CHIROPRACTIC REGISTRATION AND HISTORY d11ft--p-a_t_i E_N_T_I_N_F_O_R_M_A_ T_I 0-N-----. -Date SS/HIC/Patient ID # Patient Name -.----,~---------------------------------- Last Name First Name Middle Initial Address E-mail City State Sex 0 M 0 F Age Birthdate --------------------------- Zip 0 Married OWidowed 0 Single 0 Minor 0 Separated 0 Divorced 0 Partnered for years Patient Employer/School Occupation ------------------------------------------- Employer/School Address ------------------------------- Employer/School Phone ( ) Spouse's Name---------------------------------------- Birthdate ------------------------------------------- SS# _ Spouse's Employer INSURANCE I NFORMATION Who is responsible for this account? Relationship to Patient --------------------------------- Insurance Co. ----------------------------------------- Group# Is patient covered by additional insurance? DYes 0 No Subscriber's Name ------------------------------------- Birthdate SS# Relationship to Patient --------------------------------- Insurance Co. ----------------------------------------- Group# ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with ---------;:-;-::-:c:-::-::...-c:-::c-c:::-:-::-::-c~::c::c:c:cc,.-::-::-c------ and assign directly to Name of Insurance Company(ies) Dr. 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 or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signature _of Patient, Parent, Guardian or Personal Re_l?resentative Please print name of Patient, Parent, Guardian or Personal Representative Whom may we thank for referring you? Date Relationship to Patient PHONE NUMBERS ACCIDENT INFORMATION Cell Phone( ) Home Phone ( ) Is condition due to an accident? 0 Yes 0 No Date Best time and place to reach you IN CASE OF EMERGENCY, CONTACT Name ------------------- Relationship Home Phone ( ) Work Phone ( ) Type of accident 0 Auio 0 Work 0 Home 0 Other To whom have you made a report of your accident? 0 Auto Insurance 0 Employer OWorker Camp. 0 Other Attorney Name (if applicable) PATIENT CONDITION When did your symptoms appear? ---------------------------------------- Is this condition getting progressively worse? 0 Yes 0 No 0 Unknown Mark an X on the picture where you continue to have pain, numbness, or tingling. Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain: 0 Sharp 0 Dull 0 Throbbing 0 Numbness 0 Aching 0 Burning 0 Tingling 0 Cramps 0 Stiffness 0 Swelling 0 Shooting OOther How often do you have this pain? ----------------------------------------- Is it constant or does it come and go? Does it intetiere with your 0 Work 0 Sleep 0 Daily Routine 0 Recreation Activities or movements that are painful to perform 0 Sitting 0 Standing 0 Walking 0 Bending 0 Lying Down (Vers C2SSS04) - 0 V E R - U20572-2004 Medical Arts Press 1 800-328 2179
-------- ----- -- [(lj HEALTH HISTORY -What treatment have you already received for your condition? D Medications D Surgery D Physical Therapy D Chiropractic Services D None D Other Name and 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 Place a mark on "Yes" or "No" to indicate if you have had any of the following: AIDS/HIV Diabetes Liver Disease Rheumatic Fever Alcoholism Emphysema Measles Scarlet Fever Allergy Shots Epilepsy Migraine Headaches D Yes ONo Sexually Anemia Fractures Miscarriage Transmitted Disease Anorexia Glaucoma Mononucleosis Stroke Appendicitis Goiter Multiple Sclerosis Suicide Attempt Arthritis Gonorrhea Mumps Thyroid Problems Asthma Gout DYes D No Osteoporosis Tonsillitis Bleeding Disorders Heart Disease Pacemaker DYes D No Tuberculosis Breast Lump Hepatitis Parkinson's Disease Tumors, Growths Bronchitis Hernia Pinched Nerve DYes D No Typhoid Fever Bulimia Herniated Disk DYes D No Pneumonia D Yes DNo Ulcers Cancer Herpes DYes D No Polio Vaginal Infections Cataracts DYes ONo High Blood Prostate Problem Pressure Whooping Cough Chemical Prosthesis D Yes DNo Dependency High Cholesterol DYes D No Other Psychiatric Care Chicken Pox - Kidney Qisease --DYes D No Rheumatoid Arthritis D Yes DNo -- EXERCISE WORK ACTIVITY HABITS D None D Sitting D Smoking Packs/Day D Moderate D Standing D Alcohol Drinks/Week D Daily D Light Labor D Coffee/Caffeine Drinks Cups/Day D Heavy D Heavy Labor D High Stress Level Reason DYes D No DYes D No DYes D No Are you pregnant? Due Date Injuries/Surgeries you have had Description Date Falls Head Injuries Broken Bones Dislocations Surgeries rft ~ MEDICATIONS ALLERGIES VITAMINS/HERBS/M INERALS Pharmacy Name Pharmacy Phone ( )
