Kish Chiropractic 320 West Main Street Mount Horeb, WI

Transcription

1 Kish Chiropractic 320 West Main Street Mount Horeb, WI History of Primary Complaint If you are filling this form in electronically, you can use the tab key to move through the fields. First Name: MI: Last Name: Nickname: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: SSN (Include if you have Medicare/Medicaid): Birth Date: Age: Height: Weight: Who referred you? How did you choose us? Race: White Black/African American Hispanic Other Choose not to specify Multi- Racial: Yes No Choose not to specify Ethnicity: Hispanic or Latino Not Hispanic or Latino Choose not to specify Preferred Language: English Spanish Other Choose not to specify Have you been treated by a physician within the last year? Health History If so, what were you treated for? Are you currently taking prescribed medications? If so, which medications? (include dosage and frequency) Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoker What medications are you allergic to? None or List here: Do you have any implants (plates, wires, screws) or artificial joint, nerve stimulator, or pace maker? None or List here: For women: Is there a possibility that you may be pregnant? List any surgeries below Date List any accidents below Date

2 Primary Complaint Date of onset: How did your injury occur? This problem prevents me from: Location of injury Chief complaint Mode of onset Character of discomfort Overexertion or Dull ache strenuous position Burning Mid back pain Auto accident Sharp/stabbing Low back pain Fall / trip / slip Throbbing Leg pain ( L / R ) Work related Radiating Headache Gradual Hip or Buttock Pain now Circle two: pain best & worst Relation to other body systems Bowel/bladder Muscle Weakness Fever in last week Night sweats No apparent relationship Were you treated? Severity Mild annoyance, no impairment Slight some mild impairment Moderate marked impairment Severe incapacitated or bedridden Aggravating factors Cough/sneeze/bowel movement Lifting/bending/push/pull Driving/riding/sitting Walking/running/standing Change body positions Who have you seen? Duration Intermittent (< 25% of the time) Occasional (25%- 50% of the time) Frequent (50%- 75% of the time) Constant (75%- 100% of the time) Relieving factors Rest Hot packs Cold packs Bracing/taping Sitting/standing/lying Stretching / exercise Did you have: Xrays CT Scan MRI Are you taking <PAIN> medication for this condition? If so, what kind of medication? Anything else you want to share about your condition? Print Patient Name 2

3 Secondary Complaint Date of onset : How did your injury occur? This problem prevents me from: Location of injury Chief complaint Mode of onset Character of discomfort Overexertion or Dull ache strenuous position Burning Mid back pain Auto accident Sharp/stabbing Low back pain Fall / trip / slip Throbbing Leg pain ( L / R ) Work related Radiating Headache Gradual Hip or Buttock Severity Duration Pain now Circle two: pain best & worst Relation to other body systems Bowel/bladder Muscle Weakness Fever in last week Night sweats No apparent relationship Were you treated? Mild annoyance, no impairment Slight some mild impairment Moderate marked impairment Severe incapacitated or bedridden Aggravating factors Cough/sneeze/bowel movement Lifting/bending/push/pull Driving/riding/sitting Walking/running/standing Change body positions Who have you seen? Intermittent (< 25% of the time) Occasional (25%- 50% of the time) Frequent (50%- 75% of the time) Constant (75%- 100% of the time) Relieving factors Rest Hot packs Cold packs Bracing/taping Sitting/standing/lying Stretching / exercise Did you have: Xrays CT Scan MRI Are you taking <PAIN> medication for this condition? If so, what kind of medication? Anything else you want to share about your condition? Print Patient Name 3

4 Do you currently have or have you previously had any of the following: (check S for Self, M for Mother, and F for Father) Alcoholism Diabetes Anemia Disability Arthritis Indigestion/ heart burn Asthma Dislocated joint Back pain German measles Bladder trouble Bone fracture Cancer Chest pain Constipation Concussion Convulsion/ Seizures Depression Headaches Heart trouble/ disease Hepatitis A/B/C High blood pressure Kidney disorder Loss of bowel control Menstrual cramps Multiple sclerosis Muscular dystrophy Nervousness or anxiety Numbness Polio Poor circulation Psychiatric hospitalization Rhumatic fever Sinus problems Substance abuse/ addiction Tuberculosis HIV Has a doctor diagnosed you with hypertension recently? Describe: Has any doctor diagnosed you with Diabetes presently? What kind? Type 1 Type 2 Are there any other health concerns you would like to share? Please fill in the information for your immediate family members Family Member Year Born Age at death Cause of death All health conditions Mother Father Brother Brother Sister Sister Other Other Print Patient Name 4

5 Chiropractic Care Privacy Permission to contact Payment X- ray General Acknowledgements (Please check each box) I Instruct the chiropractor to deliver the care that, in his professional judgment, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and designed to reduce or correct vertebral subluxation. Chiropractic is a separate and distinct art form medicine and does not proclaim to cure any named disease or entity. I may request a copy of the Privacy Policy and understand that it describes how my personal health information is protected and released on my behalf for seeking reimbursement from any involved third parties. I grant permission to be contacted as stated in the next section. I grant permission to be contacted to confirm or reschedule an appointment via phone, text or and to be sent occasional cards, letters, s or health information as an extension of my care in this office. I acknowledge that any insurance I may have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non- covered services I receive. Payment is due at the time of service. Billing for any service not paid within 60 days will incur a rebilling fee of $5.00 and interest at 12% APR. I realize an X- ray examination may be hazardous to an unborn child and I certify that to the best of my knowledge I am not pregnant and I understand the risks. Date of last menstrual period: To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern. Please choose ONE security question and give an answer so we can set up your account: What is the name of your favorite pet? In what city were you born? On what street did you grow up? What is your mother s maiden name? What was the make of your first car? What is your favorite movie? Please print the answer below, legibly: (must be at least 6 characters) Is there anything else you would like for us to know? PRINT NAME: OR PARENT/ GUARDIAN: SIGNATURE: DATE: Print Patient Name 5