PLEASE NOTE - Mt Pleasant Chiropractor

1

Advertisement Newspaper Community Event Provider Talk Family/Friend Other __________________

PLEASE NOTE:This file must be saved to your desktop before and after completing!

PATIENT INFORMATION

Date ________________ First Name ____________________ Middle Name ____________ Last Name ____________________

SSN (last 4 digits) ___________ Sex _____________ Birth Date ________________ Height ______ Weight ______________

Marital Status ___________________ Spouse Name _____________________________________ Number of Children _______

Address ______________________________________ City _________________________ State ________ Zip ___________

Home Phone ________________________________________ Cell Phone _______________________________________________

Email _______________________________________________ Emergency Contact _______________________________________

Emergency Relation ___________________________________ Emergency Phone ________________________________________

REFERRAL INFORMATION

I was referred by _______________________________________________________________________________________________

How did you hear about the clinic?

EMPLOYER INFORMATION

Employed? Yes No Employer Name ____________________________________________________

Occupation __________________________________________________________________________________

2

REASON FOR VISITDescribe in your own words why you wanted to come for an appointment today:

PERSONAL HEALTH INFORMATIONComplaints/ConcernsPlease list your chief symptoms in order of decreasing severity, starting with the worst one. Please note how long each symptom has been present.

Problem Onset Frequency Severity

E.g. Headaches June 2007 4 times per week Mild / Moderate / Severe

1.

2.

3.

4.

5.

6.

7.

When was the last time you felt well? __________________________________________________________________________

Did something trigger your health changes?

SleepAverage number of hours you sleep? __________ Do you have trouble falling asleep? Yes No

Do you feel rested upon awakening? Yes No Do you have problems with insomnia? Yes No

Do you snore? Yes No Do you use sleeping aids? Yes No Explain: __________________________

InjuriesDescribe your injury and pain:Pain level on scale of 1 - 10 (10 is excruciating pain) At its best? _________ At its worst? __________ Now? ___________

Type of injury ______________________________________________________________________________________________

How did it occur? Work Automobile Fall Other _______________________________________________

Injury Date ___________________________________ Have you missed work related to this injury? Yes No

Unable to work from (dates) ____________________________ to ___________________________

Received other treatment for this? Yes No Where or by whom? __________________________________________

X-rays taken? Yes No Do you currently receive chiropractic care? Yes No

What clinic or chiropractor provides that care? __________________________________________________________________

Tobacco/AlcoholCurrently using tobacco? Yes No How many years? _____ Packs per day _____

If yes, what type? Cigarette Smokeless Cigar Pipe Patch/Gum

Previous smoking? How many years? _____ Packs per day _____ Are you exposed to 2nd hand smoke? Yes No

If yes, explain: _____________________________________________________________________________________________

How many drinks currently per week? (1 drink=5 oz. wine, 12 oz. beer, and/or 1.5 oz. spirits)

None 1 to 3 4 to 6 7 to 10 More than 10

Previous alcohol intake? Yes No If yes, was it: Mild Moderate High

3

Stiffness Weakness

Please check the character of your current pain (you may check more than one):

Sharp Stabbing Dull Aching Soreness

Throbbing Numbness Shooting Burning Tingling

Please rate the degree of you pain between 0-10, 0 being no pain and 10 being unbearable: ______

How often are your symptoms present?

Constant Frequent Occasional Intermittent

Since your problem began, is the pain? Increasing Decreasing No Change

What activities make symptoms BETTER? Sitting Standing Laying Down

Movement/Exercise Sleep/Rest Other(describe) _____________________________

What activities make symptoms WORSE? Sitting Standing Coughing/Sneezing

Movement/Exercise Sleep/Rest Other(describe) _____________________________

4

Medications and Supplements

Medications: Please list any medications that you are currently taking or have taken in the last month, including antibiotics, non-prescription drugs, and prescription drugs.

Medication Name Dosage

Supplements: List all vitamins, minerals, and other nutritional supplements that you are currently taking.

Supplement Name Dosage

Allergies

I am allergic to the following medications:

I am allergic to the following foods or supplements:

Please list your symptoms/reactions to the above medications and/or foods:

QUADRUPLE VISUAL ANALOGUE SCALE

Patient Name ________________________________________________ Date ___________________________

Please read carefully:

Instructions: Please circle the number that best describes the question being asked.

Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for eachcomplaint. Please indicate your pain level right now, average pain, and pain at its best and worst.

Example:

Headache Neck Low Back No pain ________________________________________________________________________________ worst possible pain

0 1 2 3 4 5 6 7 8 9 10

1 – What is your pain RIGHT NOW?

No pain ________________________________________________________________________________ worst possible pain 0 1 2 3 4 5 6 7 8 9 10

2 – What is your TYPICAL or AVERAGE pain?


3 – What is your pain level AT ITS BEST (How close to “0” does your pain get at its best)?


4 – What is your pain level AT ITS WORST (How close to “10” does your pain get at its worst)?


OTHER COMMENTS:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

______________________________________________ Examiner Reprinted from Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, 855-862, 1993, with permission from Elsevier Science.

5

Health HistoryHave you ever had any of the following:

Illnesses A LIST OF ILLNESSES Yes No

Chicken Pox

Measles

Mumps

Anemia

Arthritis

Asthma

Bronchitis

Cancer

Chronic Fatigue Syndrome

Crohn’s Disease or Ulcerative Colitis

Diabetes

Emphysema

Epilepsy, convulsions

Gallstones

Gout

Heart attack/Angina

Heart failure

Hepatitis

High Blood Pressure

Irritable bowel

Kidney stones

Mononucleosis

Pneumonia

Rheumatic fever

Sinusitis

Sleep Apnea

Stroke

Thyroid disease

Other (describe)

Injuries A LIST OF ILLNESSES Yes No

Head Injury

Neck Injury

Back Injury

Fracture

Other (describe)

Diagnostic Studies Yes No Date Performed

Chest X-ray

Mammogram

EKG

Colonoscopy

Upper GI Series

Barium Enema

CAT scan of abdomen

CAT scan of brain

CAT scan of spine

Liver scan

Bone scan

Neck X-rays

Back X-rays

MRI

Bone Density Test

Blood Tests

Other (describe)

Operations A LIST OF ILLNESS

Yes No

Tonsillectomy

Tubes in Ears

Appendectomy

Gall Bladder

Hernia

Hysterectomy

Dental Surgery

Other (describe)

Hospitalizations A LIST OF ILLNESSES

When For What Reason

6

Women Specific

Check the box if yes and provide number.

Pregnancies _____ Miscarriage _____ Living Children _____ Abortion _____ Cesarean _____

Vaginal Delivery _____ Postpartum Depression _____ Toxemia _____ Baby Over 8 Pounds _____

Gestational Diabetes _____

Menstrual History

Age At 1st Period _____ Menses Frequency _______________________ Length __________________________________

Painful? Yes No Clotting? Yes No Have you ever missed your period? Yes No

For how long? ________________________ Are you menopausal? Yes No Age At Menopause ______

Last Menstrual Period _________________________________

Do you take any hormone contraception? Birth Control Pill Patch Nuva Ring

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to Ideal Posture & Spine – A Wellness Way Affiliate. I authorize Ideal Posture & Spine – A Wellness Way Affiliate and its staff to examine and treat my condition as the practitioners see fit. I hereby authorize Ideal Posture & Spine – A Wellness Way Affiliate to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. Verifying insurance benefits does not guarantee payment from my insurance company. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that there is a 72 business hour cancellation policy for new patient and consultation appointments. Failure to comply with the cancellation policy may result in additional charges. A $25 fee will be applied to all NSF checks. By clicking the submit button below, I agree to the financial policy described above and will adhere to all of its practices.

Please email this completed form to [email protected]

By typing or signing your name below on the signature line, you are agreeing to all of the paragraph above.

________________________________________________________________________________Signature Date

Thank you!

FINANCIAL POLICY

To help us meet all you healthcare needs, please read this form completely. If you have any questions or need assistance, please ask us and we will be happy to help.

To reduce confusion and misunderstanding between our patients and practice, we have adopted the following financial policies. If you have any questions regarding these policies, please discuss them with our office manager. We are dedicated to providing the best possible care and service to you, and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment.