Back Index Form 81100 rev 312712003 Patient Name----------------------------- Date This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem. Pain Intensity @ The pain comes and goes and is very mild. G) The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary much. @ The pain comes and goes and is very severe. @ The pain is very severe and does not vary much. Sleeping @ I get no pain in bed. CD I get pain in bed but it does not prevent me from sleeping well. @ Because of pain my normal sleep is reduced by less than 25%. Because of pain my normal sleep is reduced by less than 50%. @ Because of pain my normal sleep is reduced by less than 75%. @ Pain prevents me from sleeping at all. Personal Care @ I do not have to change my way of washing or dressing in order to avoid pain. <D I do not normally change my way of washing or dressing even though it causes some pain. @ Washing and dressing increases the pain but I manage not to change my way of doing it. Q) Washing and dressing increases the pain and I find it necessary to change my way of doing it. @ Because of the pain I am unable to do some washing and dressing without help. Because of the pain I am unable to do any washing and dressing without help. Lifting @ I cqn lift heavy weights without extra pain. <D I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table). @ Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights. Sitting @ I can sit in any chair as long as I like. <D I can only sit in my favorite chair as long as I like. Pain prevents me from sitting more than 1 hour. Pain prevents me from sitting more than 1/2 hour. @ Pain prevents me from sitting more than 10 minutes. @ I avoid sitting because it increases pain immediately. Trav~ling.. @ I get no pain while traveling. <D I get some pain while traveling but none of my usual forms of travel make it worse. ~ I get ex1ra pain while traveling but it does not cause me to seek alternate forms of travel. I get ex1ra pain while traveling which causes me to seek alternate forms of travel. @ Pain restricts all forms of travel except that done while lying down. Pain restricts all forms of travel. Standing @ I can stand as long as I want without pain. <D I have some pain while standing but it does not increase with time. I cannot stand for longer than 1 hour without increasing pain. @ I cannot stand for longer than 1/2 hour without increasing pain. @ I cannot stand for longer than 10 minutes without increasing pain. @ I avoid standing because it increases pain immediately. Social Life @ My social life is normal and gives me no extra pain. <D My social life is normal but increases the degree of pain. ~ Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, etc). @ Pain has restricted my social life and I do not go out very often. @ Pain has restricted my social life to my home. @ I have hardly any social life because of the pain. Walking @ I have no pain while walking. CD I have some pain while walking but it doesn't increase with distance. I cannot walk more than 1 mile without increasing pain. Q) I c~n not walk more than 1/2 mile without increasing pain. @ I cannot walk more than 1/4 mile without increasing pain. @ I cannot walk at all without increasing pain. Changing degree of pain My pain is rapidly getting better. <D My pain fluctuates but overall is definitely getting better. ~ My pain seems to be getting better but improvement is slow. My pain is neither getting better or worse. @ My pain is gradually worsening. @ My pain is rapidly worsening. Back Index Score D
Neck Index Form N1-100 Patient Name _ rev 312712003 Da te _ This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem. Pain Intensity @ I have no pain at the moment. G) The pain is very mild at the moment. @ The pain comes and goes and is moderate. The pain is fairty severe at the moment. The pain is very severe at the moment. @ The pain is the worst imaginable at the moment. Sleeping @ I have no trouble sleeping. G) My sleep is slightly disturbed (less than 1 hour sleepless). @ My sleep is mildly disturbed (1-2 hours sleepless). My sleep is moderately disturbed (2-3 hours sleepless). My sleep is greatly disturbed (3-5 hours sleepless). @ My sleep is completely disturbed (5-7 hours sleepless).. f?eading @ I can read as