Milham Family Chirpractic Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex M F Marital Status M S D W Date f Birth Age Occupatin Emplyer Referred by: Have yu ever received Chirpractic Care? Yes N If yes, when? Name f mst recent Chirpractr: 1. Reasns fr seeking chirpractic care: Primary reasn: Secndary reasn: 2. Previus interventins, treatments, medicatins, surgery, r care yu ve sught fr yur cmplaint(s): 3. Past Health Histry: A. Please indicate if yu have a histry f any f the fllwing: Anticagulant use Heart prblems/high bld pressure/chest pain Bleeding prblems Lung prblems/shrtness f breath Cancer Diabetes Psychiatric disrders Biplar disrder Majr depressin Schizphrenia Strke/TIA s Other Nne f the abve B. Previus Injury r Trauma: Have yu ever brken any bnes? Which? C. Allergies: D. Medicatins: Medicatin Reasn fr taking 1
Milham Family Chirpractic E. Surgeries: Date Type f Surgery F. Females/ Pregnancies and utcmes: Pregnancies/Date f Delivery Outcme 4. Family Health Histry: D yu have a family histry f? (Please indicate all that apply) Cancer Strkes/TIA s Headaches Cardiac disease Neurlgical diseases Adpted/Unknwn Cardiac disease belw age 40 Psychiatric disease Diabetes Other Nne f the abve Deaths in immediate family: Cause f parents r siblings death Age at death Scial and Occupatinal Histry: A. Jb descriptin: B. Wrk schedule: C. Recreatinal activities: D. Lifestyle (hbbies, level f exercise, alchl, tbacc and drug use, diet): 2
Milham Family Chirpractic Review f Systems Have yu had any f the fllwing pulmnary (lung-related) issues? Asthma/difficulty breathing COPD Emphysema Other Nne f the abve Have yu had any f the fllwing cardivascular (heart-related) issues r prcedures? Heart surgeries Cngestive heart failure Murmurs r valvular disease Heart attacks/mis Heart disease/prblems Hypertensin Pacemaker Angina/chest pain Irregular heartbeat Other Nne f the abve Have yu had any f the fllwing neurlgical (nerve-related) issues? Visual changes/lss f visin One-sided weakness f face r bdy Histry f seizures One-sided decreased feeling in the face r bdy Headaches Memry lss Tremrs Vertig Lss f sense f smell Strkes/TIAs Other Nne f the abve Have yu had any f the fllwing endcrine (glandular/hrmnal) related issues r prcedures? Thyrid disease Hrmne replacement therapy Injectable sterid replacements Diabetes Other Nne f the abve Have yu had any f the fllwing renal (kidney-related) issues r prcedures? Renal calculi/stnes Hematuria (bld in the urine) Incntinence (can t cntrl) Bladder Infectins Difficulty urinating Kidney disease Dialysis Other Nne f the abve Have yu had any f the fllwing gastrenterlgical (stmach-related) issues? Nausea Difficulty swallwing Ulcerative disease Frequent abdminal pain Hiatal hernia Cnstipatin Pancreatic disease Irritable bwel/clitis Hepatitis r liver disease Bldy r black tarry stls Vmiting bld Bwel incntinence Gastresphageal reflux/heartburn Other Nne f the abve Have yu had any f the fllwing hematlgical (bld-related) issues? Anemia Regular anti-inflammatry use (Mtrin/Ibuprfen/Naprxen/Naprsyn/Aleve) HIV psitive Abnrmal bleeding/bruising Sickle-cell anemia Enlarged lymph ndes Hemphilia Hypercagulatin r deep venus thrmbsis/histry f bld clts Anticagulant therapy Regular aspirin use Other Nne f the abve Have yu had any f the fllwing dermatlgical (skin-related) issues? Significant burns Significant rashes Skin grafts Psriatic disrders Other Nne f the abve Have yu had any f the fllwing musculskeletal (bne/muscle-related) issues? Rheumatid arthritis Gut Ostearthritis Brken bnes Spinal fracture Spinal surgery Jint surgery Arthritis (unknwn type) Sclisis Metal implants Other Nne f the abve Have yu had any f the fllwing psychlgical issues? Psychiatric diagnsis Depressin Suicidal ideatins Biplar disrder Hmicidal ideatins Schizphrenia Psychiatric hspitalizatins Other Nne f the abve Is there anything else in yur past medical histry that yu feel is imprtant t yur care here? I have read the abve infrmatin and certify it t be true and crrect t the best f my knwledge, and hereby authrize this ffice f Chirpractic t prvide me with chirpractic care, in accrdance with this state's statutes. If my insurance will be billed, I authrize payment f medical benefits t James C. Milham, DC, Milham Family Chirpractic fr services perfrmed. I clearly understand that all insurance cverage, whether accidental, wrk-related, r general cverage, is an arrangement between my insurance carrier and myself. If this ffice chses t bill any services t my insurance carrier, they are perfrming this service strictly as a cnvenience fr me. The Dctr s ffice will prvide any necessary reprts r required infrmatin t aid in insurance reimbursement f services, but I understand that insurance carriers may deny my claims and that I am ultimately respnsible fr any unpaid balances. Any mnies received will be credited t my accunt. Patient r Guardian Signature Date 3
