HEALTH COMPLAINTS PLEASE LIST IN ORDER SEVERITY & IMPORTANCE
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1 265 W. Uwchlan Ave. Dwningtwn, PA NEW PATIENT INTAKE Name: Date: / /20 Persnal Infrmatin: Date f Birth: Age: Sex: Female Male Hme Address: City: State: Zip: Hme Phne: ( ) Cell Phne: ( ) Hme Emergency Cntact: Other: HEALTH COMPLAINTS PLEASE LIST IN ORDER SEVERITY & IMPORTANCE Please List Any Hbby/ Outside Interests: Please Describe Hw Yu Hurt Yurself? PLEASE NOTIFY FRONT DESK IF YES BELOW: Was this injury frm Aut-Accident? Yes N Date f accident: Claim # PLEASE NOTIFY FRONT DESK IF YES BELOW: Was this injury frm Wrking? Yes N Date f accident: Claim # Emplyer Infrmatin: Emplyer: Wrk Address: City: State:_ Zip: Type f wrk: Wrk requirements: Prir Dctr f Chirpractic (DC): Name: Phne Number:( ) Preferred Adjusting Technique: Last Adjustment Date: Primary Care Dctr (MD, DO): Name: Phne Number:( ) Other Specialists: Name: Specialty: Phne Number:( ) Name: Specialty: Phne Number:( ) Please State Any Treatments & Medicatins Received Treatment: Name: Date: Results: Date(s) Surgery(s) Reasn(s) WHOM MAY WE THANK FOR RECOMMENDIN CHIROPRACTIC CARE? Insurance Online YellwPages Friend/Family:
2 265 W. Uwchlan Ave Dwningtwn, PA PAIN DRAWIN Name: Date: Please be sure t fill this ut extremely accurately. Mark the area n yur bdy where yu feel the described sensatin(s). Use the apprpriate symbl(s), mark areas f radiating pain, and include all affected areas. Yu may draw in the face as well. Numbness: N Pins & Needles: P Burning: B Stabbing Pain: S Aching: A
3 265 W. Uwchlan Ave Dwningtwn, PA SYMPTOM SURVEY MISC: Headache Seizures Sinus prblems Allergies: Migraines Lss f memry Fainting Light bthers eyes Blurred visin Lss f visin Lss f taste Lss f hearing Pain in ears Ringing in ears Arthritis Swllen jints Cld extremities Smker TMJ syndrme Stiffness in mrning NECK: Pain in neck Neck pain with mvement Pinched nerve in neck Neck feels ut f place rinding sunds in neck Ppping sunds in neck Arthritis in neck 'Have yu had this type f head/ neck/face pain befre YES NO SHOULDERS: Pain in shulder jints Pain acrss shulders Bursitis (R-L) Can t raise arm Abve shulder level Over head Tensin in shulder ARM & HANDS: Pain in upper arm Pain in elbw Tennis elbw Sensatin f pins & needles Numbness in arms/fingers Fingers g t sleep Lss f grip strength MID-BACK: Pain between shulder blades Rib pain CHEST: Chest pain Shrtness f breath Irregular heartbeat ABDOMEN: Nervus Stmach Feel Blated Nausea Vmiting as Cnstipatin Diarrhea Hemrrhids IBS Chn s disease Reflux LOW BACK: Lw back pain Sacriliac Lw back pain is wrse: Standing Sitting Cughing Walking Lying dwn (sleeping) Pain relieves when: HIPS, LES & FEET: Pain in buttcks (R-L) Pain dwn leg (R-L) Pain dwn bth legs Knee pain Inside Outside Hip pain Leg cramps Cramps in feet (R-L) Pins & needles in legs (R-L) Numbness f leg (R-L) Numbness f tes /feet (R-L) Feet feel cld Swllen ankles /feet(r-l) Mrtn s neurma Bunins Arch pain WOMEN ONLY: 'Are yu PRENANT? Yes N Menstrual pain Irregular perids Cystic breasts Cystitis Yeast infectins Hysterectmy Menpausal Pst-menpausal Taking estrgen PMS Symptms MEN ONLY: Urinary frequency Prstate pain High PSA ENERAL: Depressin/Depressed Fatigue/Tire easily enerally feel run-dwn/ Malaise STD s Diabetes Hypglycemia Had kidney stnes Cffee cups/day Tea cups/day Check NO If yu CAN NOT: Smile Raise Bth Arms Stand steady n bth feet with eyes clsed Speak simple sentences Stick ut tngue Check YES If yu have: Duble visin Dizziness/lightheaded Sudden numb/weakness f face/arm/leg Speech disrders Difficulty swallwing Difficulty walking Vmiting/nausea Lss f sensatin n 1side Invluntary rapid eye mvement Please Describe a Subluxatin? Taking any Vitamins: (please list) Type: Taking any Medicatin: (please list) Type: Are interested in r d yu currently use any f the fllwing: Orthtics Cervical pillw Back brace Other Wellness Care Patient Signature: X Date: / /20
