Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: DOB: Age: Male Female Address: City: State: Zip: E-mail: Home Phone: Work Phone: Mobile Phone: Cell Phone Provider: Marital Status: Single Married Do you have Insurance: Yes No Social Security #: Driver s License #: Employer: Occupation: Spouse s Name: Spouse s Employer: Number of children and ages: Name & Number of Emergency Contact: Relationship: HISTORY of COMPLAINT Please identify the condition(s) that brought you to this office: Primary: Secondary: Third: Fourth: When did the problem(s) begin? When is the problem at its worst? AM PM mid-day late PM How long does it last? Constant OR I experience it on and off during the day OR It comes and goes throughout the week How did the injury happen? Condition(s) ever been treated by anyone in the past? No Yes if yes, when: by whom? How long were you under care? What were the results?
Name of Previous Chiropractor: N/A PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/Stabbing T = Tingling What relieves your symptoms? What makes your symptoms feel worse? Is your problem the result of ANY type of accident? Yes No Identify any other injury(s) to your spine, minor or major, that the doctor should know about:
QUADRUPLE VISUAL ANALOGUE SCALE Patient Name Date Please read carefully: Instructions: Please circle the number that best describes the question being asked. Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: Headache Neck Low Back 1 What is your pain RIGHT NOW? 2 What is your TYPICAL or AVERAGE pain? 3 What is your pain level AT ITS BEST (How close to 0 does your pain get at its best)? 4 What is your pain level AT ITS WORST (How close to 10 does your pain get at its worst)? OTHER COMMENTS: Examiner Reprinted from Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, 855-862, 1993, with permission from Elsevier Science.
PAST HISTORY Have you suffered with any of this or a similar problem in the past? No Yes If yes, how many times? When was the last episode? How did the injury happen? Other forms of treatment tried: No Yes If yes, please state what type of treatment: Who provided it: How long ago? What were the results. Favorable Unfavorable please explain. Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body: PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem: HOW LONG AGO TYPE OF CARE RECEIVED BY WHOM INJURIES SURGERIES CHILDHOOD DISEASES ADULT DISEASES SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes How often? Daily Weekends Occasionally Never 2. Alcoholic Beverage: consumption occurs Daily Weekends Occasionally Never 3. Recreational Drug use: Daily Weekends Occasionally Never FAMILY HISTORY 1. Does anyone in your family suffer with the same condition(s)? No Yes If yes whom: grandmother grandfather mother father sister(s) brother(s) son(s) daughter(s) Have they ever been treated for their condition? No Yes I don t know 2. Any other hereditary conditions the doctor should be aware of? No Yes:
ACTIVITIES OF DAILY LIVING (ADL) Please identify how your current condition affects the following: ACTIVITIES/ATIVIDATES: EFFECT: : Carry children/groceries NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Lift children/groceries NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Sit to Stand NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Climb Stairs NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Sitting/Driving +30 mins NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Computer Use +30 mins NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Read/Concentrate NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Getting Dressed NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Personal Care NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Sexual Activities NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Sleep NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Static Sitting +15 mins NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Static Standing +15 mins NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Yard/House Work NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Walking +15 mins NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Running+15 mins NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM Other: NO EFFECT PAINFUL( CAN DO) PAINFUL (LIMITS) UNABLE TO PERFORM
List Prescription & Non-Prescription drugs you take: Please mark P for in the Past, C for Currently Have, or N for Never: Headache Pregnant (Now) Dizziness Prostate Problems Ulcers Neck Pain Frequent Colds/Flu Loss of Balance Impotence/Sexual Dysfxn. Heartburn Jaw Pain, TMJ Convulsions/Epilepsy Fainting Digestive Problems Heart Problems Shoulder Pain Tremors Double Vision Colon Problems High Blood Pressure Upper Back Pain Chest Pain Blurred Vision Diarrhea/Constipation Low Blood Pressure Mid Back Pain Pain w/cough/sneeze Ringing in Ears Menopausal Problems Asthma Low Back Pain Foot or Knee Problems Hearing Loss Menstrual Problems Difficulty Breathing Hip Pain Sinus/Drainage Problems Depression PMS Lung Problems Back Curvature Swollen/Painful Joints Irritable Bed Wetting Kidney Problems Scoliosis Skin Problems Mood Changes Learning Disability Gallbladder Problems Numb/Tingling arms, hands, fingers ADD/ADHD Eating Disorder Liver Problems Numb/Tingling legs, feet, toes Allergies Trouble Sleeping Hepatitis (A,B,C) Broken Bone/Fracture Dislocations Tumors Rheumatoid Arthritis Disability Heart Attack Osteoarthritis Cancer Diabetes Cerebral Vascular Other serious conditions:
I hereby authorize payment to be made directly to Launch Chiropractic for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Launch Chiropractic for any and all services I receive at this office. Patient or Authorized Person s Signature Date Completed Doctor s Signature Date Form Reviewed X-RAY AUTHORIZATION AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF YOUR X-RAYS IN OUR FILES. THE FEE FOR COPYING YOUR X-RAYS ON A DISC IS $15.00. THIS FEE MUST BE PAID IN ADVANCE. DIGITAL X-RAYS ON CD WILL BE AVAILABLE WITHIN 72 HOURS OF PREPAYMENT ON ANY REGULAR PRACTICE HOURS DAY. PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF REACH CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE. BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS. Patient or Authorized Person s Signature Date Completed Age FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT LAUNCH CHIROPRACTIC. Patient or Authorized Person s Signature Date Completed INSURANCE POLICIES AND FEE SCHEDULE Consultation- includes practice member history. This service is complimentary. Assessment (new or established practice member)- includes one or more of the following: thermography, surface electromyography, range of motion, motion and/or static palpation, leg check. Chiropractic Adjustment- The actual re-alignment of the vertebra done by hand or instrument assisted. Often a sound will be heard, but if there is no auditory result, it does not mean that the adjustment has not taken place. X-rays- Specific x-ray views taken of your spine to determine a misalignment/subluxation of your vertebrae. These can also be used to indicate progress after period of care.
RELEASE OF AUTHORIZATION/ASSIGNMENT OF BENEFITS I authorize and request payment of insurance benefits directly to Launch Chiropractic, LLC/Tony Stasi, DC/Paige Stasi, DC. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. Patient or Authorized Person s Signature Date Completed Doctor/Witness Signature Date Form Reviewed INFORMED CONSENT FOR CHIROPRACTIC CARE CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE. PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE. I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT. Patient or Authorized Person s Signature Date Completed IF PATIENT IS A MINOR, PLEASE STATE RELATIONSHIP Doctor/Witness Signature Date Form Reviewed