Patient Health History

Transcription

1 Today s Date: Patient Information First Name: M.I. Last Name: Mailing Address: City: State: Zip: Telephone:(home) (work) (cell) address: Secondary Occupation: Employer: Preferred language: English Other Ethnicity: Hispanic Not Hispanic Choose not to specify Multi-racial? Yes No Choose not to specify Race: White Other Male Female Age: Date of Birth: Social Security #: Single Married Divorced Separated Widowed Minor Spouse s Name: Parent s name if under 18: Emergency Contact: Relationship: Phone # Name of Last Chiropractor: Name of MD/DO: Are you Right Handed Left Handed? What is your shoe size?: Whom may we thank for referring us? Financial Information I am paying for these services Health Insurance Auto Insurance Worker s Comp Other Insurance Company: Policy #: Group #: Subscriber s Name: Subscriber s Date of Birth: Subscriber s Social Security #: Relationship to Patient: Current Symptoms Reason for this visit?: Auto Accident Injury Worker s Comp Other: When did these symptoms begin? How did these symptoms begin? Type of pain: (select all the apply) Sharp Dull Throbbing Numb Achy Stabbing Radiating Burning Tingling Cramping Stiff Deep My Pain Is: Constant (75-100% of the day) Frequent (50-75% of the day) Intermittent (25-50% of the day) Occasional (0-25% of the day) Pain Intensity: (no pain) (severe pain) My pain improves when I: My pain worsens when I: My pain prevents me from: My symptoms are: Getting Better Getting Worse Staying the Same Who have you seen for these symptoms? No One Chiropractor Physical Therapist Verification Question: Answer ONLY one question Patient Health History MD Surgeon Other Please mark the location of your current symptoms: Favorite pet s name: Mother s maiden name: Name of high school: First car: Wedding anniversary: City you were born in:

2 Health History Have you ever experienced this problem before? Yes Have you ever had any fractures or dislocations? Yes Have you ever been in any auto accidents? Yes Are you nursing? Yes No Are you currently taking birth control? Yes No Conditions: Please indicate any conditions that you have, or have had in the past: No Describe: No Describe: No Describe: Please list any surgeries you have had: Do you take any prescribed medication? No Yes, please list: Do you take any vitamins or supplements? Yes No Please List: Please list any medication allergies: How frequently do you exercise? Regularly Frequently Occasionally Rarely Never What do your daily work habits include? (sitting, standing, light labor, heavy labor, computer work) Please describe: Do you use tobacco? Current smoker Former smoker Never smoker How often do you smoke? Everyday smoker Sometimes smoker What is you level of interest in quitting? Do you consume alcohol? Yes (No interest) Name: (Strong interest) No How much per week? Women Only: Are you pregnant? Yes No Expected Due Date: AIDS/HIV Chest Pain Neck Pain/Stiffness Stroke Alcoholism Constipation Headaches Osteoporosis High Blood Pressure Allergies Cramps Heart Disease Pacemaker Suicide Attempt Anemia Hepatitis Chemical Dependency Thyroid Problem Hernia Pinched Nerve Appendicitis Concussion Herniated Disc Pneumonia Tuberculosis Arteriosclerosis Depression Polio Tumors/Growth Arthritis Diabetes Asthma Prostate Problems Typhoid Fever Digestive Problems High Cholesterol Prosthesis Ulcers Back Pain Dizziness Kidney Disease Psychiatric Care Bleeding disorders Liver Disease Rheumatoid Arthritis Breast Lump Epilepsy Rheumatic Fever Whooping Cough Bronchitis Fatigue Migraines Scarlet Fever Other: Bruise Easily Fractures Miscarriage Sciatica Glaucoma Mononucleosis Shortness of Breath Cancer Cataracts Multiple Sclerosis Sinus Infection Mumps Sleep Problems Family History: Do you have a first line relative (mother, father, sister, brother, daughter, son) with any of these conditions? Cancer Kidney disease Heart Disease Diabetes Osteoporosis Clotting disorder Stroke High Blood Pressure Lung Disease Septicemia High cholesterol Psychological disorder SIDS Dementia/Alzheimer s Gastrointestinal disorder In the event that x-rays are medically necessary, I GIVE/DO NOT GIVE (circle one) my permission for Durant Chiropractic Clinic to take the necessary films and I accept responsibility for the charges. By signing below I certify that the above questions have been accurately answered to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health.

