Patient Information. Legal First Name: MI: Last Name: Street: Apt: City: State: Zip: Social Security #: Marital Status: S M W D Spouse:

Transcription

1 Patient Information Legal First Name: MI: Last Name: Street: Apt: City: State: Zip: Social Security #: Marital Status: S M W D Spouse: Language: English Spanish Other Race: White American Indian or Alaska Native Asian Native Hawaiian/Other Pacific Islander Black or African American Hispanic or Latino Decline to Answer Other Ethnicity: Hispanic or Latino t Hispanic or Latino Decline to Answer DOB: Home Phone: Work Phone: Cell Phone: Cell Carrier Please check your contact preference: Home Work Cell Postal Mail (For occasional office updates, massage coupons, giveaways) Emergency Contact: Phone Number: How did you hear about our office? Occupation: Employer: Primary Care Doctor: Clinic: Address: Phone # Massage Therapy Have you had a massage before: When was your last massage: How often do you receive massage therapy: Any part of your body you do NOT want massaged: feet hands face scalp Type of Massage Preferred: Swedish Deep Tissue Trigger Point Sports Hot Stone Are you sensitive to fragrances or perfumes: Would you like Essential Oil Add On ($3): Would you like Hot Stone Add On ($5):

2 Patient Intake Form Name: Today s Date: Height: Weight: Hand Dominance: Right/Left/Both Blood Pressure: Pulse: Radial/Carotid L/R Are you pregnant? If so how far along are you Chief Complaint Problem that brings you to our facility: Left side/right side How were you injured: Previous Treatment for this problem: Date of Injury/Onset: Is this a work compensation injury? / What is your pain on a scale of 0-10 (10 being the worst): /10 (best) /10 (worst) Please Mark on Body where your problem is Please Circle Appropriate Answer Describe Pain: Mild Moderate Severe Dull Sharp Achy Throbbing Other: Shooting How Often: Constant Frequent Intermittent Occasional When is it better or worse? Worse: Morning Day Evening Better: Morning Day Evening What makes the pain better: What makes the pain worse: Any Muscle Weakness: Any numbness or tingling:

3 General Medical History Please circle appropriate answers Neurological Stroke Migraine Concussion Peripheral Neuropathy Epilepsy Cardiovascular Heart Attack High Blood Pressure Coronary Artery Disease High Cholesterol Kidney Renal Insufficiency Kidney Stones Frequent Urination Infrequent Urination Gastrointestinal Ulcers Reflux Skin Psoriasis Eczema Pulmonary Asthma Emphysema COPD Pulmonary Embolism Infectious HIV/AIDS Hepatitis B Hepatitis C TB MRSA (last 5 years) Hematological Bleeding Problems Blood Clots Concussion Blood Transfusion Anemia Musculoskeletal Osteoarthritis Rheumatoid Arthritis Fibromyalgia Osteoporosis Gout Endocrine Diabetes Thyroid Disease Prednisone Use Psychological Depression Anxiety ADHD Bipolar Claustrophobia Problem not Listed Explain: Current Medications I do not currently take any medications: 1. Medication Reason for Medication Date Started

4 Allergies I do not have any allergies: 1. Allergies Reaction Date Previous Surgery/Hospitalizations past history of surgry/hospitalizations: Surgery/Reason for Hospitalization Hospital/Facility Date Family History Please list for immediate family (parents, grandparents, siblings, children) Disease Relative Age at Diagnosis High Blood Pressure Heart Disease Stroke Asthma Cancer (list relative and type) Other

