PATIENT APPLICATION PLEASE PRINT. All requested information must be completed. If any question does not apply, please enter the term N/A. Last Name First Name M.I. Date of Birth Age Home Address Street/City/State/Zip Code Nickname : Race / Ethnicity: Gender: MALE / FEMALE Social Security # Home Phone_ ( ) Cell Phone_ ( ) Work Phone_ ( ) Employer Occupation May we contact you at work? Y/ N Home? Y/ N Marital Status S M D W Spouse s Last Name First Name M.I. Responsible Party Self Spouse Other If Other, relationship to you? Responsible Party Phone_ ( ) Responsible Party Information: If Self, state Same. Last Name First Name DOB. Do we have permission to discuss your condition with or provide information from your chart to your spouse or other named individual? Y / N Last Name First Name M.I. Relationship to you Primary Care Physician Phone_ ( ) Who may we thank for this referral? Your email address: CONSENT FOR CARE AND TREATMENT I, the undersigned, do hereby agree and give my consent for Superior Healthcare, LLC to furnish medical/chiropractic/physical rehab and treatment that is considered necessary and proper in diagnosing or treating my/their physical condition and have received the Patient Rights and Responsibilities. Patient Initial Here: EMERGENCY CONTACT INFORMATION Last Name First Name M.I. Relationship to you TWO Emergency Contact Phone Numbers Home Phone_ ( ) Cell Phone_ ( ) Work Phone_ ( ) INSURANCE INFORMATION and FINANCIAL POLICY STATEMENT Primary Ins. Contract # Group # Effective Date Copay Name and of Policy Holder (If other than Self ) Last Name First Name M.I. Policy Holder s / Insured s Social Security # Policy Holder s / Insured s Date of Birth Secondary Ins. Contract # Group # Effective Date Name and of Policy Holder (If other than Self ) Last Name First Name M.I. Policy Holder s / Insured s Social Security # Policy Holder s / Insured s Date of Birth It is our policy to bill your insurance carrier(s) as a courtesy to you, although you are responsible for the entire bill when the services are rendered. You are required to authorize the release of any medical information necessary to process claims. We require that payment of any copay per visit be made at the time of your visit. If your insurance carrier(s) do no remit payment within 90 days, the balance will be due in full from you. If any payment is subsequently made by your insurance carrier(s) in excess of the balance of your account, we will promptly refund the credit. If any payment is made directly to you for services billed by us, you recognize an obligation to promptly remit to this office. The policy does not apply to individuals who have contracted a Care Plan Financial Agreement with Superior Healthcare, Inc. unless and until such agreement expires, and/or there is coinsurance due per your insurance company; nor does it apply to Worker s Compensation or Personal Injury patients. However, Worker s Compensation or Personal Injury patients should be advised that you may be held responsible for your charges in the event your claim is converted. I have read the above information and fully understand my responsibility for the payment of my account. Patient / Guardian Signature Date
Health History Superior Healthcare, L.L.C Patient Name DOB: Today s Date Date of last physical examination Reason for visit: Symptoms Check symptoms you currently experience or have experienced in the past year. GENERAL o Sinus Problems CARDIOVASCULAR o Vomiting o Chills o Nosebleeds o Chest Pain o Vomiting Blood o Depression o Allergies o High Blood Pressure o Dizziness o Hay Fever o Low Blood Pressure GENITO-URINARY o Fainting o TMJ/Pain/Clicking o Irregular Heartbeat o Blood in Urine o Fever o Teeth Grinding o Poor Circulation o Frequent Urination o Forgetfulness o Bleeding Gums o Rapid Heartbeat o Loss of Bladder Control o Headache o Difficulty Swallowing o Swelling of Ankles o Painful Urination o Loss of Sleep o Hoarseness o Varicose Veins o Loss of Weight o Excessive Water Retention MEN ONLY o Nervousness MUSCLE/JOINT/BONE o Breast Lump(s) o Sweats Pain, Weakness, Numbness LUNGS o Erectile Dysfunction o Low Energy/Fatigue o Arms o Lump(s) in Testicle o Back o Legs o Difficulty Breathing o Discharge from Penis SKIN o Feet o Neck o Persistent Cough o Sore(s) on Genitalia o Bruise Easily o Hands o Shoulders o Bloody Mucus o Other o Hives o Bloody Sputum o Itching CERVICAL THORACIC WOMEN ONLY o Change in Moles LUMBAR SPINE o Recurrent Colds or Flu o Abnormal Pap Smear o Rash o Neck Pain o Bleeding Between Periods o Scars o Radiating Pain Shoulder GASTROINTESTINAL o Breast Lump(s) o Sores that will not heal o Radiating Pain Arms/Hands o Bloating o Extreme Menstrual Pain o Weakness in Grip o Bowel Changes o Hot Flashes HEENT o Coldness in Hands o Constipation o Nipple Discharge EYE, EAR, NOSE, THROAT o Numb/Tingling Arms/Hands o Diarrhea o Painful Intercourse o Blurred Vision o Pain on Deep Breathing o Excessive Hunger o Vaginal Discharge o Double Vision o Mid Back Pain o Excessive Thirst o Sexual Dysfunction o Vision Flashes o Pain into Ribs/Chest o Gas o Other o Vision - Halos o Pain into Hips/Legs/Feet o Hemorrhoids Last Menstrual Period o Crossed Eyes o Numbness/Tingling Last Pap Smear o Indigestion/Heartburn/Reflux Legs/Feet o Earache o Coldness Legs/Feet o Nausea Last Mammogram o Ear Discharge o Muscle Cramps Legs/Feet o Rectal Bleeding Are you pregnant? o Yes o No o Ringing in Ears o Lower Back Pain o Stomach Pain Number of Children Conditions Check conditions you currently experience or have experienced in the past year. o AIDS o Chicken Pox o HIV Positive o Restless Leg Syndrome o Alcoholism o Chronic Fatigue o Kidney Disease o Rheumatic Fever o Anemia o Diabetes o Liver Disease o Rheumatoid Arthritis o Anorexia o Emphysema o Measles o Scarlet Fever o Appendicitis o Epilepsy o Migraine Headaches o Stroke o Arthritis o Glaucoma o Miscarriage o Suicide Attempt o Asthma o Goiter o Mononucleosis o Systemic Lupus o Bleeding Disorders o Gonorrhea o Multiple Sclerosis o Thyroid Problem o Breast Lump o Gout o Mumps o Tonsillitis o Bronchitis o Heart Disease o Pacemaker o Tuberculosis o Bulimia o Hepatitis o Pneumonia o Typhoid Fever