3 FINANCIAL AGREEMENT The purpose of this agreement is to clarify your financial responsibilities. Below are our most commonly provided services. Procedure Purpose When Performed Fee Consultation Meet the doctor, discuss your health problem, review your case history. First Visit No Charge Examinations Determine the nature and severity of your health problem and to evaluate First visit, new condition, exacerbation, any new or current health problems and determine a treatment plan. and re-evaluation $20-$76 -Rays Visualize the location of spinal problems and confirm other examination First visit, re-injuries, and at certain progress evaluations, if necessary findings. $39-$175 Adjustment Reduce the Vertebral Subluxation Complex and help stabilize your spinal or joint problem. As indicated by examination or evaluation $38-$54 Therapy Reduce inflammation and swelling, speed the healing process, and help provide relief. As indicated by examination or evaluation $14-$65 per unit FORMS OF PAYMENT Patients are responsible for full payment at the time services are rendered. We accept cash, personal checks, Visa, MasterCard, Discover, or Care Credit. FINANCING No interest financing is available at our office through Care Credit. If you would like more information about financing, or to fill out an application, please ask our office representative at the front desk. INSURANCE If you have insurance, worker s compensation, personal injury, or if you were involved in an auto accident we can supply you with documents to help you receive reimbursement from a third party. Your insurance coverage is a contract between you and your insurance company. We will not become involved in disputes with your insurance company regarding deductibles, co-payments or other charges other than to supply factual information. BILLING Any outstanding balances are billed monthly and considered past due 10 days after the invoice date. MISSED APPOINTMENTS It is our policy to make up any missed appointments as soon as possible. Please help us to better serve you and our other patients by keeping scheduled appointments. We reserve the right to charge you, the patient, for any appointment missed without notice. PATIENT AGREEMENT I have read, understood, and agree to this financial policy. AUTHORIZATION AND ASSIGNMENT In consideration of Durant Chiropractic Clinic providing care for me, I agree to the following: 1. You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred. 2. I authorize direct payment to you of any sum I now or hereafter owe you by my attorney, out of the proceeds of any settlement of my case, and by any insurance company obligated to make payment to me or you based in whole, or in part, upon the charges made for your services. 3. In the event any insurance company obligated by any contractual agreement to make payment to me, or to you, for the charges made for your services refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is believed to be correctly set forth under pertinent data) and authorize you to prosecute said action in my name as you see fit and further authorize you to compromise, settle, or otherwise resolve said claim as you see fit. It is understood, however, that until all reasonable efforts have been made to collect the sums due form the insurance company or companies contractually obligated, you will refrain from attempts and efforts to collect the amounts owed directly from me. I understand that whatever amounts you do not collect from insurance company proceeds, whether it be all or part of what is due, I personally owe you.

4 NOTICE OF PRIVACY PRACTICES This notice describes how medical information about you may be used and disclosed and how you can get access to this information. I understand that as part of my healthcare this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health professionals who contribute to my care A source of information for applying my diagnosis information to my bill A means by which a third-party payer can verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change its notice and practices and, prior to implementation, will provide me with a copy of any revised notice. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance upon this agreement. I wish to have the following restrictions to the use or disclosure of my health information: I FULLY UNDERSTAND AND ACCEPT THE TERMS OF THIS CONSENT. INFORMED CONSENT The profession of Chiropractic is regulated in the state of Iowa under Iowa Code Chapter 147. Patient care provided by Doctors of Chiropractic, as with any health professional, have known risks, and you should be aware of the existence of some known risks and limitations. These are seldom enough to contraindicate care, but should be considered in making a decision to receive chiropractic care. All health care procedures have some risks associated with them. Risk associated with some chiropractic adjusting procedures may include musculoskeletal sprain/strain, neurological deficits, disc injuries, dislocations, osseous fractures, cervical myelopathy, vertebral artery syndrome (VAS), including stroke or perhaps death through complicating factors. Some patients may feel some stiffness and soreness following the first few days after treatment. By signing below I state that I have been informed of the possible risks associated with chiropractic care, including the risk that the care may not accomplish the desired objective. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment. I HAVE READ THE ABOVE PARAGRAPHS. I UNDERSTAND THE INFORMATION PROVIDED. THE INFORMATION PROVIDED HAS BEEN E- PLAINED TO ME, AND ALL QUESTIONS WHICH I HAVE ASKED HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE DURANT CHIROPRACTIC CLINIC TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.