5 Social History Smoking Status: Please Circle and explain Never Current How Often: Former Smoker How long ago Alcohol Consumption: Please Circle and explain ne Casual Drinker Moderate Drinker Heavy Drinker Type of Alcohol: Caffeine Consumption: Please Circle and explain ne <3 drinks per day 3-6 drinks per day >6 drinks per day Type of Caffeine: Drug Use: Please Circle and explain ne Recreational User Addict Type of Drug: Exercise: Please Circle and explain Never Daily Weekly Type and Frequency: Assignment & Release I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand tht this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this doctors office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees or outstanding balances for services I have received will be immediately due and payable. Patients/Parent s/ Guardian s Signature: Consent to the Release of Information I herby authorize and release the doctor and whomever he/she may designate as his/her assistants, to administer treatment, physical examination, x-ray studies, laboratory procedures, chiropractic care, massage therapy, or any clinic services that he/she deems necessary in my case; I furthermore authorize him/her to disclose all or any part of my patient record to any person or corporation which is or may be liable under a contract to this office or to the patient or to a family member or employer of the patient for all or part of the clinic s charge, including, and not limited to hospital or medical service companies, insurance companies, worker s compensation carriers, welfare funds, or the patient's employer Patients/Parent s/ Guardian s Signature:

6 Protocols and Consent to be treated at Fruita Chiropractic and Massage Inc. In order to promote a good patient-doctor relationship and to foster an environment in which the patient and doctor feel comfortable, Fruita Chiropractic and Massage wants to review that chiropractic treatment is a hands on treatment approach. The doctors may need to palpate and touch your body including you back, legs, feet, buttocks, low back, and associated muscles, abdomen groin, shoulders, chest, and ribs etc. If during the patient s examination it becomes necessary to expose a portion of a patients breast tissue, genital, or gluteal area, the doctor shall inform the patient of the reasons for that portion of the examination and the patient s understanding and consent shall be confirmed by the doctor. If you want someone else to be in the treatment room at any time, Fruita Chiropractic and Massage is happy to accommodate this request. Each practitioner at Fruita Chiropractic and Massage is licensed by the State of Colorado and is an employee practicing at Fruita Chiropractic and Massage. The most common adverse outcomes from chiropractic spinal manipulation have been shown to be: rib fracture, exacerbation of existing painful complains including increased soreness, stiffness and decrease of mobility, and headaches. A very rare risk is a vertebrobasilar (VBS) stroke. It has been estimated that 1 in 400,000 to 1 in 1,000,000 upper cervical spine manipulations could result in a vertebrobasilar stroke. Please ask the doctor if you have any specific questions about this risk. In an attempt to speed your recovery and decrease you pain, Fruita Chiropractic and Massage may use modalities to help compliment the spinal adjustment. The use of modalities such as massage, electrical stimulation, ultra sound, Graston, hot pack/cold pack, and traction are not without risks. I,, acknowledge that I have been provided a copy of Fruita Chiropractic and Massage Protocols and Consent to be treated at Fruita Chiropractic and Massage. Signature Date

7 Fruita Chiropractic and Massage PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS, hereby states that by signing this Consent, I acknowledge and agree as follows: 1. The Practice s Privacy tice has been provided to me prior to my signing this Consent. The Privacy tice includes a complete description of the uses and/or disclosures of my protected health information ( PHI ) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out is health care operations. The Practice explained to me that the Privacy tice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy tice prior to signing this Consent, and has encouraged me to read the Privacy tice carefully prior to my signing this Consent. 2. The Practice reserves the right to change its privacy practices that are described in its Privacy tice, in accordance with applicable law. 3. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) a postcard mailed to me at the address provided by me; and b) telephoning my home and leaving a message on my answering machine or with the individual answering the phone. 4. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations. 5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice. 6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent. 7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me. 8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy tice, then the Practice will not treat me. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand. Name of Individual (Printed) Signature of Individual Signature of Legal Representative Relationship (e.g. attorney-in-fact, guardian, parent if minor) Date signed Witness This form was developed by the ACA (American Chiropractic Association and is distributed with their permission.

8 Cancellation Policy I understand that I am asked to provide 24 hours notice if I need to cancel my appointment, and that I may be charged the following: $25 for chiropractic appointments. (Which will not be covered by your insurance policy) 50% of massage appointment if cancelled after 24 hours cut off, but 4 hours before your appointment time. 100% of massage appointment if cancelled within 4 hours or less of appointment or missed completely. We do understand that special circumstance may arise that might cause unforeseen missed appointments. We may waive the policy if you give us a courtesy call to explain your situation. We strive to give the best quality care and would like to listen and help you the best we can. Signature: Date: