(978) 448-2800 Last Name: First Name: MI: Mailing Address: City: State: Zip: O.K. to call home? Yes No Home Phone: O.K. to call cell? Yes No: Cell Phone: Sex M F Birthdate: Age: Marital Status: Single Married Sep Div Emergency contact name: Employer Name: Occupation: O.K. to call you at work? Yes No; Work Phone: Ext. Primary Insurance Co. Card # Secondary Ins. Company (if applicable): How did you hear about Dr. Tansey? Dr. Friend/ Family Insurance Book Phone Book Internet Other May we contact them to thank them for referring you to our office? Yes No Family Physician Town / Phone Date of last physical Do we have permission to forward a copy of your evaluation to your medical physician? Yes No Family Dentist Town Date of last Exam/ Cleaning Previous Chiropractor? No Yes Dr. Town / Phone Date last seen If, for any reason you are concerned about the cost of services you will be provided in this office, please let us know before your visit. We are always willing to discuss the cost of your care and provide you with payment options. For your convenience and information the following are our policies. Please read them and sign this sheet to acknowledge your understanding of these policies. You will be required to pay for your initial examination unless you are insured under auto insurance, workers compensation or a verified insurance policy that covers such services. We accept cash, check, Mastercard and Visa. You are responsible for understanding the policy limitations of your insurance coverage. Although we will attempt to assist you in verifying your insurance, you are responsible for charges not covered or that exceed your policy limits. I, the undersigned hereby authorize Dr. Tansey to administer examination and/or treatment as is necessary, and to perform appropriate diagnostic and therapeutic procedures as are considered necessary on the basis of findings during course of said treatment. I authorize the release of information to or from other past, present or future health care professionals, facilities, attorneys, or agencies for the purpose of continuity of my health care or for the purpose of collection for services rendered. Any other uses of this information will only occur with your specific authorization which you may revoke at any time. I also certify that no guarantee has been made as to the results that may be obtained from any treatment given. I have been offered a copy of Nashoba Valley Chiropractic s Privacy Policy Insurance Assignment and Release I, the undersigned assign directly to Dr. Tansey all medical 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. Signature Date
Informed Consent for Chiropractic Treatment Clinicians who use spinal manual therapy techniques, such as for example, joint adjustment or manipulation or mobilization, are required to inform patients that there are or may be some risks associated with such treatment. In particular: a) While rare, some patients have experienced muscle and ligament sprains or strains, or rib fractures following spinal manual therapy. b) There have been reported cases of injury to a vertebral artery following neck adjustment, manipulation and mobilization. Such vertebral artery injuries may on rare occasion cause stroke, which may result in serious neurological injury and/or physical impairment. This form of complication is an extremely rare event, occurring about 1 time per 1 million treatments. c) There have been reported cases of disc injuries following spinal manual therapy, although no scientific study has ever demonstrated that such injuries are caused, or may be caused, by adjustment or manipulative techniques and such cases are also very rare. Treatments provided at this office, including spinal adjustment, manipulation and/or mobilization, have been the subject of much research conducted over many years and have been demonstrated to be appropriate and effective treatments for many common forms of spinal pain, pain in the shoulders/arms/legs, headaches and other similar symptoms. Treatment provided here may also contribute to your overall well-being. The risk of injury or complication from manual treatment is substantially lower than the risk associated with many medications, other treatments and procedures frequently given as alternative treatments for the same forms of musculoskeletal pain and other associated syndromes. Dr. Tansey will evaluate your individual case, provide an explanation of care and a suggested treatment plan, or alternatively a referral for consultation and/or further evaluation if deemed necessary. Acknowledgement: I acknowledge I have discussed, or have been given the opportunity to discuss, with Dr. Tansey the nature of chiropractic treatment in general and my treatment in particular as well as the contents of this consent. Consent: I consent to the chiropractic treatments offered or recommended to me by Dr. Tansey, including joint adjustment or manipulation or mobilization to the joints of my spine (neck and back), pelvis and extremities (shoulder, upper limbs and lower limbs). I intend this consent to apply to all my present and future treatments at this clinic. Patient Signature (or Legal Guardian) (Please print name of patient) Date (Please print name of guardian) (Please print name of Witness/Translator) Date