o Cancer o Hernia o Polio o Ulcers o Cataracts o Herpes o Prostate Problem o Vaginal Infections o Chemical Dependency o High Cholesterol o Psychiatric Care o Venereal Disease NAME: DOB: Current Medications DATE: Allergies Pharmacy Name Phone Relation Father Mother Brothers Sisters Age State of Health Age at Death Family History Cause of Death Check if your blood relatives had/have any of the following. Disease Relationship to you o Arthritis/Gout o Asthma/Hay Fever o Cancer o Chemical Dependency o Diabetes o Heart Disease o High Blood Pressure o Kidney Disease o SLE/CFS/Other Rheumatoid o Tuberculosis Hospitalizations Year Hospital Reason for Hospitalization and Outcome Appx. Date Serious Illnesses/Injuries Type of Serious Illness/Injury and Outcome Pregnancies Health Habits Occupational Year Sex Complications if Any Check and describe how much you use or do below: o Alcohol o Caffeine o Illegal Drugs o Tobacco o Exercise Check if your work exposes you to the following: o Hazardous Substances o Heavy Lifting o Stress o Other o Other o Other
I certify that the above information is correct to the best of my knowledge. I will not hold my physician or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Patient Signature: Date: Health Questionnaire Name: E-mail Address: Check off any of the following symptoms you have experienced in the past 6 months: Mid Back Pain Unexplained Weight Gain/ Loss Difficulty Losing Weight Low Back Pain Tension Across Top of Shoulders Tired/Fatigued Pain between Shoulder Blades Numbing/Tingling in Arms/Hands Difficulty Sleeping Neck Pain Numbing/Tingling in Legs/Feet Allergies/Asthma/ Respiratory Problems Tension/Headaches/migraine Pain in the legs Digestive Problems Fibromyalgia Pain in the Feet Carpal Tunnel Dizziness Pain in Knees, Shoulder, Elbow, Hands Coldness in Feet, Hands Cramping in Arms, Hands, Legs, Feet TMJ Weakness in Arms, Hands (Grip), Hips, Knees, Feet, Shoulder OTHER (explain) Which of the above is the worst? How long have you had it? How often does it occur? What does it feel like?(describe) What have you done that has helped this problem? What activities would you like to do if this was not a problem? Does this cause you to be: Does this affect your work: Does this affect your life: Moody Decision making Lose patience with spouse/children Irritable Poor attitude Restricted household duties Interrupt sleep Decreased productivity Hinders ability to exercise or sports Restricted in your daily activities Exhausted at the end of the day Interferes with ability to do hobbies Unable to work long hours or other activities What have you tried to help relieve/get rid of this problem and how much did it help? ( circle appropriately) Medications Helped: Little Some Much Exercise Helped: Little Some Much Physical Therapy Helped: Little Some Much Nutrition Helped: Little Some Much Chiropractic Helped: Little Some Much Stretching Helped: Little Some Much Signature: Date: / /
`Neurological / MRI/ Vascular Patient Questionnaire Name Date For any YES answer, please explain under comment and notify the doctor: 1. Do you suffer from neck pain in your shoulder, arms or hands? NO YES 2. Do you have weakness, numbness or burning in your shoulder arms, or hands? NO YES 3. Do your hands or arms fall asleep regularly? NO YES 4. Do you have reduced feeling (sensation) or swelling in your hands or arms? NO YES 5. Do you suffer from a loss of handgrip strength? NO YES 6. Do you suffer with back pain with pain in your buttocks, legs, or feet? NO YES 7. Do you have weakness, numbness or burning in your buttocks, legs, or feet? NO YES 8. Do your legs or feet fall asleep regularly? NO YES 9. Do you have reduced feeling (sensation) or swelling in your legs or feet? NO YES 10. Do you suffer from cold hands or feet? NO YES 11. Have you tried any medications such as anti-inflammatory? NO YES If yes, what kind of medication? 12. Have you tried any physical therapy or Chiropractic treatments before? NO YES If yes: When? For how long? What kind? 13. Have you had an MRI? NO YES If yes: When? Who ordered it? What was it ordered for? 14. Have you used any splint or braces or other prescribed treatment by an MD? NO YES If yes: When? What kind? Who ordered it?
15. If you have tried any treatment or medications, did this make your problem better? NO YES Note: Your health information will be kept strictly confidential. Any information that we collect about you on this form will be kept confidential in our office. If a claim is submitted to Medicare, your health information on this form may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare. Reports