JACKSONVILLE HEALTH AND WELLNESS / CASE HISTORY

Transcription

1 JACKSONVILLE HEALTH AND WELLNESS / CASE HISTORY PATIENT INFORMATION Name Date Sex M F Age Height Weight Birthdate Social Security # [ ] Married [ ] Widowed [ ] Single [ ] Minor [ ] Separated [ ] Divorced [ ] Partnered for years Address City State Zip Occupation Patient Employer/School SPOUSE/PARTNER Name Birthdate Social Security # Employer PHONE NUMBERS/CONTACT INFORMATION Home Phone ( ) Cell Phone ( ) Work Phone ( ) Best time to call and reach you address In case of emergency contact: Name Relationship Phone PRIMARY MEDICAL DOCTOR Doctor Name Practice Name Phone Number Address REFFERAL How were you referred to our office INSURANCE Who is responsible for this account and relationship to patient? Primary Insurance Co. Policy # Group # Secondary Insurance Co. Policy # Group# Subscriber s Name D.O.B. Social Security # ACCIDENT INFORMATION Is condition due to accident? [ ]Yes [ ]No Date of Accident Type of accident [ ] Auto [ ]Work [ ] Home Attorney Name(if applicable) Have you reported your accident and to whom? Location of Accident Insurance Co. Address Phone # Policy # Claim # Adjuster s Name PATIENT CONDITION Reason for visit Location/Description of Complaint Complaint Began when and how? Please circle quality of complaint/pain: dull ache sharp shooting burning throbbing deep other Does the complaint/pain radiate or travel (shoot) to any areas of your body? Where? Do you have any numbness or tingling in your body? Where? Grade Intensity/Severity (No complaint/pain) (Worst possible pain imaginable) Is the complaint/pain [ ] constant [ ] come and go How long does it last? Does anything aggravate the complaint? Does anything make the complaint better?

2 JACKSONVILLE HEALTH AND WELLNESS / CASE HISTORY PATIENT CONDITION CONTINUED What treatment have you already received for your condition? [ ] None [ ] Surgery [ ] Medications [ ] Physical Therapy [ ] Massage [] Yoga [] Meditation [] Nutrition Counseling [ ] Chiropractic - When? [ ] Other PAST/ CURRENT MEDICAL HISTORY ****IMPORTANT****YOUR CURRENT OR PAST HEALTH, SURGERIES, & MEDICATION WILL EFFECT THE TYPE OF TREATMENT YOU RECEIVE AT OUR OFFICE Date of Last: Physical Exam Spinal X-Ray Blood Work MRI Please list ALL PAST and CURRENT MEDICAL Problems and Conditions Please list ALL surgeries Please list ALL Medications and/or Vitamins and Herbs AND THE REASON FOR TAKING THEM Allergies FAMILY HISTORY Family Member Medical Condition Family Member Medical Condition

3 JACKSONVILLE HEALTH AND WELLNESS / CASE HISTORY CURRENT LIFESTYLE Please describe your current OR past exercise regimen (if applicable) Work Activity: [ ] Sitting [ ] Standing [ ] Light Labor [ ] Heavy Labor [ ] Student Habits: [ ] Smoking; Packs/Day [ ] Alcohol;Drinks/Week [ ] Coffee; Cups/Day Stress Level: [ ] High [ ] Medium [ ] Low Reason? Dietary Habits: Glasses of Water Daily; Carbonated Beverages Daily; Dairy Daily Please list typical: Breakfast Lunch Dinner Snacks Sleeping Pattern: [ ] Inability to Fall Asleep [ ] Wake up Often [ ] Other WELLNESS GOALS Are you interested in achieving (Please check one)? [] Symptomatic Relief relief of your signs and symptoms (pain, heartburn, etc.) [] Symptomatic Relief & Corrective Care relief of signs and symptoms as well as correcting the cause of the symptom [] Symptomatic Relief, Corrective Care & Optimal Health addition of physical, mental, & chemical well being; prevention; & improving quality and quantity of life. Our treatment protocols incorporate a WHOLE BODY approach to health and wellness as we offer a comprehensive array of services for many health related problems. Therefore, by answering the following questions it will help us to individualize/customize your treatment plan. Would you like help with: NO YES Additional Health Goals or Comments Exercise [] [] Nutrition & Eating Better [] [] Stress Reduction [] [] Weight Loss [] [] Decreased Reliance on Medication [] [] Improving Posture [] [] Flexibility [] [] Learning about wellness [] [] Energy Levels [] [] ACTIVITIES OF DAILY LIVING Please grade the following activities on how they are impacted by your current health status/condition Unable to perform Able to perform Personal Care Lifting Reading & Concentration Work Driving & Traveling Sleeping Recreation Hand Coordination Walking Sitting Standing Social Life Household Duties (laundry, etc.) Exercising Other: Patient Signature and Date:

