INTODUCTION PATIENT CASE HISTOY Today s Date: / / PATIENT INFOMATION Name: (First MI ast) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #:_ Home: Mobile: Work: Email: Preferred Method of Contact: Text Email Home Phone Other: *eferred By: (Name) Family Friend Co-Worker Doctor Other: ace & Ethnicity: (Choose up to 2) Preferred anguage: African American or Black English American Indian or Alaskan Native Spanish Asian Other: Hispanic or atino Decline Native Hawaii or Other Pacific Islander White Decline EMEGENCY CONTACT INFOMATION Name: (First MI ast) Home: Mobile: elationship: Child Parent Spouse Other: Primary Care Physician: _ Doctor s Phone: FINANCIA INFOMATION Is today s visit the result of an accident? No Auto Work Other: Will we be working with insurance? No Yes (Details) Primary: ID#: Secondary: ID#: Where would you like statements sent? Self Other (Details below) Name: Address: _ Phone: Email: It is Usual and Customary to Pay for Services as endered Unless Otherwise Arranged
HISTOY OF PESENT INESS (Please describe) Major Complaint: When did it start? / / HISTOY OF PESENT INESS Secondary Complaints: What happened? Which daily activities are being affected by this condition? ocation of Symptoms and adiation P Pain T Tender N Numb H Hypoesthesia S Spasm Grade Intensity/Severity: (0/10) Mild (1-2/10) Mild-Moderate (2-4/10) Moderate (4-6/10) Moderate-Severe (6-8/10) Severe (8-10/10) Frequency: Off & On Constant MAJO COMPAINT Quality: Sharp Stabbing Burning Achy Dull Stiff & Sore Other: Does it radiate? No Yes (Please indicate on drawing) Improves with: Ice Heat Movement Stretching OTC Medications: Worsens with: Sitting Standing/Walking ying Down/Sleeping Overuse/ifting Previous Treatment: Chiropractor Medical Doctor Physical Therapy E/Urgent Care Orthopedic Previous Diagnostic Testing: X-rays MI CT *Women: Are you pregnant? No Yes ast Menstrual Period: / / Due date: / / Present Illness Comments: Prescription Medications & Supplements: Yes (ist Name, dosage, frequency) Allergies to Medications: No known drug allergies Yes (ist - Name and reaction) Print Name: (First MI ast)
Mother Father Sibling1 Sibling2 Sibling3 Child1 Child2 Child3 PAST, FAMIY, AND SOCIA HISTOY PAST MEDICA HISTOY Have you ever had any of the following? (Please select all that apply and use comments to elaborate.) Illnesses: Asthma Autoimmune Disorder (Type) Blood Clots Cancer (Type) CVA/TIA (stroke) Diabetes Migraine Headaches Osteoporosis Injuries: Back Injury Broken Bones Head Injury Neck Injury Falls Hospitalizations: (Non-surgical with Date) Surgeries: (If yes, provide type & surgery date) Cancer Orthopedic Shoulder / Elbow/Forearm / Wrist/Hand / Hip / Knee / Ankle/Foot / Spinal Surgery Neck: Back: Medical History Comments: FAMIY HISTOY (Please mark X to all that apply and use comments to elaborate.) Unknown Age at death (if Deceased) Aneurysms CVA (Stroke) Cancer Diabetes Heart Disease Hypertension Other Family History Unremarkable Gender F M Family History Comments: SOCIA AND OCCUPATIONA HISTOY Marital Status: Single Married Divorced Other Children: 1 2 3 4 Other: Student Status: Full Student Part Student Non-Student Highest level of Education: High School College Grad. Post Grad. Employed: No Yes (Occupation) Dominant Hand: ight eft Ambidextrous Smoking/Tobacco Use: If current smoker, amount = Every Day Some Days Former Never Alcohol Use: Every Day Weekly Occasionally Never Caffeine Use: Coffee Tea Energy Drinks Soda Never Exercise frequency: Daily 3-4xs/week 2-3xs/week arely Never Social History Comments: Print Name: (First MI ast)
EVIEW OF SYSTEMS EVIEW OF SYSTEMS Many of the following conditions respond to Chiropractic and Acupuncture treatment. Are you currently experiencing any of these symptoms? (Please select all that apply and use comments to elaborate.) Constitutional: (General) Fever Fatigue in this Category Musculoskeletal: Joint Pain/Stiffness/Swelling Muscle Pain/Stiffness/Spasms Broken Bones in this Category Neurological: Dizziness or ightheaded Convulsions or Seizures Tremors in this Category Psychiatric: (Mind/Stress) Nervousness/Anxiety Depression Sleep Problems Memory oss or Confusion in this Category Genitourinary: Frequent or Painful Urination Blood in Urine Incontinence or Bed Wetting Painful or Irregular Periods in this Category Gastrointestinal: oss of Appetite Blood in Stool or Black Stool Nausea or Vomiting Abdominal Pain Frequent Diarrhea Constipation in this Category Cardiovascular & Heart: Chest Pains/Tightness apid or Heartbeat Changes Swelling of Hands, Ankles, or Feet in this Category espiratory: Difficulty Breathing Cough Other: in this Category Eyes & Vision: Eye Pain Blurred or Double Vision Sensitivity to ight in this Category Head, Ears, Nose, & Mouth/Throat: Frequent or ecurrent Headaches Ear - Ache/inging/Drainage Hearing oss Sensitivity to oud Noises Sinus Problems Sore Throat in this Category Endocrine: Infertility ecent Weight Change Eating Disorder in this Category Hematologic & ymphatic: Excessive Thirst or Urination Cold Extremities Swollen Glands in this Category Integumentary: (Skin, Nails, & Breasts) ash or Itching Change in Skin, Hair, or Nails Non-healing Sores or esions Change of Appearance of a Mole Breast Pain, ump, or Discharge in this Category Allergic/Immunologic: Food Allergies Environmental Allergies in this Category eview of Systems Comments: Print Name: (First MI ast)
unnels Chiropractic,..C. Authorization and elease I authorize payment of insurance benefits directly to Dr. Steven K. unnels or unnels Chiropractic, C. I authorize unnels Chiropractic, C to release any information pertinent to my case to any insurance company, adjusters, and/or attorney involved in the case, I hereby release unnels Chiropractic, C of any consequence thereof. I agree to be financially responsible for all charges incurred at unnels Chiropractic, C including my insurance deductible, co-payment, and any other services rejected by my insurance company. Any account unpaid after 30 days of the date of service shall bear interest at the rate of 16% per month. Should it become necessary to resort to collections, the patient shall be responsible for all costs of collections including a reasonable attorney s fee. Insurance: Yes No Company: Patient s Signature:_ Date: Guardian s Signature:Date: Clinical Summary eport (CC) I understand that a clinical summary report is created after each visit for the purpose of EH and is available for my review. At this time, I am asking unnels Chiropractic to save these electronically for me and not print them out after each visit. I understand that, upon request, these reports are available to be printed or emailed to me for review. Patient s Signature: Date: