Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address: Employer: Address: City: State: Zip Code: Work Phone #: ( ) - Are You (Please check one) Married Single Widowed Divorced Separated Name of Spouse: Spouse s Employer: Work Phone #: ( ) - Who should be contacted in case of an emergency: Their relationship to you: Emergency Phone #: ( ) - Who is responsible for your bill? (please check one) Self Spouse Parent(s) How will payment be made? Cash Check Credit/Debit Card FEES FOR EXAMINATION AND TREATMENT ARE PAYABLE AT THE TIME SERVICES ARE RENDERED, UNLESS OTHER ARRANGEMENTS ARE MADE IN ADVANCE. X-RAYS REMAIN THE PROPERTY OF THIS OFFICE. Patient s Signature: We ask that a 24 hour notice be given if you cannot keep your scheduled appointment so that we may serve others in need. A fee will be charged to all cancels, transfers, and no shows without a 24 hour notice. Dr. Janet L. Yarger
Patient Name: Date: Patient Condition Describe your symptoms. When did your symptoms start? How did your symptoms begin? How often do you experience your symptoms: Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Please describe the nature of your symptoms: Sharp Dull Ache Numb Shooting Burning Tingling Other Does the pain spread to other areas? Yes No (If so, where?) During the past 4 weeks: a) On a scale of 0 to 10, circle the average intensity of your symptoms: 0 1 2 3 4 5 6 7 8 9 10 b) How much has pain interfered with your normal work (including work outside the home and housework) Not at all A little bit Moderately Quite a bit Extremely c) How much has your condition interfered with social activities? All of the time Most of the time Some of the time A little of the time None of the time On the drawing below, please circle where your pain or symptoms are occurring. Dr. Janet L. Yarger 1
Dr. Janet L. Yarger Patient Name: Date: In general, would you say your overall health right now is Excellent Very Good Good Fair Poor Health History Who have you seen for your symptoms? No one Medical Doctor Physical Therapist Chiropractor Other Name and address of other doctor(s) who have treated you for your condition? What treatment have you already received and when? Date of Last Physical Exam: For your current symptoms, have you had an MRI CT Scan X-ray Bone Scan Other Diagnostic Testing Have you had similar symptoms in the past? Yes No If you have received treatment in the past for the same or similar symptoms, who did you see? This Office Medical Doctor Physical Therapist Chiropractor Other Review of Systems Please check any of the following that apply: Headache High Cholesterol Migraines Heart Condition Neck Pain Chest Pains (Angina) Upper Back Pain Shortness of Breath Mid Back Pain Vascular Condition/Stroke Low Back Pain Lung Condition/ Shoulder Pain Emphysema/COPD Elbow/Upper Arm Pain Asthma Wrist/Hand Pain Abdominal Pain Hip/Upper Leg Pain Ulcer Knee/Lower Leg Pain Hepatitis Ankle/Foot Pain Liver/Gall Bladder Disorder Jaw Pain Heartburn/Indigestion/GERD Joint Swelling/Stiffness Constipation Spinal Disc Pathology Diarrhea Arthritis Loss of Bowel Control Rheumatoid Arthritis Colitis Osteoporosis Irritable Bowel Anemia Cancer/Tumor Blood Disorder Thyroid Condition Muscle aches Bone Fractures High/Low Blood Pressure Diabetes Excessive Thirst Frequent Urination Painful Urination Kidney/Bladder Stones Kidney/Bladder Infection Loss of Bladder Control Dizziness Loss of Consciousness Visual Disturbance Earache Ringing in Ears Sinusitis Hearing Loss Skin Condition Loss of Appetite Abnormal Weight Gain Depression Fatigue Difficulty sleeping Allergies 2
Dr. Janet L. Yarger Patient Name: Date: EXERCISE None Light Moderate Heavy 1-2 times a week 3-5 times a week 6-7 times a week Consists of: WORK ACTIVITY Sit more than 50% Stand more than 50% Light Labor Moderate Labor Heavy Labor Computer/Telephone HABITS Smoking Packs per day Alcohol Drinks per week Caffeine Drinks per week MEN OVER 40 Date of last Prostate Exam WOMEN ONLY Birth Control Pills PMS Hormone Replacement Pregnancy: Total Are you currently breast feeding? Yes No MEDICATIONS & DOSAGE VITAMINS/MINERALS/HERBS INJURIES/SURGERIES Please indicate if an immediate family member has had any of the following conditions. Which family member? (Do not include yourself) Rheumatoid Arthritis Diabetes Heart Condition (heart attack, valve disease, blockage) _ Stroke High Cholesterol Cancer Thyroid Disease/Goiter Tuberculosis Kidney Disease High Blood Pressure Muscle, Bone, or Nerve Disease Lung Disease Ulcer Other Serious Health Condition not listed: Is there anything else you would like the doctor to know about you, your condition or your general health status: (Please describe) Patient Signature: Date: Doctor Signature: Date: 3
Patient Health Information Consent Form We want you to know how your patient health information is going to be used in this office and your rights concerning those records. Before we begin any health care procedures we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you'd like to have a more detailed account of our policies and procedures concerning the privacy of your patient health information we encourage you to read the HIPPA notice that is available to you at the front desk before signing this consent form. 1. The patient understands and agrees to allow this chiropractic office to use their patient health information for the purpose of treatment, payment, health care operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested patient health information to the health insurance company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all patient health information to the minimum needed for what the insurance companies require for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submitted in writing any further restrictions on the use of their patient health information. Our office is not obligated to agree to those restrictions. 3. The patient's written consent need only be obtained one time for all subsequent care given at this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records of the care given prior to the written request to revoke consent, but would only apply to any care given after the request has been presented. 5. For your security and right to privacy all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to ensure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the doctor has the right to refuse care. I have read and understand how my patient health information will be used and I agree to these policies and procedures. Signature of Patient Date
DISCLOSURE & INFORMED CONSENT CHIROPRACTIC ADJUSTMENTS AND CARE I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physiotherapy (electrical stimulation, ultrasound, rehabilitative exercises, heat/ice) on me (or the patient named below, for whom I am legally responsible) by the Doctor of Chiropractic named below and/or other licensed Doctors of Chiropractic who now or in the future work at the clinic or office listed below. I have had the opportunity to discuss with the Doctor of Chiropractic named below, the nature and purpose of chiropractic adjustments and other procedures and alternatives. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains and increased symptoms and pain or no improvement of symptoms or pain. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. To be completed by the patient: To be completed by the patient s representative, if necessary, e.g., if the patient is a minor or is physically or legally incapacitated: Print Name Signature of Patient Date Signed To be completed by doctor or staff: Witness to Patient s Signature Print name of Patient Print Name of Patient s Representative Signature of Patient s Representative As: Relationship to Patient Date Yarger Chiropractic and Acupuncture Dr. Janet L. Yarger
Website Membership Enrollment The information on our website will help you Get Well and Stay Well. Please provide the following details so we can establish you as a member of our website today: First name: Last name: Date of birth: / / Email address: Please check the health subjects that most interest you: Headaches and Neck Pain Backaches and Sciatica Children s Health Issues Exercise and Fitness Diet and Nutrition Stress Management Wellness Topics Women s Health Issues By joining our website, you authorize us to send occasional health care related emails to you. Naturally, you may opt-out at any time. Please review our complete privacy policy on our website. Lifecycle: Chiropractor: