Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm Patient Name: Date: Address City/State Zip Cde Hme. Phne Cell: Wrk. Email Address: Sex: M F (Please circle) Date f Birth: Referred by: Have yu ever received chirpractic care? (Please circle) Yes N If yes, when? Name f mst recent Chirpractr: Health Histry: 1. Previus Injury r Trauma: 2. Have yu ever brken any bnes? Which? 3. Allergies: 4. Medicatins: 5. Surgeries: Date Type f Surgery 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 Scial and Occupatinal Histry: Jb descriptin: Level f Activity? (Please check ne) High Medium Lw Any alchl, tbacc r drug use: Yes N (Please circle) Frequency per day week mnth 1
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm Review f Systems (Please check all that apply) 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 Gastr esphageal 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 Hyper cagulatin 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 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 State f Wiscnsin statutes. Patient r Guardian Signature Date 2
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm PATIENT SYMPTOM FORM Please start at the tp f yur bdy and wrk yur way dwn, i.e. Headache, Neck Pain, etc. SYMPTOM 1 1. Exact Lcatin (right, left, frnt, back, etc.) 2. When did the symptm begin? Did the symptm begin suddenly r gradually? (please circle ne) Describe hw the symptm began? Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging, r Other (please describe): 3. On a scale 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 4. What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 5. Des the symptm radiate t anther part f yur bdy (please circle ne): Yes N If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (please circle) Mrning Afternn Evening Night Unaffected by time f day 6. What makes the symptm wrse? (please circle all that apply): Bending neck backward r frward, tilting head t left, tilting head t right, turning head t left r right, bending frward r backward at waist, tilting left r right at waist, twisting right r left at waist, sitting, standing, r describe belw: 7. What makes the symptm better? (please circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): _ 3
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm SYMPTOM 2: 1. Exact Lcatin (right, left, frnt, back, etc.) 2. When did the symptm begin? Did the symptm begin suddenly r gradually? (please circle ne) Describe hw the symptm began? Describe the quality f the symptm (please circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging, r Other (please describe): 3. On a scale 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 4. What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 5. Des the symptm radiate t anther part f yur bdy (please circle ne): Yes N If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (please circle) Mrning Afternn Evening Night Unaffected by time f day 6. What makes the symptm wrse? (please circle all that apply): Bending neck backward r frward, tilting head t left, tilting head t right, turning head t left r right, bending frward r backward at waist, tilting left r right at waist, twisting right r left at waist, sitting, standing, r describe belw: 7. What makes the symptm better? (please circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): _ 4
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm PATIENT SYMPTOM FORM Please start at the tp f yur bdy and wrk yur way dwn, i.e. Headache, Neck Pain, etc. SYMPTOM 3 1. Exact Lcatin (right, left, frnt, back, etc.) 8. When did the symptm begin? Did the symptm begin suddenly r gradually? (please circle ne) Describe hw the symptm began? Describe the quality f the symptm (circle all that apply): Sharp, dull, achy, burning, thrbbing, piercing, stabbing, deep, nagging, shting, stinging, r Other (please describe): 9. On a scale 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 10. What percentage f the time yu are awake d yu experience the abve symptm at the abve intensity: 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 11. Des the symptm radiate t anther part f yur bdy (please circle ne): Yes N If yes, where des the symptm radiate? Is the symptm wrse at certain times f the day r night? (please circle) Mrning Afternn Evening Night Unaffected by time f day 12. What makes the symptm wrse? (please circle all that apply): Bending neck backward r frward, tilting head t left, tilting head t right, turning head t left r right, bending frward r backward at waist, tilting left r right at waist, twisting right r left at waist, sitting, standing, r describe belw: 13. What makes the symptm better? (please circle all that apply): Rest, ice, heat, stretching, exercise, massage, pain medicatin, muscle relaxers, nthing, Other (please describe): _ 5
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm HIPAA NOTICE OF PRIVACY PRACTICES AND INFORMED CONSENT FOR TREATMENT THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED. 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 fr ther purpses that are permitted r required by law. Yur Prtected Health Infrmatin is infrmatin pertaining t yu, including yur demgraphic infrmatin that may identify yu and that is 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 chirpractr, 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, request and receive payment fr yur health care bills, t supprt the peratins f this chirpractic 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, yur health care infrmatin may be prvided t a physician r health care facility t whm yu have been referred t ensure that the physician r facility 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 frm yur insurance cmpany r insurance representatives. Infrmed Cnsent fr Chirpractic Treatment: We may disclse, as needed, yur Prtected Health Infrmatin in rder t supprt the business activities f this ffice. Sme f these activities may include, but nt limited t: 1. Quality assessment activities; training f chirpractic ffice persnnel, marketing, and fund raising activities in and utside the ffice. 2. We may ask fr yur permissin t use yur phtgraph fr prmtins r activities within ur ffice. 3. We may cntact yu regarding yur appintments, using text alerts, phnes messages and emails. 4. I (patient) give us cnsent t the perfrmance f chirpractic spinal manipulatins/adjustments and ther prcedures, which may include an examinatin, spinal x-rays, massage therapy, kinesitaping, at the Dctr's discretin and as part f my spinal care plan. 5. I(patient) understand that my spinal manipulatins will be perfrmed in a semi-private setting. If I request additinal privacy, this ffice will try t accmmdate me. 6. I (patient) may revke this authrizatin, at any time, in writing, except t the extent that yur chirpractr r the practice has taken an actin in reliance n the use r disclsure indicated in the authrizatin. 7. If my insurance is billed, I authrize payment f medical benefits directly t Excel Family Chirpractic & Wellness, Inc. fr services perfrmed. We are happy t prvide a cpy f this infrmatin fr yur review, please let us knw. Signature f Patient r Representative Date Printed Name Minr Child Name: (if applicable) 6