Have you been seen by your local medical doctor for any related problems in the past year? If so please indicate when and for what exactly:
Cardiovascular
No
Respiratory
No
Present
Past
No
Present
Past
No
Poor Circulation
Asthma
High Blood Pressure
Tuberculosis
Aortic Aneuryan
Shortness of Breath
Heart Disease
Emphysema
Vascular Disease
Cold/Flu
Heart Attack
Cough/Wheezing
Chest Pain
High Cholesterol
Ears/Nose/Throat
No
Pace Maker
Present
Past
No
Jaw Pain
Dizziness
Irregular Heartbeat
Hearing Loss
Swelling of Legs
Sinus Infection
Nosebleed
Genitourinary
No
Sore Throat
Present
Past
No
Difficulty Swallowing
Kidney Disease
Bleeding Gums
Lower Side Pain
Burning Urination
Eyes
No
Frequent Urination
Present
Past
No
Blood in Urine
Glaucoma
Kidney Stone
Double Vision
Blurred Vision
Hemotologic/Lymphatic
No
Present
Past
No
Integumentary
No
Hepatitus
Present
Past
No
Blood Clots
Skin Ulcers
Cancer
Skin Disease
Easy Bruising
Eczema
Easy Bleeding
Psoriasis
Fevers/Chills/Sweats
Rashes
Have you had trouble with the following?
Allergic/Immunologic
No
Neurological
No
Present
Past
No
Present
Past
No
Hives
Stroke
Immune Disorder
Seizures
HIV/AIDS
Head Injury
Allergy Shots
Brain Aneurysm
Cortisone Use
Numbness
Severe Headaches
Gastrointestinal
No
Pinched Nerves
Present
Past
No
Parkinson's Disease
Gal bladder problems
Carpal Tunnel
Bowel Problems
Spinning/balance
Constipation
Liver Problems
Endocrine
No
Ulcers
Present
Past
No
Diarrhea
Thyroid Disease
Nausea/Vomiting
Diabetes
Bloody Stools
Hair Loss
Poor Appetite
Menopausal
Menstrual Problems
Musculoskeletal
No
Present
Past
No
Psychiatric
No
Gout
Present
Past
No
Arthritis
Depression
Joint Stiffness
Anxiety Disorder
Muscle Weakness
Unusual Stress
Osteoporosis
Broken Bones
Constitutional
No
Joints Replaced
Present
Past
No
Weight Loss/Gain
Energy Level problem
Difficulty Sleeping
Please describe your symptoms and how they began:
Onset date of your symptoms?
Have you had similar symptoms in the past?
Yes No
Please circle all that apply How often do you experience your symptoms? Constantly (76-100% of the day), Frequently (51-75%), Occasionally (26-50%), Intermittently (0-25%)
What describes the nature of your symptoms? Sharp, Dull Ache, Numbness, Shooting, Burning, Tingling, Stabbing, Pins and Needles
How are your symptoms changing? Getting better, Not changing, Getting Worse
During the past 4 weeks, indicate the average intensity of your symptoms: 1 being no pain - 10 being unbearable
During the past 4 weeks, how much has pain interfered with work in and out of the home? Not at all, A little bit, Moderately, Quite a bit, Extremely
During the past 4 weeks, how much has your condition interfered with your social activities? All of the time, Most of the Time, Some of the time, A little of the time, None of the time
In general would you say your overall health right now is? Excellent, Very good, Good, Fair, Poor
Who have you seen for your symptoms? No one, Other Chiropractor, Medical Doctor, Physical Therapist, Other
What treatment did you receive for your symptoms? Adjustments, Physical therapy, Medication, Surgery, Other
When did you receive this treatment? In the last month, 2-3 months ago, 6 months to 1 year, 1-2 years, 2-5 years, 5-10 years
What tests did you have for your symptoms? X-rays, MRI, CT Scan, Other
When were these tests done? In the last month, 2-3 months ago, 3-6 months,
6 months - 1 year, 1-2 years, 2-5 years, 5-10 years
If you have received treatment in the past for the same or similar symptoms, who did you see? This Office, Other Chiropractor, Medical Doctor, Physical Therapist, Other
What is you occupation? Professional/Executive, White Collar/Secretarial, Trades person, Laborer, Homemaker, FT Student, Retired, Other
If you are not retired, a homemaker, or a student, what is your current work status?
Full time, Part time, Self employed, Unemployed, Off work, Other,
Disabled/Date Disabled
Please list any operations:
Other Serious illnesses:
Have you ever had Chiropractic care?
Dr:
Significant family history (who):
Heart Disease:
Diabetes:
Cancer:
Type:
Stroke:
Other:
Allergies
Food:
Drugs:
List any medications you are presently taking:
FEES ARE PAYABLE AT TIME OF X-RAYS, EXAMINATIONS AND TREATMENTS UNLESS OTHER ARRANGEMENTS ARE MADE IN ADVANCE.
I understand and agree that health/accident insurance policies are an agreement between an insurance carrier and myself I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I hereby authorize the above named Doctor or Clinic to furnish information concerning my present illness or injury and DIRECT the insurer to pay, without equivocation directly to the above named DOCTOR or CLINIC, any and all benefits due them as a result of this claim. I am also aware that I am personally responsible for charges and/or balances not covered by my insurance. I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all parties as the original copy. I also agree to pay any costs of collection should this account become delinquent and reasonable attorneys fee, and hereby waive my rights to exemption under the laws of the state of Alabama and any other state. I also understand that any unpaid balance over 30 days will be subject to a $5.00 a month billing fee and/or 1 1/2% monthly service fee.
I consent to any physical examination, x-ray study, laboratory procedures, Chiropractic or adjunctive therapy or clinic service that is ordered under general and specific instruction of the doctor.
Patient's Signature Date
Guardian or Insured's Signature Date
Authorizing Care
_______________________________ _____________
_______________________________ _____________
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations 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 would 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 HIPAA NOTICE that is available to you at the front desk before signing this consent.
1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI 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 PHI 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 submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.
4. The patient may provide a written request to revoke consent at any time during care.
This would not effect the use of those records for the care given prior to the written request to revoke consent but would 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 assure 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 chiropractic physician has the right to refuse to give care.
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
Name of Patient Date
_______________________________ _____________
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I wasprovided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understood the Notice.
________________________________________ ____________________
Patient Name (please print) Date
________________________________________
Signature of Authorized representative (if applicable)
________________________________________ Signature of Patient
