California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)

Transcription

1 California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909) Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female Age: Date of Birth: Marital Status: Single Married Divorced Widowed Occupation: Employer: Spouse s Name: Whom may we thank for referring you? Social Security Number: Drivers License# Insurance Who is responsible for this account? Relationship to patient? Name of Insurance Company? Group # Is Patient covered by additional insurance? Yes or No If yes, please complete below. Subscriber s Name: Patient s Date of Birth: Relationship to Patient: Insurance Company: Group # Accident Information ( If applicable ) Is condition due to an accident? Yes No ( If yes, please complete below) Date of accident: Hour Am/ Pm Where? City Type of accident Auto Work Home Other To whom have you made a report of your accident? Auto insurance Employer Worker comp. Other

2 ACCIDENT INFORMATION ( CONTINUED) Please describe the accident: Have you been treated by another Doctor for this accident? [ ] Yes [ ] No If Yes Who? If Yes How long were you treated by this Doctor? Are you: [ ] Improved [ ] Unchanged [ ] Getting worse ASSIGNMENT AND RELEASE (If applicable) I, the undersigned certify that I, and or my dependent (s), have insurance coverage with Insurance company and assign directly to Dr. Boshears all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment pain is completed or one year from the date signed below. Signature of patient, parent, guardian, or personal representative Please print name of patient, parent, guardian, or personal representative Date Relationship to patient ================================================================= Medications Reason For Taking It Allergies: Vitamins:

3 In case of emergency contact Name Relationship Home phone( ) Work phone( ) PATIENT CONDITION Reason for visit When did your symptoms appear? Is this symptom getting progressively worse? Yes No Unknown Rate the severity of the pain on a scale from 1 (least pain) to 10 (severe pain) What makes your pain worse? What makes the pain better? Have you ever had a prior episode of this pain? Yes / No If yes, when? Type of pain Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling How often do you have this pain? Is it constant or does it come and go? Does it interfere with your Work Sleep Daily routine Activities or movements that are painful to perform Sitting Standing Walking Bending Lying down HEALTH HISTORY What treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic services None Other Name & address of other doctor (s) who have treated you for your condition Date of last: Physical Exam Spinal X-ray Blood test Spinal Exam Chest X-ray Urine test Dental X-ray MRI, Ct scan, Bone scan

4 Check YES to indicate if you had any of the following, And indicate WHEN: Yes AIDS/HIV Yes Liver Disease Yes Alcoholism Yes Measles Yes Allergy Shots Yes Migraine Yes Anemia Yes Headaches Yes Anorexia Yes Chicken Pox Yes Appendicitis Yes Miscarriage Yes Arthritis Yes Mononucleosis Yes Asthma Yes Multiple Sclerosis Yes Breast Lump Yes Mumps Yes Bleeding Yes Osteoporosis Disorders Yes Pacemaker Yes Bronchitis Yes Parkinson s Disease Yes Bulimia Yes Pinched nerve Yes Cancer Yes Pneumonia Yes Cataracts Yes Polio Yes Chemical Yes Prostate Problem Dependency Yes Prosthesis Yes Diabetes Yes Psychiatric Care Yes Emphysema Yes Rheumatoid Arthritis Yes Epilepsy Yes Rheumatic Fever Yes Fractures Yes Scarlet Fever Yes Gout Yes Stroke Yes Gonorrhea Yes Suicide Attempt Yes Glaucoma Yes Thyroid Problems Yes Goiter Yes Tonsillitis Yes Hernia Yes Tumors, Growths Yes Heart Disease Yes Typhoid Fever Yes Hepatitis Yes Ulcers Yes Herniated Disk Yes Venereal Disease Yes Herpes Yes Whooping Chough Yes Kidney Disease Other ================================================================= EXERCISE WORK ACTIVITY HABITS None Sitting Smoking/ pk per day Moderate Standing Alcohol Daily Light Labor Coffee/caffeine Heavy Heavy Labor High stress level Are you pregnant? yes / no (If so, please notify the Doctor today) Due Date Injuries/ Surgeries you ve had Description Date Falls Head Injuries Broken Bones Dislocations Surgeries