4 JACKSONVILLE HEALTH AND WELLNESS AUTHORIZATION FOR TREATMENT THIS CONSTITUTES INFORMED CONSENT FOR MASSAGE, PHYSICAL THERAPY, AND/OR CHIROPRACTIC I hereby authorize the giving of treatment, performance of diagnostic procedures, examination and the administration of any other judgment by my physician that may be considered necessary or advisable for my diagnosis or treatment while a patient at Jacksonville Health and Wellness Center. Female patients only : I am not pregnant. PATIENT INITIAL PAYMENT AGREEMENT I acknowledge that I am financially responsible for non-covered services. I also understand that if I terminate my care and treatment, any fees for professional services rendered me at Jacksonville Health and Wellness Center will be immediately due and payable. PATIENT INITIAL ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By my signature on the bottom, I acknowledge that I have received a copy of the Notice of Privacy Practices. PATIENT INITIAL AUTHORIZATION, ASSIGNMENT AND RELEASE I hereby assign, direct and authorize my insurance benefits to be paid by check made out and mailed directly to: C/O (in care of) Jacksonville Health and Wellness Center. If my current policy prohibits direct payment to doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows: C/O (in care of) Jacksonville Health and Wellness Center for professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. I understand that there is a possibility that I will receive a payment from my insurance company for services rendered from this facility, thus, those payments will be rendered to said facility otherwise I will be billed. A PHOTOCOPY OF THIS ASSIGNMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. Patient/Policy Holder also authorizes the doctor to complain to the insurance commissioner for any reason. I hereby authorize my insurance carrier to release information regarding my insurance coverage PATIENT INITIAL

5 JACKSONVILLE HEALTH AND WELLNESS AUTHORIZATION AND ASSIGNMENT MEDICARE BENEFICIARY ONLY I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration, or its intermediaries or carriers any information needed for this or a related Medicare claim. I request payment of authorized Medicare benefits on my behalf for any servicres furnished me to Jacksonville Health and Wellness Center. PATIENT INITIAL PATIENT RECORD OF DISCLOSURE I wish to be contacted in the following manner (for emergency, non emergency, disclosure of testing/diagnostic results, scheduling of appointments, etc.) (check all that apply). Home Telephone Work Telephone Written communication Date Name of Patient (Please Print) Signature of Guardian (If Minor) Date Signature of Policy Holder Witness

6 You & Your Massage Massage can be a very beneficial tool on your way to recovering and feeling better. Massage is an excellent stress buster and can relieve sore muscles. In order to maximize your treatment, listed below are the types of massage that we offer: Swedish Massage This form of massage is used to loosen muscles due to stress and overuse. Swedish is wonderful for relaxation and tension release. The pressure used is usually light to moderate. Deep Tissue Massage Deep tissue is just as it sounds. This is for someone with knotted muscles that can benefit from a massage that is given with a lot of pressure Neuromuscular Therapy (NMT) NMT is designed to zero in on one problem area. It targets a muscle or trigger point that is ultimately causing the pain and discomfort. The pressure is moderate to deep. This is to release the tight and knotted muscle (s). Pregnancy Massage Pregnancy Massage is very beneficial for the Mom-to-be. The Mom is positioned comfortably (usually lying on her side) and then given a light/moderate massage on the areas that are causing her discomfort. Please indicate which massage you are interested in today: Everyone is different and requires different pressure. Please indicate below the pressure that you would prefer so that we can make your massage the most comfortable for you. With 0 being the least amount of pressure and 10 being the most amount of pressure that you can withstand. Circle one below: Thank you so much for entrusting us with your care and please let us know if there is anything we can do to make your Massage experience more pleasurable. Patient Name: Date: / /