much as I want with no neck pain. <D I can read as much as I want with slight neck pain. @ I can read as much as I want with moderate neck pain. I cannot read as much as I want because of moderate neck pain. @) I can hardly read at all because of severe neck pain. @ I cannot read at all because of neck pain. Personal Care @ I can look after myself normally without causing extra pain. G) I can look after myself normally but it causes extra pain. ~ It is painful to look after myself and I am slow and careful. I need some help but I manage most of my personal care. @ I need help every day in most aspects of self care. @ I do not get dressed, I wash with difficulty and stay in bed. Lifting @ I ca.n lift heavy weights without extra pain. <D I can lift heavy weights but it causes extra pain. ~ Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table). Pain prevents me from lifting heavy weights off the floor, but! can manage light to medium weights if they are conveniently positioned. @ I can only lift very light weights. @ I cannot lift or carry anything at all. Driving @ I can drive my car without any neck pain. <D I can drive my car as long as I want with slight neck pain. CZ> I can drive my car as long as I want with moderate neck pain. I cannot drive my car as long as I want because of moderate neck pain. @ I can hardly drive at all because of severe neck pain. @ I cannot drive my car at all because of neck pain. Concentration @ I can concentrate fully when I want with no difficulty. <D I can concentrate fully when I want with slight difficulty. I have a fair.degree of difficulty concentrating when I want. @ I have a lot of difficulty concentrating when I want. I have a great deal of difficulty concentrating when I want. @ I cannot concentrate at all. Recreation @ I am able to engage in all my recreation activities without neck pain. <D I am able to engage in all my usual recreation activities with some neck pain. CZ> I am able to engage in most but not all my usual recreation activities because of neck pain. I am only able to engage in a few of my usual recreation activities because of neck pain. @ I can hardly do any recreation activities because of neck pain. @ I cannot do any recreation activities at all. Work @ I can do as much work as I want. G) I can only do my usual work but no more. ~ I can only do most of my usual work but no more. I C!Jnnot do my usual work. I ca n hardly do any work at all. @ I ca nnot do any work at all. Cndcx Score Headaches @ I have no headaches at all. <D I have slight headaches which come infrequently. CZ> I have moderate headaches which come infrequently. I have moderate headaches which come frequentl y. @ I have severe headaches which come frequently. @ t have headaches almost all the time. [S um of all statements-selected I (#of sections with a statement selected x 5)] x 100 J Neck Index Score [~]
Patient Name(Print) Date - ------ Patient ID # Please draw the location of your pain or discomfort on the images below. Use the symbols shown to represent the type(s) of pain: D =Dull 8 =Burning N =Numb S = Stabbing/Cutting T =Tingling (Pins & Needles) C =Cramping '--' On the scales below, please draw a vertical line representing your pain or discomfort: Rate the pain you have right now: Rate your pain at its best in the past week: No Pain Unbearable Pain No Pain Unbearable Pain R'ate your average pain in the past week: Rate your worst pain in the past week: No Pain Unbearable Pain No Pain Unbearable Pain
i". WELLNESS INSTITUTE OF NEVADA DR. SHAN A SING I R, 0.C. Consent to Treat/ Notice of Privacy Practices I, understand that, as in the practice of medicine, in the practice of other clinical therapies there are some risks to treatment. I understand that if I receive chiropractic treatments the most common risks are temporary aggravation of my condition and/or soreness. I do not expect the Chiropractic Physicians to be able to anticipate and explain all risks and complications, and I wish to rely on her to exercise judgment during the course of the procedure which she feels at the time, based on the facts then known, and is in my best interest. I acknowledge that during the course of my care I may receive chiropractic adjustments, active release techniques, physical therapy modalities both passive and active. I have read, or had read to me, the above consent and completely