WELCOME 3 LOCATIONS TO SERVE YOU BETTER! PINES WEST CHIROPRACTIC EAST SIDE CHIROPRACTIC MARTINEZ CHIROPRACTIC 18501 Pines Blvd., Suite 104 8228 Biscayne Blvd. 12595 S.W. 137 Ave., Ste 108 Miami, FL 33029 Miami, FL 33138 Miami, FL 33186 PATIENT INFORMATION Patient: ------------------:..:., -"" Address:------ -------------------'--- City: State: Zip Code:...:..,_...:... Sex: OM OF Age: DOB: 0 Single D Married D Widowed D Divorced Patient SS No. Occupation: Employer Employer Phone No. Employer Address:---------------------:-,...:... Spouse's Name: Birthdate: ------,-:..-...:..: Patient SS No. Occupation:-----...,:.::...:...::. : Spouse's Employer:.:..._~-~:...:--: Primary Care Physician: Whom may we thank for referring you: - Phone Number: ----'-:---..::::._~-=..:..-'----' -------------,.-,--"'-::,..--,:---:--:--- PHONES NUMBERS Home: Work: Ext: Best time to call Cell Phone: Email: IN CASE OF EMERGENCY Name: Relationship: Home#: Work: INSURANCE........ ACCIDENT INFORMATION Who is responsible for this account? ----------:-'----'=-''---':---'---~ Relationship to Patient ------------::-::-~-=-:-:-=-=----=-:-:---=~ Insurance Co. Name -----------~----=--?-7:"+-:+---:=-:-:----:~ Group or Card No. ------ ----------...,...,...-=-,...-=-+- Is Patient covered by additional insurance D Yes Subscriber's Name------------------- Birthdate SS No. ~,-,---...,..,..--,-,...,.,-:,---,--- Relationship to Patient ----~-----::..,.--~-::-~..:...:,:..,...:.:..,.----- Insurance Co. Name -----:--""':-"--.-:---:-..:., -~~-7----:-=-:-:----- lnsurance I.D. No. ----...;..,--=...:~...:....:_...:...;_;..:---:---'------- Is condition due to an accident? DYes D No Type of Accident? D Auto D Work D Home 0 Other Explain Other: If yes, please tell our front office and fill out correct accident form in addition to this form. PATIENT CONDITION _. Reason for Visit: Preventive health check up: D Yes 0 No When did your symptoms appear? Is condition getting progressively worse? D Yes D 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 of 1 (least pain to 10 (server pain) Type of Pain: D Sharp D Dull D Throbbing 0 Numbness 0 Aching D Shooting D Burning D Tingling D Cramps D Stiffness D Swelling 0 Other How many days in the last week did you feel the pain? D Is it constant or D Occasional Does it interfere with your D Work D Family Life D Sleep D Recreation D Exercise Activities or movements that are painful to perform D Sitting D Standing D Walking D Bending D Lying Down D Driving Do~ u s~erkoma~otherh~~cond~on~---------------------~---- PAST HEALTH HISTORY Please Check and Describe: ---- ------------ ---------------- Major Surgery/Operations: D Appendectomy D Tonsillectomy D Gall Bladder D Hernia D Back Surgery 0 Broken Bones 0 Other---- ----------------- --------- Car accidents, falls, i~uries: -------------------------------~ Hosp~al~ationiDtherThanAbove): Previous Chiropractic Care: D None D Doctor's Name & Approximate of Last Visit _ Drugs You Now Take: D Nerve Pills D Pain Killers/ Muscle Relaxers 0 Blood Pressure Medicine D Insulin OOther -------------------------------------
Below are a list of diseases which may seem unrelated to the purpose of your appointment. However the questions must be answered carefully as these problems can affect your overall course of chiropractic care. CHECK ANY OF THE FOLLOWING DISEASE YOU HAVE HAD OR CURRENTLY HAVE: 0 Pneumonia 0 Rheumatic Fever D Polio 0 Tuberculosis 0 Whooping Cough 0 Anemia 0 Measles 0 Chemical Dependency OAicoholism D Mumps 0 Small Pox 0 Chicken Pox 0 Diabetes 0 Cancer D Heart Disease 0 Thyroid 0 Asthma D Aids/H.I.V. 0 Influenza 0 Pleurisy 0 Arthritis 0 Epilepsy 0 Mental Disorders 0 Lumbago 0 Eczema 0 Stroke 0 Osteoporosis 0 Weak Immune System 0 Subluxations D Pacemakers 0 Multiple Sclerosis 0 Psychiatric Care D Hepatitis 0 Hernia 0 Carpal Tunnel Synd. 0 Repetitive Strain Synd. CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST SIX MONTHS: MUSCULO-SKELETAL CODE 0 Low Back Pain 0 fla~n Between Shoulders 0 Neck Pain 0 Arm Pain 0 Joint Pain/Stiffness D Shoulder Pain 0 Knee Pain 0 Hip Pain 0 Hand/Wrist Pain 0 Foot/Ankle Pain GENERAL CODE 0 Fatigue 0 Allergies D Loss of Sleep 0 Fever D Headaches C-V-R CODE 0 Chest Pain 0 Shortness of Breath 0 Blood Pressure D Irregular Heartbeat 0 Heart Problems 0 Lung Problems/Congestion 0 Varicose Veins 0 Ankle Swelling 0 Stroke GASTRO-INTESTINAL CODE 0 Poor/Excessive Appetite D Excessive Thirst D Frequent Nausea D Vomiting D Diarrhea 0 Constipation 0 Hemorrhoids 0 Liver Problems 0 Weight Trouble 0 Abdominal Cramps 0 Gas/Bloating After Meals 0 Heartburn 0 Black/Bloody Stool 0 Colitis GENITO-URINARY CODE D Bladder Trouble 0 Painful/Excessive Urination 0 Discolored Urine MALE/FEMALE CODE 0 Menstrual Irregularity 0 Menstrual Cramps 0 Vaginal Painjlnfection 0 Breast Pain/Lumps 0 Prostate/Sexual Dysfunction 0 Venereal Disease 0 Other Problems NERVOUS SYSTEM CODE 0 Nervous 0 Numbness 0 Paralysis 0 Dizziness 0 Forgetfulness 0 Confusion/Depression 0 Fainting 0 Convulsions 0 Cold/Tingling Extremities 0 Stress EENTCODE 0 Vision Probers 0 Dental Problems 0 Sore Throat 0 Ear Aches 0 Hearing Difficulty 0 Stuffed Nose FAMILY HISTORY The following members have the same or sim1lar problems as I do: 0 Mother 0 Father 0 Brother 0 Sister 0 Spouse 0 Child FEMALES ONLY When was your last menstrual cycle? Are you pregnant? 