement that mst clsely describes yur prblem. Pain Intensity The pain cmes and ges and is very mild. The pain is mild and des nt vary much. The pain cmes and ges and is mderate. The pain is mderate and des nt vary much. The pain cmes and ges and is very severe. The pain is very severe and des nt vary much. Sleeping I get n pain in bed. I get pain in bed but it des nt prevent me frm sleeping well. Because f pain my nrmal sleep is reduced by less than 25%. Because f pain my nrmal sleep is reduced by less than 50%. Because f pain my nrmal sleep is reduced by less than 75%. Pain prevents me frm sleeping at all. 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 1 hur. Pain prevents me frm sitting mre than 1/2 hur. Pain prevents me frm sitting mre than 10 minutes. I avid sitting because it increases pain immediately. Persnal Care I d nt have t change my way f washing r dressing in rder t avid pain. I d nt nrmally change my way f washing r dressing even thugh it causes sme pain. Washing and dressing increases the pain but I manage nt t change my way f ding it. Washing and dressing increases the pain and I find it necessary t change my way f ding it. Because f the pain I am unable t d sme washing and dressing withut help. Because f the pain I am unable t d any washing and dressing withut help. Lifting I can lift heavy weights withut extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me frm lifting heavy weights ff the flr. Pain prevents me frm lifting heavy weights ff the flr, but I can manage if they are cnveniently psitined (e.g., n a table). Pain prevents me frm lifting heavy weights ff the flr, but I can manage light t medium weights if they are cnveniently psitined. I can nly lift very light weights. Traveling I get n pain while traveling. I get sme pain while traveling but nne f my usual frms f travel make it wrse. I get extra pain while traveling but it des nt cause me t seek alternate frms f travel. I get extra pain while traveling which causes me t seek alternate frms f travel. Pain restricts all frms f travel except that dne while lying dwn. Pain restricts all frms f travel. Standing I can stand as lng as I want withut pain. I have sme pain while standing but it des nt increase with time. I cannt stand fr lnger than 1 hur withut increasing pain. I cannt stand fr lnger than 1/2 hur withut increasing pain. I cannt stand fr lnger than 10 minutes withut increasing pain. I avid standing because it increases pain immediately. Scial Life My scial life is nrmal and gives me n extra pain. My scial life is nrmal but increases the degree f pain. Pain has n significant affect n my scial life apart frm limiting my mre energetic interests (e.g., dancing, etc). Pain has restricted my scial life and I d nt g ut very ften. Pain has restricted my scial life t my hme. I have hardly any scial life because f the pain. Walking I have n pain while walking. I have sme pain while walking but it desn t increase with distance. I cannt walk mre than 1 mile withut increasing pain. I cannt walk mre than 1/2 mile withut increasing pain. I cannt walk mre than 1/4 mile withut increasing pain. I cannt walk at all withut increasing pain. Changing degree f pain My pain is rapidly getting better. My pain fluctuates but verall is definitely getting better. My pain seems t be getting better but imprvement is slw. My pain is neither getting better r wrse. My pain is gradually wrsening. My pain is rapidly wrsening. Index Scre = [Sum f all statements selected / (# f sectins with a statement selected x 5)] x 100 Back Index Scre

7 Neck Index Frm N1-100 ACN Grup, Inc. Use Only rev 3/27/2003 Patient Name Date This questinnaire will give yur prvider infrmatin abut hw yur neck cnditin affects yur everyday life. Please answer every sectin by marking the ne statement that applies t yu. If tw r mre statements in ne sectin apply, please mark the ne statement that mst clsely describes yur prblem. Pain Intensity I have n pain at the mment. The pain is very mild at the mment. The pain cmes and ges and is mderate. 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. Sleeping I have n truble sleeping. My sleep is slightly disturbed (less than 1 hur sleepless). My sleep is mildly disturbed (1-2 hurs sleepless). My sleep is mderately disturbed (2-3 hurs sleepless). My sleep is greatly disturbed (3-5 hurs sleepless). My sleep is cmpletely disturbed (5-7 hurs sleepless). Reading I can read as much as I want with n neck pain. I can read as much as I want with slight neck pain. I can read as much as I want with mderate neck pain. I cannt read as much as I want because f mderate neck pain. I can hardly read at all because f severe neck pain. I cannt read at all because f neck pain. Persnal Care 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 I 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. Lifting I can lift heavy weights withut extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me frm lifting heavy weights ff the flr, but I can manage if they are cnveniently psitined (e.g., n a table). Pain prevents me frm lifting heavy weights ff the flr, but I can manage light t medium weights if they are cnveniently psitined. I can nly lift very light weights. I cannt lift r carry anything at all. Driving I can drive my car withut any neck pain. I can drive my car as lng as I want with slight neck pain. I can drive my car as lng as I want with mderate neck pain. I cannt drive my car as lng as I want because f mderate neck pain. I can hardly drive at all because f severe neck pain. I cannt drive my car at all because f neck pain. Cncentratin I can cncentrate fully when I want with n difficulty. I can cncentrate fully when I want with slight difficulty. I have a fair degree f difficulty cncentrating when I want. I have a lt f difficulty cncentrating when I want. I have a great deal f difficulty cncentrating when I want. I cannt cncentrate at all. Recreatin I am able t engage in all my recreatin activities withut neck pain. I am able t engage in all my usual recreatin activities with sme neck pain. I am able t engage in mst but nt all my usual recreatin activities because f neck pain. I am nly able t engage in a few f my usual recreatin activities because f neck pain. I can hardly d any recreatin activities because f neck pain. I cannt d any recreatin activities at all. Wrk I can d as much wrk as I want. I can nly d my usual wrk but n mre. I can nly 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. Headaches I have n headaches at all. I have slight headaches which cme infrequently. I have mderate headaches which cme infrequently. I have mderate headaches which cme frequently. I have severe headaches which cme frequently. I have headaches almst all the time. Index Scre = [Sum f all statements selected / (# f sectins with a statement selected x 5)] x 100 Neck Index Scre

8 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 cancellatin ntice. We are unable t bill insurance cmpanies fr missed appintments. Thse wh repeatedly miss appintments will be asked t pay $25 fee fr missed/cancelled appintments withut 24-hur ntice. Thank yu fr yur understanding f this matter. Cmmunicatin Cnsent Here at Neighbr Chirpractic and Acupuncture LLC, we are adding different ptins fr cmmunicatin t allw t have better access t yur medical recrds, billing, and appintments. 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 marketing purpses. I, authrize Neighbrhd Chirpractic t cntact me 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 Reminders: Yes Text: N, Prvider may nly leave a name and phne number. Detailed Vic Yes Phne: N, Prvider may nly leave a name and phne number. Detailed Billing: Yes N, prvider may nt cntact me by . Yes N, I prefer billing statements/ crrespndence t be mailed in paper frm. 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