Download Patient Information - Teller County Chiropractic

Chiropractic Case History/Patient Information
Date:
.
Name:
Social Security #
Address:
City:
(If Different than above.)
Mailing Address:.
City
E-mail address:
Age:
Home Phone: (
Race:
Occupation:
.
State:______ Zip:
.
State:______ Zip:
Fax #
Birth Date:
)
.
Cell Phone:
.
Marital: M S W D How many children?
.
Employer:
Employer's Address:
Spouse:
Occupation:
.
Office Phone:
.
Employer:
.
Name of Nearest Relative Not Living With You :
.
Address:
Phone: (
)
.
How were you referred to our office?
.
Family Medical Doctor:
City
.
When doctors work together it benefits you. May we have your permission to update your medical doctor regarding
your care at this office? YES NO
HISTORY OF PRESENT ILLNESS:
Chief Complaint: Purpose of this appointment:
.
Date symptoms appeared or accident happened:
.
How frequent is the condition? Constant
Daily
Is there anything you can do to relieve the problem? Yes
Intermittent
No
Night Only
.
If yes, describe
.
.
If no, what have you tried to do that has not helped?
What makes the problem worse? Standing
Lifting
Twisting
Is this due to: Auto
Sitting
.
Lying
Other
Work
Bending
.
.
Other
Have you ever had the same or a similar condition? YES NO If yes, when and describe:
.
.
..
Other Doctors seen for this condition
Days lost from work:
.
Date of last physical examination:
.
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PAST MEDICAL HISTORY
Have you had or do you now have any of the following symptoms that are or have been of significant distress to you? Please
indicate with the letter N if you have these conditions now or P if you have had these conditions previously.
N = Now
P = Previously
Broken or fractured bones
________
Osteoarthritis
________
Circulatory Problems
________
A Congenital Disease
________
Depression
________
Ulcers
________
Alcoholism
________
Drug Addiction
________
Eating Disorders
________
Coughing Blood
________
Headaches_________ Frequency ________
Neck Pain
________
Stiff Neck
________
Sleeping Problems
________
Back Pain
________
Nervousness
________
Tension
________
Irritability
________
Chest Pains/Tightness
________
Dizziness
________
Shoulder/Neck/Arm Pain
________
Numbness in Fingers
________
Numbness in Toes
________
High/low Blood Pressure
________
Difficulty Urinating
________
Weakness in Extremities
________
Breathing Problems
________
Fatigue
________
Lights Bother Eyes
________
Ears Ring
________
Rheumatoid Arthritis
Seizures/ Convulsions
Strokes
Cancer
Epilepsy
Pace Maker
HIV Positive
Gall Bladder
Ruptures
Excessive Bleeding
Loss of Balance
Fainting
Loss of Smell
Loss of Taste
Unusual Bowel Patterns
Feet Cold
Hands Cold
Arthritis
Muscle Spasms
Frequent Colds
Fever
Sinus Problems
Diabetes
Indigestion Problems
Joint Pain/Swelling
Menstrual Difficulties
Weight Loss/Gain
Loss of Memory
Buzzing in Ears
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
P= Previously
N= Now
Leave blank
if none
Do you have a history of stroke or hypertension?
.
Have you had any major illnesses, injuries, and falls, auto accidents or surgeries? Women, please include
information about childbirth (include dates):
.
.
Has a physician treated you for any health condition in the last year?
YES
NO
If yes, describe:
.
What medications or drugs are you taking?
.
.
What vitamins/supplements are you taking?
.
.
Do you have any allergies to any medications? YES
NO
If yes, describe:
Do you have any allergies of any kind? YES
.
NO
If yes, describe:
.
Please list any other health problems you have, no matter how insignificant they
maybe:
.
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On the diagram mark the areas on your body where you
feel your pain. Include all affected areas. Mark areas
of radiation. If your pain radiates, draw an arrow from
where it starts to where it stops. Please extend the
arrow as far as the pain travels. Use the appropriate
symbol (s) listed below.
Ache *****
Numbness +++++ Pins & Needles ooooo
Burning xxxxx Stabbing <<<<<< Throbbing /////////
SOCIAL HISTORY:
Do you drink alcoholic beverages?
If so, how much per week?
Do you use any tobacco products?
Do you smoke?
Do you consume caffeine?
.
If so, packs per day:
If so, how much per day:
Do you exercise?
.
.
If yes, what is the frequency and type of exercise?
.
What are your hobbies?
.
What are your biggest life stressors: FAMILY FINANCES
WORK OTHER
.
What percentage of time during the day (at home or at your job away from home) do you spend:
Lifting
sitting
bending
working at a computer
.
FAMILY HISTORY:
Father: living
deceased
Current age if still living:
Cause of death and age at death if deceased:
.
Health problems or Illnesses
Mother: living
deceased
.
Current age if still living:
Cause of death and age at death if deceased:
.
Health problems or Illnesses
Paternal Grandfather: living
.
deceased
Current age if still living:
Cause of death and age at death if
deceased:
.
Health problems or Illnesses
.
Paternal Grandmother: living
deceased
Current age if still living:
Cause of death and age at death if
deceased:
.
Health problems or Illnesses
.
Maternal Grandfather: living
deceased
Current age if still living:
Cause of death and age at death if
deceased:
.
Health problems or Illnesses
.
Maternal Grandmother: living
deceased
Current age if still living:
Cause of death and age at death if
deceased:
.
Health problems or Illnesses
.
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FAMILY HISTORY cont.:
Sibling: living
deceased
Current age if still living:
Cause of death and age at death if deceased:
.
Health problems or Illnesses
Sibling: living
deceased
.
Current age if still living:
Cause of death and age at death if deceased:
.
Health problems or Illnesses
Sibling: living
deceased
.
Current age if still living:
Cause of death and age at death if deceased:
.
Health problems or Illnesses
Sibling: living
deceased
.
Current age if still living:
Cause of death and age at death if deceased:
.
Health problems or Illnesses
.
Do you have any family members who suffer from the same condition you do? If so, please list:
.
Check if applicable to you:
As an adopted child, little is known of birth parents or family.
Insurance Information
Please circle any and all insurance coverage that may be applicable in this case:
Major Medical
Worker's Compensation
Medical Savings Account & Flex Plans
Medicare
Auto Accident
Other
Name of Primary Insurance Company:
.
Name of Secondary Insurance Company (if any):
.
AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or
chiropractic office. I authorize the doctor to release all information necessary to communicate with personal
physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am
responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend
or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be
immediately due and payable.
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information
for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to
know how your Patient Health Information is going to be used in this office and your rights concerning
those records. 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. If there is anyone you do not want to receive
your medical records, please inform our office.
Patient's Signature:
Date:
.
Guardian's Signature Authorizing Care:
Date:
.
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