4 265 W. Uwchlan Ave Dwningtwn, PA Services & Supplies Thank yu fr chsing the A Wellness Frm Within, LLC fr yur health care needs. CHIROPRACTIC HAS ONE MISSION: ELIMINATE MISALINMENTS/SUBLUXATIONS THAT INTERFERE WITH THE EXPRESSION OF THE BODY S INNATE WISDOM. SUBLUXATION CAUSES ALTERATION OF NERVE FUNCTION AND INTERFERENCE TO THE TRANSMISSION OF MENTAL IMPULSES, RESULTIN IN A LESSENIN OF THE BODY S ABILITY TO EXPRESS ITS MAXIMUM HEALTH POTENTIAL. HEALTH BEIN A STATE OF OPTIMAL PHYSICAL, MENTAL AND SOCIAL WELL-BEIN, NOT MERELY THE ABSENCE OF DISEASE, PAIN OR INFIRMITY. OUR ONLY PRACTICE OBJECTIVE IS TO ELIMINATE MAJOR INTERFERENCE TO THE EXPRESSION OF THE BODY S INNATE WISDOM. SPECIFIC ADJUSTIN IS USED TO CORRECT THE SUBLUXATION. SERVICES AND SUPPLIES WE OFFER The fllwing list f services and supplies is ffered by this ffice fr yur cnvenience. Chirpractic PP, TT, Div, Act & Flexin Distractin (COX) Electr Therapy & Cld Laser Therapy Exercise & Rehabilitatin Instructin Orthtics & Orthpedic Supplies Vitamin & Nutritinal Supplements Weight Lss & Detxificatin Prgrams Whle Bdy Health-Hlistic Appraches & Health Cnscius Newsletters Insurance Cverage Varies and Depends n yur PLAN s Cverage Our pririty is t get yu better as quick as pssible and keep yu healthy: Yur treatment plan is determined by YOUR needs NOT by what yur Ins. Cmpany Cvers. If yu are having financial difficulties, please speak with the frnt desk fr payment ptins Please Keep In Mind: Many insurance cmpanies, fr the mst part, will NOT cver: anything that seeks t prevent disease, prmte health and prlng and enhance the quality f life (eg: maintenance/ wellness care, gym memberships, vitamins, electr-therapy pads, mst rthpedic supplies, massage, and ther health maintaining/preventative measures). Yu are respnsible fr all services rendered by this ffice. Please speak with ur ffice if yu need a payment plan. Unpaid balances may be subject t fees if they g t cllectins. If yur insurance cmpany DOES pay fr a service yu have been charged fr, we will credit yur accunt fr that amunt. In rder t keep ur fees dwn, payment is due at time f service. We may send ut bills patients fr services verdue r carry credits frward fr yur next appintment. If this is incnvenient fr yu, yu may pay fr services in advance. It is yur respnsibility t cntact ur ffice if yu need t reschedule yur appintment. If yu repeatedly miss yur appintments r we must cntinually call yu t reschedule yur appintments, we regretfully have t discharge yu frm ur care. X_ Signature Date
5 265 W. Uwchlan Ave Dwningtwn, PA ENERAL PAIN DISABILITY INDEX QUESTIONNAIRE The rating scales belw are designed t measure the degree t which several aspects f yur life are presently disrupted by chrnic pain. In ther wrds, hw much is yur pain preventing yu frm ding what yu wuld nrmally d, r frm ding it as well as yu nrmally wuld. Please indicate the verall impact f in yur life, nt just when the pain is at its wrst. PLEASE CIRCLE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LEVEL OF ABILITY. < OVERALL: Disruptin f Chres-Hme Respnsibilities: Activities perfrmed arund the huse. (Examples -yard wrk, driving the children t schl, running errands) < OVERALL: Disruptin