5 IMPORTANT: Please check (X) all present symptoms. HEAD: MID-BACK: WOMEN ONLY: [ ] Headache [ ] Mid-back pain [ ] Menstrual pain (where) [ ] sinus (allergy) [ ] Location [ ] Cramping [ ] entire head [ ] Pain between shoulder blades [ ] Irregularity [ ] back of head [ ] Sharp stabbing [ ] Cycle days [ ] forehead [ ] Dull Ache [ ] Birth control type [ ] temples [ ] Pain from front to back [ ] Hysterectomy [ ] migraine [ ] Muscle spasms [ ] Genital cancer [ ] Head feels heavy [ ] Pain in kidney area [ ] Discharge [ ] Loss of memory [ ] Color [ ] Light-headedness CHEST: [ ] Tumors [ ] Fainting [ ] Chest pain [ ] Abortions [ ] Light bothers eyes [ ] Shortness of breath [ ] Menopause [ ] Blurred vision [ ] Pain around ribs [ ] Double vision [ ] Breast pain [ ] Loss of vision [ ] Dimpled or swollen breast MEN ONLY : [ ] Loss of taste [ ] Irregular heartbeat [ ] Urinary frequency [ ] Loss of balance [ ] Difficulty in starting flow [ ] Dizziness ABDOMEN: [ ] Night urination [ ] Loss of hearing [ ] Nervous stomach [ ] Prostate pain/ swelling [ ] Pain in ears [ ] Foods can t eat [ ] Ringing in ears [ ] Nausea [ ] Buzzing in ears [ ] Gas GENERAL: [ ] Constipation [ ] Nervousness NECK: [ ] Diarrhea [ ] Irritable [ ] Pain in neck [ ] Hemorrhoids [ ] Depressed [ ] Neck pain with movement [ ] Fatigue [ ] Forward LOW BACK: [ ] Generally feel run down [ ] Backward [ ] Low back pain [ ] Normal sleep [ ] Turn to left [ ] upper lumbar [ ] Loss of sleep hrs./night [ ] Turn to right [ ] lower lumbar [ ] Loss of weight lbs. [ ] Bend to left [ ] sacroiliac [ ] Coffee cups/day [ ] Bend to right [ ] Low back pain is worse when: [ ] Tea cups/day [ ] Pinched nerve in neck [ ] working [ ] Cigarettes packs/day [ ] Neck feels out of place [ ] lifting [ ] Other [ ] Muscle spasms in neck [ ] stooping [ ] Diabetes [ ] Grinding sounds in neck [ ] standing [ ] Hypoglycemia [ ] Popping sounds in neck [ ] sitting [ ] Arthritis in neck [ ] bending [ ] coughing HEALTH HISTORY: (DOCTOR S USE ONLY) SHOULDERS: [ ] lying down (sleeping) [ ] Pain in shoulder joint (R L) [ ] walking [ ] Pain across shoulders [ ] Pain relieves when [ ] Bursitis (R L) [ ] Slipped disk [ ] Arthritis (R L) [ ] Low back feels out of place [ ] Can t raise arm [ ] Muscle spasms [ ] above shoulder level [ ] Arthritis [ ] over head [ ] Tension in shoulders HIPS, LEGS & FEET: [ ] Pinched nerve in shoulder (R L) [ ] Pain in buttocks (R L) [ ] Muscle spasms in shoulders [ ] Pain in hip joint (R L) [ ] Pain down leg (R L) ARMS & HANDS: [ ] Pain down both legs [ ] Pain in upper arm [ ] Knee pain [ ] Pain in elbow [ ] Inside [ ] Movement aggravated [ ] Outside [ ] Tennis elbow [ ] Leg cramps [ ] Pain in forearm [ ] Cramps in foot (R L) [ ] Pain in hands [ ] Pins & needles in legs (R L) [ ] Pain in fingers [ ] Numbness in legs (R L) [ ] Sensation of pins & needles in arms [ ] Numbness in feet (R L) [ ] Sensation of pins & needles in fingers [ ] Numbness in toes [ ] Numbness in arms (R L) [ ] Feet feel cold [ ] Numbness in fingers (R L) [ ] Swollen ankles (R L) [ ] Fingers go to sleep [ ] Swollen feet [ ] Hands cold [ ] Swollen joints in fingers [ ] Sore joints in fingers [ ] Arthritis in fingers [ ] Loss of grip strength