understand the treatment 1 will receive by the practitioners ofwellness Institute of Nevada (WIN) and hereby consent to receive 'treatment. I consent to WIN use and disclosure of my Protected Health Information (PHI) for the purpose of providing treatment to me, for the purposes relating to the payment of services rendered to me, and fo r WIN's general healthcare operations purposes. I understand that WIN's diagnosis or treatment of me may be conditioned upon my consent as evidenced by my signature on this docume~t. Forth.e purposes ofthis Co.nsent, PHI means any information, including my-demo-graphic information, created or received by WIN, that relates to my past, present, or future physical or mental health condition; the provision of health care t o me; or the past, present, or future payment for the provision of health care services to me; and that either identifies me or from which there is reasonable basis to believe the information can be used to identify me. I understand I have the right to request a restriction on the use and disclosure of my PHI for the purposes of treatment, payment, or health care operations of the provider, but WIN is not required t o agree with these restrictions. However, if the provider agrees to a restriction that I requ'est, the restriction is binding on the provider. I understand I have a right to review the Providers' Notice of Privacy Practices prior to signing this document. The notice of Privacy Practices describes my rights and the providers' duties regarding the types of uses and disclosures of my PHI. I have the right to revoke this consent, in w riting, at any time, except to the extent that the provider has acted in reliance on this consent. Signature of Patient or Representative Date N ame of Par lent or Represe ntat ive
...------------------- -- WELLNESS INSTITUTE OF NEVADA DR. SHAN A SiNGER, D.C. APPOINTMENT POLICY WIN is dedicated to providing you with the best care possible. We will devise a treatment plan for you that will help do exactly that. This treatment plan will include the number and frequency of visits that we project will help you. For this reason, it is crucial that you do not miss appointments and adhere to the plan that the doctor gives you. We do understand that things come up and that it is not feasible to ask that you never cancel an appointment, however, keep in mind that if you must cancel, a make-up appointment should be scheduled. Because Dr Singer is responsible for your care, it is our policy that if you miss 3 appointments within one month, we may discontinue your care due to inability to adhere to their treatment plan. If you are unable to follow the treatment plan, simply speak to Dr. Singer about your concerns and together you can come up with something you are able to follow. Also, you will notice that when you come in, there is generally a short wait time. We pride ourselves in not keeping our patients waiting for very long. In order to keep wait times short, we ask that you schedule your appq_intments appropriately, according to your treatment plan. Walk ins are always welcpme, but rem-ember we always take scheduled appointment-s before, as t-hey do affect wait time-s. For these reasons, please understand that we do impose a $25.00 fee for missed appointments without 1 hour notice. This does include massage appointments. I have read and understand the appointment policies. Patient/Guardian Date 2557 Wigwam Parkway, Henderson, Nevada 89074 (702) 896-2700 (phone) (702) 896-7046 wellnesslnstituteofnevada@yahoo.com
WELLNESS INSTITUTE OF NEVADA DR. SHAN A SINGER, D.C. AUTHORIZATION TO RELEASE MEDICAL INFORMATION Dr. I Company:-------------------- Address: Phone: Fax: Patient: SSN: DOB: I,.J am requesting the following information to be released to Well~ess Institute of Nevada for~he purpose of review and ev_~luation of mtcondition. 0 X-Rays 0 History D Records D Reports/Notes 0 Diagnosis 0 Treatment Concerning my current: Oiliness 0 Accident D lnjuryd Other (Description below) I understand that I have the right to receive a copy of this authorization upon my request. Patient/ Legal Representative Sign: Patient/ Legal Representative Print:----------------------- Relationship to Patient:-------------- Date:------------- 2557 Wigwam Parkway, Henderson, Nevada 89074 (702) 896-2700 (phone) (702) 895-7045 wellnesslnstituteofn evada @yah oo.com