f Hbbies-Recreatin: Activities f leisure time. (Examples-after schl sprts, hiking, ging t the gym) < OVERALL: Disruptin f Scial Life: Activities with friends & events. (Examples- attending parties, theater/cncerts & dining ut ) < OVERALL: Disruptin f Occupatin: Activities directly related t wrk, hmemaker r vlunteer wrk. (Examples-sitting at cmputer, lifting heavy bjects, standing fr lng perids f time, repetitive mtins) < OVERALL: Disruptin f Self Care: Activities such as persnal maintenance & independent daily living (Examples-bathing, driving, getting dressed). < OVERALL: Disruptin f Life- Supprt: Activities f basic life-supprting behavirs (Examples-eating, sleeping, reprductin & breathing) SINATURE: DATE : TOTAL SCORE: FOR OFFICE USE ONLY Disability Rating: 0-20% Min 21-40% Mderate 41-60% Severe 61-80% Crippling % Bed bun Key: Ttal / 60 * 100 = Disability index
6 265 W. Uwchlan Ave Dwningtwn, PA Patient Cnsent & Authrizatin I. My Cnsent I hereby give cnsent t A Wellness Frm Within, LLC: Family Chirpractic Center: T perfrm pertinent diagnstic testing, chirpractic care and ther adjunctive treatments at the dctr s discretin regarding my care. II. My Authrizatin Yu may use r disclse the fllwing health care infrmatin: Cnduct, plan and direct my treatment and fllw-up amng multiple healthcare prviders wh may be invlved in my treatment directly r indirectly. Obtain payment frm third-party payers ( eg: yur insurance cmpany). I IVE PERMISSION TO INFORM THE FOLLOWIN PEOPLE ABOUT MY PRORESS: (FOR EXAMPLE: SPOUSE/OTHER FAMILY MEMBERS/EMERENCY CONTACTS/CLOSE FRIENDS, ETC) Please list here: Yu may cntact me: Thrugh mail, r phne. Yu may leave a message either at wrk r at hme t a persn r n an answering machine directly related t my health & care plan. Send birthday cards, reminders, newsletters/mailings generated by A Wellness Frm Within, LLC: Family Chirpractic Center. I understand that I may request in writing that yu restrict hw my private infrmatin is used r disclsed t carry ut treatment, payment r health care peratins. I als understand yu are nt required t agree t my requested restrictins, but if yu d agree then yu are bund t abide by such restrictins. I have been infrmed by yu f yur Ntice f Privacy Practices cntaining a mre cmplete descriptin f the uses and disclsures f my health infrmatin. I have been given the right t review such Ntice f Privacy Practices prir t signing this cnsent. I understand that this rganizatin has the right t change its Ntice f Privacy Practices frm time t time and that I may cntact this rganizatin at any time at the address belw t btain a current cpy f the Ntice f Privacy Practices. III. My Rights Patient Rights I may revke this cnsent and authrizatin in writing at any time, hwever, it will nt affect any actins already taken by A Wellness Frm Within, LLC: Family Chirpractic Center based upn the cnsent and authrizatin already granted. Once health care infrmatin is disclsed t the persn (eg: ther healthcare prvider) r rganizatin (eg: insurance cmpany) they may re-disclse it. Privacy laws may n lnger prtect it. If yu understand and agree with all f the abve plicies, please sign yur name belw. Print Full Name Signature Date OFFICE USE ONLY INITIALS:
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn
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Name Date / / Age Male/Female Address City State Zip Phne: Hme Cell_ Date f Birth / / Email Address Fr cnfirming appintments, wuld yu prefer? EMAIL r TEXT CELL PROVIDER IS Occupatin Emplyer s Name Single
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