Current Complaints: Shade in any areas of pain or complaint and use the following symbols to describe A- Aching S- Sharp/ Stabbing B- Burning N- Numbness T- Tingling/ Pins & Needles O-Other Example - Shade in Pain
In the space below list medical/ surgical history from birth including approximate. Include: Conditions you take medications for, serious illnesses, hospital admissions, surgeries, births, accidents, broken bones, sports injuries, allergies etc. Taking medication for this (list): List any vitamins or other supplements you currently or frequently take : Multivitamin brand Other Suppplements Please list any specialists you are currently seeing: Dr. Town: Specialty: Dr. Town: Specialty: Dr. Town: Specialty:
Stress: Rate your stress level: HEALTH HABITS None - 1 2 3 4 5 6 7 8 9 10 - Terrible Rate how well you manage your stress: Horribly - 1 2 3 4 5 6 7 8 9 10 - I m immune from stress Exercise: [ ] Sedentary (no exercise) [ ] Mild Exercise (i.e. climb stairs, walk 3 blocks, golf) [ ] Occasional Vigorous Exercise (i.e. work or recreation, less than 4x wk for 30 min.) [ ] Regular Vigorous Exercise (i.e. work or recreation 4x wk for 30 min.) Describe your exercise Diet: Are you dieting? Yes No If yes, are you on a physician prescribed medical diet? Yes No # of meals you eat in an average day? Please rate the quality of your diet: Perfect 1 2 3 4 5 6 7 8 9 10 Terrible Caffeine: [ ] None [ ] Coffee [ ] Tea [ ] Cola / Caffeineated soft drinks # of Cups/Cans Per Day? Alcohol: Tobacco: How many alcohol containing beverages do you consume daily? or weekly? None: [ ] Non-Drinker [ ] X, Drinker Do you use tobacco? [ ] Yes [ ] No Cigarettes pks/day # of Years or year quit Sleep: Does your complaint disrupt your sleep? [ ] Yes [ ] No How do you rate the quality of your sleep now? Terrible 1 2 3 4 5 6 7 8 9 10 Perfect How do you rate the quality of your sleep in general? Terrible 1 2 3 4 5 6 7 8 9 10 Perfect Rate your usualenergy levels throughout the day? Exhausted 1 2 3 4 5 6 7 8 9 10 Lots of energy
Please help us to identify your potential health risks by placing a check in any column that applies to you or your relatives. Spouse Parents Siblings Children Grandparents Age (if living) Age (at death) Hepatitis / Aids / HIV Arthritis Headache / Neck / Back Problems Bleeding Disorders Cancer (what type) Endocrine / glandular (diabetes,thyroid) Immune Problems Asthma, Allergy Heart Problems High Blood Pressure Stroke / TIA Circulatory Prob.(blood vessels,heart) Respiratory (lung, breathing) Gastrointestinal (stomach, intestines) Genitourinary (urinary, kidney, prostate) Ear, Nose, Throat Skin Neurological (brain, nerves) Psychological Other Other Pregnancy / Children: # Pregnancies # Birth Children Currently Pregnant? [ ]Yes [ ]No If any of your family members are deceased, please list the cause of death in the following space:
Check the category that best describes your activity level: Physical Demands Description Sedentary: Lifting up to 10lbs. maximum and occasionally lifting and/ or carrying such articles as dockets, ledgers, and small tools. Mostly desk work Light Activity: lifting 20 lbs. maximum with frequent lifting/ carrying of objects weighing up to 10 lbs. A job in this category requires standing or walking to a significant degree or sitting with a degree of pulling/ pushing arm and/ or leg controls. Medium Activity: Lifting 50 lbs. maximum with frequent lifting and/ or carrying of objects up to 25 lbs. Heavy Activity: Lifting objects in excess of 100 lbs. with frequent lifting and/ or carrying of objects up to 50 lbs. Excessive exposure at work or home to? Fumes Dust Solvents Air-Borne Particles Noise I perform the following activities : Never Occas. Frequently Use Computer Use Telephone Bend / Stoop Squat Crawl Climb Never Occas Frequently Crouch Kneel Push/ Pull Balancing Reach above shoulder Current work status: Full time Part time Restricted duties Not working Disabled Student Occupation Do you enjoy your job? (circle) Not at all - 0 1 2 3 4 5 6 7 8 9 10 - Fantastic Job Have you lost time from work due to your symptoms? Partial disability: From To No Yes Full disability From To How many hours do you work per week? In a typical workday, I Sit hours, Stand hours Walk hours I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any error or omissions that I may have made in completion of this form. Patient Signature Date