5 Headache Disability Inventory Patient Name: Date: Doctor: Instructions: (Please read carefully): The purpose of this scale is to identify difficulties that you may be experiencing because of your headache. Please answer YES, SOMETIMES, or NO to each item only as it relates to your headache and not some other health problem you may have. 1. I have headaches: a) One per month b) More than one but less than four per month c) More than one per week 2. My headache is: a) Mild b) Moderate c) Severe YES SOMETIMES NO 3. Because of my headaches I feel handicapped. o o o 4. Because of my headaches I feel restricted in performing my routine daily activities. o o o 5. No one understands the effect that my headaches have on my life. o o o 6. I restrict my recreational activities (eg. sports, hobbies) because of my headaches. o o o 7. My headaches make me angry. o o o 8. Sometimes I feel that I am going to lose control because of my headaches. o o o 9. Because of my headaches I am less likely to socialize. o o o 10.My spouse (significant other) or family and friends have no idea what I am going through because of my headaches. o o o 11. My headaches are so bad that I feel I am going insane. o o o 12. My outlook on the world is affected by my headaches. o o o 13. I am afraid to go outside when I feel that a headache is starting. o o o 14. I feel desperate because of my headaches. o o o 15. My headaches are so bad I m concerned that I m paying penalties at work or at home. o o o 16. My headaches place stress on my relationships with family or friends. o o o 17. I avoid being around people when I have a headache. o o o 18. I believe my headaches are making it difficult for me to achieve my goals in life. o o o 19. I am unable to think clearly because of my headaches. o o o 20. I get tense (eg. muscle tension) because of my headaches. o o o 21. I avoid traveling because of my headaches. o o o 22. My headaches make me feel confused. o o o 23. My headaches make me feel frustrated. o o o 24. I find it difficult to read because of my headaches. o o o 25. I find it difficult to focus my attention away from my headaches and onto other things. o o o Patient s Signature Score:

6 Neck Pain Disability Index Questionnaire Patient Name: Date: Doctor: Instructions: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage your everyday activities. Please answer each section below utilizing the one best answer that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just circle the one choice that closely describes your problem right now. 1. Pain Intensity: A. I have no pain at the moment. B. The pain is very mild at the moment. C. The pain is moderate at the moment. D. The pain is fairly severe at the moment. E. The pain is very severe at the moment. F. The pain is the worst imaginable at the moment. Personal Care: A. I can look after myself without causing extra pain. B. I can look after myself normally, but it causes extra pain. C. It is painful to look after myself and I am slow and careful. D. I need some help, but manage most of my personal care. E. I need help every day in most aspects of self care. F. I do not get dressed, I wash with difficulty and stay in bed. Lifting: A. I can lift heavy weights without extra pain. B. I can lift heavy weights, but it gives extra pain. C. Pain prevents me from lifting heavy objects off the floor, but I can manage if they are conveniently positioned, e.g., on a table. D. Pain prevents me from lifting heavy weights off the floor, but I can manage it they are conveniently positioned, e.g., on a table. E. I can lift very light weights. F. I cannot lift or carry anything at all. Reading: A. I can read as much as I want to with no pain in my neck. B. I can read as much as I want with slight pain in my neck. C. I can read as much as I want to with moderate pain in my neck. D. I cannot read as much as I want because of moderate pain in my neck. E. I cannot read as much as I want because of severe pain in my neck. Concentration: A. I can concentrate fully when I want to with no difficulty. B. I can concentrate fully when I want to with slight difficulty. C. I have a fair degree of difficulty in concentrating when I want to. D. I have a lot of difficulty in concentrating when I want to. E. I have a great deal of difficulty in concentrating when I want to. F. I cannot concentrate at all. Work: A. I can do as much work as I want to. B. I can only do my usual work, but no more. C. I can do most of my usual work, but no more. D. I cannot do my usual work. E. I can hardly do any work at all. F. I cannot do any work at all. Driving: A. I can drive my car without any neck pain. B. I can drive my car as long as I want with slight pain in my neck. C. I can drive my car as long as I want with moderate pain in my neck. D. I cannot drive my car as long as I want because of moderate pain in my neck. E. I can hardly drive at all because of severe pain in my neck. F. I cannot drive my car at all. Sleeping: A. I have no trouble sleeping. B. My sleep is slightly disturbed (less than 1 hour sleep). C. My sleep is mildly disturbed (1-2 hours sleepless). D. My sleep is moderately disturbed (2-3 hours sleepless). E. My sleep is greatly disturbed (3-5 hours sleepless).. F. My sleep is completely disturbed (5-7 hours sleepless). F. I cannot read at all, it causes too much pain. Headaches: A. I have no headaches at all. B. I have slight headaches which come infrequently. C. I have moderate headaches which come infrequently. D. I have moderate headaches which come frequently. E. I have severe headaches which come frequently. F. I have headaches almost all the time. Recreation: A. I am able to engage in all of my recreational activities, with no neck pain at all. B. I am able to engage in all of my recreational activities with some pain in my neck. C. I am able to engage in most, but not all of my recreational activities because of pain in my neck. D. I have neck pain with most recreational activities. E. I can hardly do any recreation activities because of pain in my neck. F. I cannot do any recreation activities at all. Patient s Signature Score:

