Brewster Chiropractic Michael B. Singleton DC, MS, CNS, CSCS

Transcription

1 Michael B. Singleton DC, MS, CNS, CSCS How did you hear about this office? Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Preferred to be called Last Name Middle Name Suffix Address 1 Address 2 City State Zip Code Primary Phone Mobile Phone Secondary Phone By providing my address, I authorize my doctor to contact me for office related reasons. Your contact information will not be given out. Preferred Contact Method (check one) Primary Phone Secondary Phone Mobile Phone Home Work By checking this allows the office to contact you. The office sends out a monthly newsletter focused on health chiropractic and exercise, check if you do not want to receive s newsletter Date of Birth / / Age Gender Male Female Unspecified Marital Status (check one) Single Married Other Reason for your visit: When did it start Have you had a similar condition in the past? Yes No If so how many times Have you been treated by any other doctors for this complaint? Yes No Have you been treated by a Chiropractor before? Yes No Was your injury due to an automobile accident? Yes No (if yes, accident date: ) Was your injury related to a accident that happened at work? Yes No (if yes, accident dates: ) If yes, did you report it to anyone? Yes No What was their name position: Occupation: Employer: Name of your medical doctor: Do we have permission to send progress reports to your doctor? Yes No Initials

2 Michael B. Singleton DC, MS, CNS, CSCS PAST MEDICAL HISTORY: Please mark with a check any of the following illnesses that you have had or currently have. Please indicate the dates (estimate the best you can) High Blood Pressure Prostate Disease Multiple Sclerosis Heart disease Venereal Disease Ulcer Stroke Allergies Cancer Diabetes Scoliosis Serious Injury Kidney Disease Mental/emotional Auto accident HIV Seizures Other Is there anything else in your medical history that we should know? List previous hospitalizations: Do not list normal pregnancies. YEAR REASON HOSPITAL Please mark any of the following that you have noticed since the onset of your condition: Fever Headache Chest pain Breast mass Chills Dizziness Palpitations breast pain Night sweats Fainting Difficulty breathing Anxiety Visual changes Appetite changes Swollen extremities Depression Eye pain Abdominal pain Rash Mood changes hearing changes Vomiting Hair changes Memory changes Ringing Diarrhea nail changes Ear pain Painful urination numbness in the arms or legs Family History Have any of your blood relatives had any of the flowing illness? (Please indicate how they are related) High Blood Pressure Heart disease Stroke Blood disease Cancer Epilepsy Diabetes Rheumatoid Arthritis Other

3 Michael B. Singleton DC, MS, CNS, CSCS Many people come to the office for pain relief, which we intend on helping with. This office cares about whole body health. Please let us know if we can help with any of your health goals: More energy and endurance Be stronger Improve balance Have more motivation Be more flexible Have stronger Bones Be less tired Get leaner Sleeping better Get less colds and flu Be happier Immune system Get rid of allergies Be more focused Eating better Stop using laxatives Improve my memory Irritable bowls Reduce my risk of degenerative disease Learn how to reduce stress Concerned about Lyme infection Slow down my accelerated aging learn how to meditate Interested in food sensitivity testing Monitor biomarkers of aging Interested in a cleanse detox program Change from a treating illness orientation to a creating wellness lifestyle Other Decrease the dependency of over the counter pain meds The following information is part of the healthcare reform that the office is required to collect. Thank you for your cooperation with this. Employment Status (check one) Employed FT Student PT Student Other Retired Self Employed Race (check one) White Black/African American Hispanic American Indian/Alaskan Native Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Samoan Native Hawaiian or other Pacific Island Guamanian or Chamorro Other I choose not to specify Multi-Racial (check one) Yes No Unknown Ethnicity (check one) Hispanic or Latino Preferred Language (check one) Not Hispanic or Latino I choose not to specify English Spanish Chinese French German Polish Tagalog Vietnamese Italian Korean Russian Arabic Portuguese Japanese French Creole Greek Hindi Persian Urdu Gujarati Armenian American Sign Language I choose not to specify Verification Question (choose only one question by circling the question, then give the answer to that question) What is the name of your favorite pet? In what city were you born? What high school did you attend? What is your favorite movie? What is your mother s maiden name? On what street did you grow up? What was the make of your first car? When is your anniversary? Verification Answer to the Chosen question: Answers must be at least 6 characters.

4 Do you currently smoke tobacco of any kind? Yes Former smoker Never been a smoker If yes, how often do you smoke: Current every day smoker Current sometimes smoker If yes, what is your level of interest in quitting smoking? No interest Very Interested Current medications, including frequency and dosage if known. If there are no current medications, check here: Start Date 1) 5) 2) 6) 3) 7) 4) 8) Start Date List any known allergies you have had to any medications. If no allergies are known, check here: 1) 3) 2) 4) Has any doctor diagnosed you with Hypertension presently? Yes No, If yes, describe: Has any doctor diagnosed you with Diabetes presently? Yes Type I Type II No If yes, what kind? If yes to Diabetes, was your blood lab-work test for hemoglobin A1c > 9.0%? Yes No Not Sure If yes, other comments or symptoms regarding Diabetes: Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes No To be performed by clinic staff: Height: inches Weight: pounds BP: /

5 SHOW AREA(S) OF PAIN OR UNUSUAL FEELING Mark the areas on this body where you feel the described sensations. Use the appropriate symbols below. Mark areas of radiation. Include all affected areas. Please mark on the pain scale from zero to 10 the pain you feel with this condition. 10 being the worst pain you have felt with this condition. Neck-Shoulder-Arm Pain On a scale of zero to 10, I rate my discomfort as follows: Pain Level NOW? Pain on AVERAGE? Pain AT ITS WORST? Numbness N Pins & Needles P Burning Mid Back Pain On a scale of zero to 10, I rate my discomfort as follows: Pain Level NOW? Aching B Pain on AVERAGE? A Pain AT ITS WORST? Stabbing Low Back & Leg Pain On a scale of zero to 10, I rate my discomfort as follows: Pain Level NOW? Pain on AVERAGE? Pain AT ITS WORST? S Signature: Date: Michael B. Singleton, DC, MS, CNS, 1573 Main Street, Brewster, MA (508)

6 Michael B. Singleton DC, MS, CNS 1573 Main St Brewster, MA Telephone (508) FAX (508) Financial Policy Do not sign until you have read and understand the following I understand and agree that the health and accident policies are in agreement between my insurance carrier and myself. I ( the patient) understand that this office will prepare any necessary reports and forms to assist me in the making of collections from the insurance company, and that any amount authorized to be paid to this office will be credited to my account upon receipt. However, I (the patient) clearly understand and agree that all services rendered are charged directly to my account and that I am personally responsible for payment. I (the patient) hereby authorize payment directly to this office for the professional services rendered and shall be personally responsible for any unpaid balance. I (the patient) hereby authorize the attending doctor to release any pertinent information needed to process such claims. I understand that I ultimately responsible for all services rendered as well as any fees, legal fees, and/or costs that may result if collection action is required. Patient s Signature Date