7 JACKSONVILLE HEALTH & WELLNESS CANCELLATION POLICY 9957 Moorings Drive, Suite 403 Jacksonville, Fl DATE: CANCELLATION POLICY 24-hour notice from time of scheduled appointment is required for: 1. Massage appointments (30 MINUTES OR GREATER) & 2. ALL NUTRITIONAL appointments to avoid a $25.00 charge. With my signature below, I have been made aware of the 24-hour cancellation policy. Printed Name: Signature:

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9 Nutritional Assessment Questionnaire 1.5 Name: / / Birth Date: Please list your five major health concerns in order of importance: 1. Notes: Date: Gender: PART I KEY: Read the following questions and circle the number that applies: 0 = Do not consume or use 1 = Consume or use 2 to 3 times monthly 2 = Consume or use weekly 3 = Consume or use daily DIET Alcohol Artificial sweeteners Candy, desserts, refined sugar Carbonated beverages Chewing tobacco Cigarettes Cigars/pipes Caffeinated beverages Fast foods Fried foods Luncheon meats Margarine Milk products Radiation exposure (0=no, Refined flour/baked goods Vitamins and minerals Water, distilled Water, tap Water, well Diet often for weight control LIFESTYLE Exercise per week (0 = 2 or more times a week, 1 = 1 time a week, 2 = 1 or 2 times a month, 3 = never, less than once a month) Changed jobs (0 = over 12 months ago, 1 = within last 12 months, 2 = within last 6 months, 3 = within last 2 months) Divorced (0 = never, over 2 years ago, 1 = within last 2 years, 2 = within last year, 3 = within last 6 months) Work over 60 hours/week (0 = never, 1 = occasionally, 2 = usually, 3 = always) MEDICATIONS Indicate any medications you re currently taking or have taken in the last month (0=no, : Antacids Antianxiety medications Antibiotics Anticonvulsants Antidepressants Antifungals Aspirin/Ibuprofen Asthma inhalers Beta blockers Birth control pills/implant contraceptives Chemotherapy Cholesterol lowering medications Cortisone/steroids Diabetic medications/insulin Diuretics Estrogen or progesterone (pharmaceutical, prescription) Estrogen or progesterone (natural) Heart medications High blood pressure medications Laxatives Recreational drugs Relaxants/Sleeping pills Testosterone (natural or prescription) Thyroid medication Acetaminophen (Tylenol) Ulcer medications Sildenafal citrate (Viagra) PART II: Key (0=No, symptom does not occur, 5=Severe symptom, occurs frequently) Section Belching or gas within one hour after eating Heartburn or acid reflux Bloating within one hour after eating Vegan diet (no dairy, meat, fish or eggs) (0=no, Bad breath (halitosis) Loss of taste for meat Sweat has a strong odor Stomach upset by taking vitamins Sense of excess fullness after meals Feel like skipping breakfast Feel better if you don t eat Sleepy after meals Fingernails chip, peel or break easily Anemia unresponsive to iron Stomach pains or cramps Diarrhea, chronic Diarrhea shortly after meals Black or tarry colored stools Undigested food in stool