7 Revised OSWESTRY Low Back Pain Disability Questionnaire Patient Name: Date: Doctor: Instructions: This questionnaire is designed to enable us to understand how much your low back pain has affected your ability to manage your everyday activities. Please answer each section below utilizing the one best answer that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just circle the one choice that closely describes your problem right now. Pain Intensity: A. The pain is mild and comes and goes. B. The pain is mild and does not vary much. C. The pain is moderate and comes and goes. D. The pain is moderate and does not vary much. E. The pain is severe and comes and goes. F. The pain is severe and does not vary much. Personal Care: A. I do not have to change the way I wash and dress myself to avoid pain. B. I do not normally change the way I wash or dress myself even though it causes some pain. C. Washing and dressing increases my pain, but I can do it without changing my way of doing it. D. Washing and dressing increases my pain, and I find it necessary to change the way I do it. E. Because of my pain, I am partially unable to wash and dress without help. F. Because of my pain, I am completely unable to wash or dress without help. Sleeping: A. I get no pain when I am in bed. B. I get pain in bed, but it does not prevent me from sleeping well. C. Because of my pain, my sleep is only 3/4 of my normal amount. D. Because of my pain, my sleep is only 1/2 of my normal amount. E. Because of my pain, my sleep is only 1/4 of my normal amount. F. Pain prevents me from sleeping at all. Walking: A. I have no pain when walking. B. I have pain when walking, but I can still walk my required normal distances. C. Pain prevents me from walking long distances. D. Pain prevents me from walking intermediate distances. E. Pain prevents me from walking even short distances. F. Pain prevents me from walking at all. Traveling: A. I get no increased pain when traveling. B. I get some pain while traveling, but none of my usual forms of travel make it any worse. C. I get increased pain while traveling, but it does not cause me to seek alternative forms of travel. D. I get increased pain while traveling which causes me to seek alternative forms of travel. E. My pain restricts all forms of travel except that which is done while I am lying down. F. My pain restricts all forms of travel. Standing: A. I can stand as long as I want without increased pain. B. I can stand as long as I want but my pain increases with time. C. Pain prevents me from standing more than 1 hour. D. Pain prevents me from standing more than 1/2 hour. E. Pain prevents me from standing more than 10 minutes. F. I avoid standing because it increases my pain right away. Lifting: A. I can lift heavy weights without increased pain. B. I can lift heavy weights, but it gives extra pain. C. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (ex. on a table, etc.). D. Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. E. I can lift only very light weights. F. I cannot lift or carry anything at all. Social Life: A. My social life is normal and does not increase my pain. B. My social life is normal, but it increases my level of pain. C. Pain prevents me from participating in more energetic activities (ex. sports, dancing, etc.). D. Pain prevents me from going out very often. E. Pain has restricted my social life to my home. F. I have hardly any social life because of my pain. Sitting: A. Sitting does not cause me any pain. B. I can only sit as long as I like providing that I have my choice of seating surfaces. C. Pain prevents me from sitting for more than 1 hour. D. Pain prevents me from sitting for more than a ½ hour. E. Pain prevents me from sitting for more than 10 minutes. F. Pain prevents me from sitting at all. Employment/Homemaking: A. My normal job/homemaking activities do not cause pain. B. My normal job/homemaking activities increase my pain, but I can still perform all that is required of me. C. I can perform most of my job/homemaking duties, but pain prevents me from performing more physically stressful activities (ex. lifting, vacuuming). D. Pain prevents me from doing anything but light duties. E. Pain prevents me from doing even light duties. F. Pain prevents me from performing any job or homemaking chores. Patient s Signature Score:

8 Roland Morris Spine Pain Questionnaire Patient Name: Date: Doctor: Instructions: When your neck or back hurts, you may find it difficult to do some of the things you normally do. Check only the sentences that describe you today. I stay at home most of the time because of my back. I change position frequently to try to get my back comfortable. I walk more slowly than usual because of my back. Because of my back, I am not doing my jobs that I usually do around the house. Because of my back, I use a handrail to get upstairs. Because of my back, I lie down to rest more. Because of my back, I hold on to something to get out of an easy chair. Because of my back, I try to get other people to do things for me. I get dressed more slowly because of my back. I only stand up for short periods of time because of my back. Because of my back, I try not to bend or kneel. I find it difficult to get out of a chair because of my back. My back is painful almost all of the time. I find it difficult to turn over in bed because of my back. My appetite is not very good because of my back. I have trouble putting on my socks because of my back I can only walk short distances because of my back pain. I sleep less well because of my back. Because of my back pain, I get dressed with help of someone else. I sit down for most of the day because of my back. I avoid heavy jobs around the house because of my back Because of back pain, I am more irritable and bad tempered with peoplel. Because of my back, I go upstairs more slowly than usual. I stay in bed most of the time because of my back. Patient s Signature Score: