Patient Information: Date: First name: Middle initial: Last name: Date of Birth: SSN# Best phone number to contact you at: Home Work Mobile How did you hear about us? Referral by: Street address: City: State: Zip: Email Address: Employment Status: Full-Time Part-Time Homemaker Student Retired Disabled Unemployed Employer Name Occupation Employer Address Phone # City State Zip Preferred Language: English Other: Marital Status: Single Married Other Race: White (Caucasian) American Indian or Alaskan Native Asian Black or African American Other I decline to answer Emergency Contact Please provide the information about the nearest relative or friend. First name Last name Best number to contact them Home Work Mobile Relation to patient MY PRIVACY I have received a copy of the Notice of Privacy Practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the healthcare providers who may be directly and indirectly involved in providing my treatment; Obtain payment from third- party payers; Conduct normal healthcare operations such as quality assessments and accreditation. Patient Signature: Date: Page 1 of 5
MEDICAL HISTORY Primary Care Physician: Phone Number: Please review the following CAREFULLY and check any conditions that apply to you as these are important to know for your care. Persistent fever Night sweats Loss of sleep Fatigue Nervousness Anemia Lung disease Irregular heart beat Chest pain Heart disease High blood pressure Pacemaker Frequent nausea/ vomiting Car accident Major fall Head injury Broken bone Bleeding problem Ankle swelling Frequent urination YES Type I diabetes Varicose veins Painful urination Type II diabetes Rheumatic fever Blood in urine Cancer Stroke Urinary Tract pregnant? Thyroid disease/ Arteriosclerosis Infection YES Goiter Itching Kidney disease Alcoholism Change in mole(s) Kidney stones Loss of balance Skin cancer Inability to control Unexplained weight Hair/ nail changes urination loss/ gain Scar(s) Difficulty starting Intentional weight Cold extremities urination loss/gain Bruise easily Getting up at night Indoor/ outdoor Poor appetite to urinate allergies Poor digestion Sexually Poor vision Difficulty transmitted disease Eye pain swallowing Sexual difficulty Hearing problems Belching or gas Testicular Problems Nosebleeds Vomiting blood Prostate problems Nose problems Pain over abdomen Painful periods Sinus trouble Stomach ulcer Excessive flow Dental problems Black or bloody Irregular cycles Hoarseness stool Vaginal burning/ Tonsillectomy Liver problems itching Loss of smell Jaundice Severe cramps Difficulty breathing Diarrhea PCOS Shortness of breath Constipation PMS Chronic cough Gall bladder PMDD Spitting phlegm problems Hot flashes Bronchitis Bloating Date of last Spitting blood Hemorrhoids menstrual period: Wheezing/ asthma Appendicitis Pneumonia Hernia Tuberculosis Date of last Pap smear: Are you currently experiencing pre or post menopause? NO Is there a possibility you are currently NO Breast lump or pain Weakness Twitching Tremor Headache Fainting Dizziness Convulsions Epilepsy/ seizures Numbing/ tingling Arm/ leg pain Mental disorder Depression Loss of memory Loss of taste Polio Painful joints Spinal curvature Osteoarthritis Sprain/ strain Swollen joints Rheumatoid Arthritis Page 2 of 5
Exercise: None 1-2 times a week 3-5 times a week 6-7 times a week Smoking status: Every day smoker Occasional smoker Former Smoker Never smoked Use recreational drugs? YES NO Do you drink alcohol? YES NO How would you describe your current health state? Poor Fair Good Excellent List any medications that you are currently taking, including birth control List any vitamins and supplements you are taking List any other health conditions, surgeries, or hospitalizations Family History Please check if your mother, father, son, daughter, brother, sister, maternal grandmother, maternal grandfather, paternal grandmother or paternal grandfather have had any of the following conditions. My family history is unknown If yes, whom? Type I Diabetes NO YES Type II Diabetes NO YES Thyroid disease NO YES Goiter NO YES Tuberculosis NO YES Kidney disease NO YES High blood pressure NO YES Heart disease NO YES Cancer NO YES Multiple sclerosis NO YES Rheumatoid arthritis NO YES Lung disease NO YES Ulcer NO YES Arthritis NO YES Seizure NO YES Stroke NO YES Muscle, bone or nerve disease NO YES Page 3 of 5
Have you seen a chiropractor/massage therapist before? NO YES Last Visit: What is your main complaint? What caused this to start? When did this start? What makes it better? What makes it worse? Circle the word or words that best describe it: Sharp, Dull, Aching, Burning, Tingling, Numb, Shooting, Mild, Moderate, Severe, Intense, Continuous, Intermittent, Random, Insidious, Comes and Goes, Numbness, Pain, Discomfort, Tightness, Throbbing, Varying with activity, Increasing with movement, Mild nuisance Does the pain start one place and travel to another? YES NO How bad is it at its worst?* (Circle the one that applies) 0 1 2 3 4 5 6 7 8 9 10 *(0 is no pain, 1-3 is mild, 4-6 is moderate, 7-9 is severe and 10 is intolerable) Is there a time of day associated with your pain? (Circle one) None Morning Afternoon Night What have you done to treat this problem? Have you had this type of problem in the past? Does this problem interfere with: Work Activities Sleep Appetite Have you had x-rays taken? NO YES If so, when? Are there any other problems you want to discuss with the chiropractor? Headaches Knee pain Weight loss Wellness care Shoulder pain Fatigue Stress Exercise counseling Sleep issues ADHD/ ASD/ Behavioral issues Vitamins/ supplements Patient Consent By signing below, I consent to an examination to determine my treatment needs and I acknowledge that Chiropractic Wellness Center has a variety of treatment options including: spinal manipulation, massage, acupuncture, hot or cold therapies, therapeutic ultrasound, electrotherapy, Graston soft tissue treatment, decompression therapy, Kinesiotaping, and imaging that may be used with my treatment plan if necessary. I understand that if there are any questions I have about any of the treatment options or would prefer to opt-out of, I will notify my doctor or therapist immediately. I also consent to understanding my financial obligations for my treatment and have given any of my insurance information necessary for billing purposes. I understand that financial obligation is based upon explanation of benefits provided by my insurance carrier and anything not covered by the carrier is my responsibility. Patient Signature: Date: Page 4 of 5
Staff Initial INSURANCE INFORMATION *Please provide your insurance card and ID to front desk to copy* Type of Insurance: Phone Number: Patient Last Name First Name Date of Birth Insured s Last name First Name Date of Birth Relationship to Insured Insurance/Member ID # Group ID # *I authorize for any staff from the facility to call on my behalf to verify my insurance benefits and coverage. This is also to verify that I will be made aware of my insurance coverage as told to this office by my insurance company. I understand that this is not a guarantee of coverage or payment. It is my policy coverage as stated by an employee of insurance company. I remain responsible for any co-payment, deductible, and difference as given by explanation of benefits. Signature: Date: ***Below will be filled out by Chiropractic Wellness Center*** Date: Spoke to: Ref # Effective Date: Plan Type: HSA/HRA: Y or N Deductible: Met: Calendar Year/Plan Year (Circle one) Co Pay/Co Insurance: Insurance Pays: Visit Limits: Max Out of Pocket: Visits Used: Applied Amount to Max: Acupuncture coverage: Page 5 of 5