10 Section Pain between shoulder blades Stomach upset by greasy foods Greasy or shiny stools Nausea Sea, car, airplane or motion sickness History of morning sickness (0 = no, 1 = yes) Light or clay colored stools Dry skin, itchy feet or skin peels on feet Headache over eyes Gallbladder attacks (0=never, 1=years ago, 2=within last year, 3=within past 3 months) Gallbladder removed (0=no, Bitter taste in mouth, especially after meals Become sick if you were to drink wine (0=no, Easily intoxicated if you were to drink wine (0=no, Easily hung over if you were to drink wine (0=no, Alcohol per week (0=<3, 1=<7, 2 =<14, 3=>14) Recovering alcoholic (0=no, History of drug or alcohol abuse (0=no, History of hepatitis (0=no, Long term use of prescription/recreational drugs (0=no, Sensitive to chemicals (perfume, cleaning agents, etc.) Sensitive to tobacco smoke Exposure to diesel fumes Pain under right side of rib cage Hemorrhoids or varicose veins Nutrasweet (aspartame) consumption Sensitive to Nutrasweet (aspartame) Chronic fatigue or Fibromyalgia Section Food allergies Abdominal bloating 1 to 2 hours after eating Specific foods make you tired or bloated (0=no, Pulse speeds after eating Airborne allergies Experience hives Sinus congestion, "stuffy head" Crave bread or noodles Alternating constipation and diarrhea Crohn's disease (0 =no, 1=yes in the past, 2=currently mild condition, 3=severe) Wheat or grain sensitivity Dairy sensitivity Are there foods you could not give up (0=no, Asthma, sinus infections, stuffy nose Bizarre vivid dreams, nightmares Use over-the-counter pain medications Feel spacey or unreal Section Anus itches Coated tongue Feel worse in moldy or musty place Taken antibiotic for a total accumulated time of (0=never, 1= <1 month, 2= <3 months, 3= >3 months) Fungus or yeast infections Ring worm, "jock itch", "athletes foot", nail fungus Yeast symptoms increase with sugar, starch or alcohol Stools hard or difficult to pass History of parasites (0=no, Less than one bowel movement per day Stools have corners or edges, are flat or ribbon shaped Stools are not well formed (loose) Irritable bowel or mucus colitis Blood in stool Mucus in stool Excessive foul smelling lower bowel gas Bad breath or strong body odors Painful to press along outer sides of thighs (Iliotibial Band) Cramping in lower abdominal region Dark circles under eyes Section History of carpal tunnel syndrome (0=no, History of lower right abdominal pains or ileocecal valve problems (0=no, History of stress fracture (0=no, Bone loss (reduced density on bone scan) Are you shorter than you used to be? (0=no, Calf, foot or toe cramps at rest Cold sores, fever blisters or herpes lesions Frequent fevers Frequent skin rashes and/or hives Herniated disc (0=no, Excessively flexible joints, "double jointed" Joints pop or click Pain or swelling in joints Bursitis or tendonitis History of bone spurs (0=no, Morning stiffness Nausea with vomiting Crave chocolate Feet have a strong odor History of anemia Whites of eyes (sclera) blue tinted Hoarseness Difficulty swallowing Lump in throat Dry mouth, eyes and/or nose Gag easily White spots on fingernails Cuts heal slowly and/or scar easily Decreased sense of taste or smell

11 Section Experience pain relief with aspirin (0=no, Crave fatty or greasy foods Low- or reduced-fat diet (0=never, 1=years ago, 2=within past year, 3=currently) Tension headaches at base of skull Headaches when out in the hot sun Sunburn easily or suffer sun poisoning Muscles easily fatigued Dry flaky skin or dandruff Section Awaken a few hours after falling asleep, hard to get back to sleep Crave sweets Binge or uncontrolled eating Excessive appetite Crave coffee or sugar in the afternoon Sleepy in afternoon Fatigue that is relieved by eating Headache if meals are skipped or delayed Irritable before meals Shaky if meals delayed Family members with diabetes (0=none, 1=1 or 2, 2=3 or 4, 3=more than 4) Frequent thirst Frequent urination Section Muscles become easily fatigued Feel exhausted or sore after moderate exercise Vulnerable to insect bites Loss of muscle tone, heaviness in arms/legs Enlarged heart or congestive heart failure Pulse below 65 per minute (0=no, Ringing in the ears (Tinnitus) Numbness, tingling or itching in hands and feet Depressed Fear of impending doom Worrier, apprehensive, anxious Nervous or agitated Feelings of insecurity Heart races Can hear heart beat on pillow at night Whole body or limb jerk as falling asleep Night sweats Restless leg syndrome Cracks at corner of mouth (Cheilosis) Fragile skin, easily chaffed, as in shaving Polyps or warts MSG sensitivity Wake up without remembering dreams Small bumps on back of arms Strong light at night irritates eyes Nose bleeds and/or tend to bruise easily Bleeding gums especially when brushing teeth Section Tend to be a "night person" Difficulty falling asleep Slow starter in the morning Tend to be keyed up, trouble calming down Blood pressure above 120/ Headache after exercising Feeling wired or jittery after drinking coffee Clench or grind teeth Calm on the outside, troubled on the inside Chronic low back pain, worse with fatigue Become dizzy when standing up suddenly Difficulty maintaining manipulative correction Pain after manipulative correction Arthritic tendencies Crave salty foods Salt foods before tasting Perspire easily Chronic fatigue, or get drowsy often Afternoon yawning Afternoon headache Asthma, wheezing or difficulty breathing Pain on the medial or inner side of the knee Tendency to sprain ankles or "shin splints" Tendency to need sunglasses Allergies and/or hives Weakness, dizziness Section Height over 6' 6" (0=no, Early sexual development (before age 10) (0=no, Increased libido Splitting type headache Memory failing Tolerate sugar, feel fine when eating sugar (0=no, Height under 4' 10" (0=no, Decreased libido Excessive thirst Weight gain around hips or waist Menstrual disorders Delayed sexual development (after age 13) (0=no, Tendency to ulcers or colitis