0 Yes 0 No 0 Not Sure EXERCISE WORK ACTIVITY HABITS D None 0 Sitting 0 Smoking D Moderate 0 Computers 0 Alcohol 0 Daily 0 Standing O Coffee/Caffeine Drinks 0 Heavy 0 Light Labor 0 High Stress Level 0 Heavy Labor Packs/Day Drinks/Week Cups/Day What is most important in your Doctor/Patient relationship?------------------------- What are your health goals? 0 pain relief only 0 correct my health problem Signature----------------
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION I authorize Martinez Chiropractic Center and any member of its staff to call, leave voice mail messages and\e-mail messages and disclose Protected Health Information (PHI) pertaining to me, including but not limited to medical information, such as test results, procedures results, appointment reminders, or any other PHI related to my treatment to the following numbers: Home Number Work Number Cell Phone Number Email Appointment Reminders: Text Message Cell Phone Company: Email No Reminder All reminders are sent approximately 24 hours prior to your appointment. I authorize Martinez Chiropractic Center and any member of its staff to fax my (PHI), including medical information needed for my treatment to the following fax number:. I authorize Martinez Chiropractic Center and any member of its staff to disclose my (PHI), including test results to the following individuals: Patient Signature
RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGMENT FORM I, have received a copy of Martinez Chiropractic Center Notice of Patient Privacy Practices. INFORMED CONSENT FORM I, hereby request and consent to the performance of chiropractic treatments and other chiropractic/medical procedures, including various forms of physical therapy and diagnostic x-rays by Martinez Chiropractic Center. This consent is extended to other licensed chiropractic Physicians, Chiropractic assistants or licensed Massage Therapists, who now or in the future, are employed by, working with or associated with this office. I certify that I have had the opportunity to discuss, with the doctor of Chiropractic and/or other office personnel, the nature and purpose of the care that is being provided. I understand that the results are not guaranteed. Further, I have been informed and I understand that, as in the practice of any of the healing arts, in the practice of Chiropractic, there are some risks to treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I also understand that the doctor, who has explained all of these things to me, is not expecting to be able to anticipate and explain all the risks and complications. I will rely on the doctor to exercise appropriate judgment during the course of care, based on the facts known at this time, and in my best interest. My signature below certifies that I have read, or have had read to me the above consent. I also certify that I have had the opportunity to ask questions and options to care have been explained. By signing this consent form, I agree to the care being provided to me for the entire course of treatment for my present condition(s) and for any future condition(s) for which I seek treatment. My signature certifies that I have read and agreed to what has been stated above. Patient Signature
No Accident Form I, am seeking care from Martinez Chiropractic Center. The treatment is not due to a work related injury, automobile accident, or slip and fall. AUTHORIZATION I hereby authorize payment of benefits due to me from my insurance company and/or attorney to be made directly to Martinez Chiropractic Center. I further authorize the release of any medical records required by my insurance carrier. I fully understand that I am financially responsible for any charges covered by this authorization to Martinez Chiropractic Center. In the event that it becomes necessary to institute litigation over the non-payment of our fees, the cost and legal expenses incurred therein are that of the patient. Insurance Certification This is to certify that I, have presented any and all information regarding my health insurance plan(s). The only health insurance policy in effect is: Name of Insurance Co. Insured s Name Relationship with Insured ID# Group# My signature certifies that the information I have filled in above is accurate, and that I am not seeking care due to an auto accident, work injury, or slip & fall nor do I have an open or pending case. Patient s Signature Print Patient s Name