Milham Family Chirpractic HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Ntice f Privacy describes hw we may use and disclse yur prtected health infrmatin (PHI) t carry ur treatment, payment r health care peratins (TPO) fr ther purpses that are permitted r required by law. Prtected Health Infrmatin is infrmatin abut yu, including demgraphic infrmatin that may identify yu and that related t yur past, present, r future physical r mental health r cnditin and related care services. Use and Disclsures f Prtected Health Infrmatin: Yur prtected health infrmatin may be used and disclsed by yur physician, ur staff and thers utside f ur ffice that are invlved in yur care and treatment fr the purpse f prviding health care services t yu, pay yur health care bills, t supprt the peratins f the physician s practice, and any ther use required by law. Treatment: We will use and disclse yur prtected health infrmatin t prvide, crdinate, r manage yur health care and any related services. This includes the crdinatin r management f yur health care with a third party. Fr example, we wuld disclse yur prtected health infrmatin, as necessary, t a hme health agency that prvides care t yu. Fr example, yur health care infrmatin may be prvided t a physician t whm yu have been referred t ensure that the physician has the necessary infrmatin t diagnse r treat yu. Payment: Yur prtected health infrmatin will be used, as needed, t btain payment fr yur health care services. Fr example, btaining apprval fr a hspital stay may require that yur relevant prtected health infrmatin be disclsed t the health plan t btain apprval fr the hspital admissin. Healthcare Operatins: We may disclse, as needed, yur prtected health infrmatin in rder t supprt the business activities f yur physician s practice. These activities include, but are nt limited t, quality assessment activities, emplyee review activities, training f medical students, licensing, marketing, and fund raising activities, and cnductin r arranging fr ther business activities. Fr example, we may disclse yur prtected health infrmatin t medical schl students that see patients at ur ffice. In additin, we may use a sign-in sheet at the registratin desk where yu will be asked t sign yur name and indicate yur physician. We may als call yu by name in the waiting rm when yur physician is ready t see yu. We may use r disclse yur prtected health infrmatin, as necessary, t cntact yu t remind yu f yur appintment. We may use r disclse yur prtected health infrmatin in the fllwing situatins withut yur authrizatin. These situatins included as required by law, public health issues, cmmunicable diseases, health versight, abuse r neglect, fd and drug administratin requirements, legal prceedings, law enfrcement, crners, funeral directrs, and rgan dnatin. Required uses and disclsures under the law, we must make disclsures t yu when required by the Secretary f the Department f Health and Human Services t investigate r determine ur cmpliance with the requirements f Sectin 164.500. OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW. Yu may revke this authrizatin, at any time, in writing, except t the extent that yur physician r the physician s practice has taken an actin in reliance n the use r disclsure indicated in the authrizatin. Signature f Patient f Representative Printed Name Date 4
Milham Family Chirpractic NEW PATIENT HISTORY FORM Please start at the tp f yur bdy and wrk yur way dwn, i.e. Headache, Neck Pain, etc. Symptm 1 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: 1 2 3 4 5 6 7 8 9 10 What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 2 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: 1 2 3 4 5 6 7 8 9 10 What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 5
Milham Family Chirpractic Symptm 3 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: 1 2 3 4 5 6 7 8 9 10 What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 4 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: 1 2 3 4 5 6 7 8 9 10 What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 5 6
Milham Family Chirpractic On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: 1 2 3 4 5 6 7 8 9 10 What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day Symptm 6 On a scale frm 0-10, with 10 being the wrst, please circle the number that best describes the symptm mst f the time: 1 2 3 4 5 6 7 8 9 10 What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: When did the symptm begin? Did the symptm begin suddenly r gradually? (circle ne) Hw did the symptm begin? What makes the symptm wrse? (circle all that apply): Bending neck frward, bending neck backward, tilting head t left, tilting head t right, turning head t left, turning head t right, bending frward at waist, bending backward at waist, tilting left at waist, tilting right at waist, sitting, standing, getting up frm sitting psitin, lifting, any mvement, driving, walking, running, nthing, ther (please What makes the symptm better? (circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging Other Des the symptm radiate t anther part f yur bdy (circle ne): yes n If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (circle ne) Mrning Afternn Evening Night Unaffected by time f day 7