12 Section Sensitive/allergic to iodine Difficulty gaining weight, even with large appetite Nervous, emotional, can't work under pressure Inward trembling Flush easily Fast pulse at rest Intolerance to high temperatures Difficulty losing weight Mentally sluggish, reduced initiative Easily fatigued, sleepy during the day Sensitive to cold, poor circulation (cold hands and feet) Constipation, chronic Excessive hair loss and/or coarse hair Morning headaches, wear off during the day Loss of lateral 1/3 of eyebrow Seasonal sadness Section 12 Men Only Prostate problems Difficulty with urination, dribbling Difficult to start and stop urine stream Pain or burning with urination Waking to urinate at night Interruption of stream during urination Pain on inside of legs or heels Feeling of incomplete bowel evacuation Decreased sexual function Section 13 Women Only Depression during periods Mood swings associated with periods (PMS) Crave chocolate around periods Breast tenderness associated with cycle Excessive menstrual flow Scanty blood flow during periods Occasional skipped periods Variations in menstrual cycles Endometriosis Uterine fibroids Breast fibroids, benign masses Painful intercourse (dysparenia) Vaginal discharge Vaginal dryness Vaginal itchiness Gain weight around hips, thighs and buttocks Excess facial or body hair Hot flashes Night sweats (in menopausal females) Thinning skin Section Aware of heavy and/or irregular breathing Discomfort at high altitudes "Air hunger" or sigh frequently Compelled to open windows in a closed room Shortness of breath with moderate exertion Ankles swell, especially at end of day Cough at night Blush or face turns red for no reason Dull pain or tightness in chest and/or radiate into right arm, worse with exertion Muscle cramps with exertion Section Pain in mid-back region Puffy around the eyes, dark circles under eyes History of kidney stones (0=no, Cloudy, bloody or darkened urine Urine has a strong odor Section Runny or drippy nose Catch colds at the beginning of winter Mucus producing cough Frequent colds or flu (0=1 or less per year, 1=2 to 3 times per year, 2=4 to 5 times per year, 3=6 or more times per year) Other infections (sinus, ear, lung, skin, bladder, kidney, etc.) (0=1 or less per year, 1=2 to 3 times per year, 2=4 to 5 times per year, 3=6 or more times per year) Never get sick (0 = sick only 1 or 2 times in last 2 years, 1 = not sick in last 2 years, 2 = not sick in last 4 years, 3 = not sick in last 7 years) Acne (adult) Itchy skin (Dermatitis) Cysts, boils, rashes History of Epstein Bar, Mono, Herpes, Shingles, Chronic Fatigue Syndrome, Hepatitis or other chronic viral condition (0 = no, 1 = yes in the past, 2 = currently mild condition, 3 = severe)

13 FOOD DIARY NAME: List 3 Typical (Breakfast Meals) Approximate Time: List 3 Typical (Lunch Meals) Approximate Time: List 3 Typical (Dinner Meals) Approximate Time: Beverages :How many glasses? Water Soda Juice Coffee Tea Other: Please List all Medication/Vitamins/Herbs as well as approximate time taken and if they were taken with/without meals.