Unless either you or your health insurance carrier have made other arrangements in advance, full payment is due at the time of service. For your convenience we accept VISA, MasterCard and Discover.

❑ The patient understands and agrees by his/her signature agrees upon the charges for professional services provided byIdeal Posture & Spine

❑ Although you are responsible for the entire balance at the time of service, it is our office policy to provide you with thenecessary paperwork for reimbursement. We do require that you take care of the balance at the time of service.

❑ Our fees are considered as usual, customary and reasonable (UCR) fees within the Charleston metro area. Someinsurance companies set their own (UCR) fees, which may not be the same as our fees.

❑ The patient further understands and agrees that if the balance due is not paid in full within 60 days from the date ofservice, there will be a billing charge of 1-1/2% per month or 18% per annum until the outstanding balance is paid in full.

❑ If the account is assigned to collections, the patient will be responsible for the entire account balance owed plus anycollection and reasonable attorney fees.

Patient/Guardian Signature_______________________________________ Date______

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including examination tests, diagnostic x-rays, and physical therapy techniques on me (or on the patient named below for who I am legally responsible) by the doctor of chiropractic named below and/o other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working or associated with, or serving as a back-up doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic.

I understand that, as with any health care procedure, there are certain complications that may arise during a chiropractic adjustment. Those complications include but are not limited to: fractures, disc injuries, dislocations, and muscle sprains and strains. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. I do not expect the doctor to be able to anticipate and explain all risks and complications and I wish to rely on the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, are in my best interests.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature, purpose and risks of chiropractic adjustments and other procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed.

I have read, or have had read to me, the above explanation of the chiropractic adjustment and related treatment. By signing below, I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest to undergo the chiropractic treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. 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.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

______________________________________ _______ ____________________________________ Print Patient’s name Print name of Patient’s Representative

_______________________________ ____________________________________ Signature of Patient or Representative Relationship/authority of Patient Representative

_____________________________________ ___________________________________________Date Translated or Read by Signature

_____________________________________Witness to patient’s signature

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

DISCLOSURE OF INFORMATION We may disclose information to other healthcare professionals and/or your insurance carrier for treatment, payment, or healthcare operations. Additional disclosures may be necessary to comply with Workers’ Compensation and Public Health Laws as well as judicial proceedings. We may contact a family member or other authorized person in consent unless compelled to do so by legal authority. Further, you will be contacted by phone or mail in the event that a request for information is made.

FACILITY SET UP While our examination and treatment rooms are private, this office utilizes an open exercise/rehabilitation setting. Staff and doctors will maintain policies to ensure privacy, but there may be some inadvertent disclosures to others in the facility at the same time. If there is private information that you need to discuss, please request to do so in a private room.

YOUR RIGHTS You may send us a written request to see or procure a copy of the information that we have about you, or to amend you personal information that you believe is incomplete or inaccurate. If the information was not originally from our office, we will refer you to the source, such as other doctors or hospitals. You may request additional restrictions on uses and disclosures of your health information. We are not required to agree to these requests and in some instances, may be prohibited by law. You may request that we communicate with you about medical matters using reasonable alternative means or at an alternate address. You may receive an accounting of our disclosures of your medical information, except when those disclosures are made for treatment, payment or health care operations, or the law otherwise restricts the accounting.

You have the right to inspect and have a copy of your medical information. There is no cost for the first copy and any copy thereafter will be $25. You have the right to amend your information. Please note that we have the right to disagree with your amendments. If there is a disagreement, you will be provided with information about your denial of your amendment and how you may appeal the denial of amendment. You have a right to a copy of the notice upon request.

COMPLAINTS Calling this office or directing a letter to the office manager can handle complaints about your privacy rights or how your privacy is handled at this office. If you are not satisfied with how this office handles your complaint, you may submit a formal complaint to: DHHS (Office of Civil Rights) 200 Independence Ave Room 509F HHH Building Washington, D.C. 20201

I have read this privacy Notice and understand my rights contained in this notice. By signing this form I provide authorization and consent to use and disclose my protected health information as noted above.

______________________________________ Patient’s Name (Print)

_______________________________Date:

Documents

PLEASE NOTE - Mt Pleasant Chiropractor