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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Patient Name_____________________________ E-mail address_______________________________ Address_______________________________ City _______________ State______ Zip code_________ Home#______________________ Work#____________________ Cell#_________________________ Which phone number and time is best to reach you? _________________________________________ Date of Birth ________________Social Security Number _________________________ Gender: M F To better serve you please answer the following questions in advance: 1. What are your health goals? _________________________________________________________________ 2. How do you expect to achieve them? __________________________________________________________ 3. Addressing what brought you into this office: (If you have no symptoms or complaints and are here for wellness services, please skip to question 5.) Please list your health concerns according to their severity Rate of severity When did this 1=mild Episode start? 10=worst imaginable If you had this Condition before, When? Did the problem % of the time pain begin with an injury? is present 1. 2. 3. 4. Check off the following symptoms or disorders you have and CIRCLE the ones that affect you the most Headache/Migraines Neck Pain Hip pain (right or left) Sinus/Allergies Shoulder pain (right or left) Knee pain (right or left) Chest/Rib pain Elbow pain (right or left) Ankle pain (right or left) Dizziness Wrist pain (right or left) Muscle Stress Ear Aches Scoliosis Constipation Asthma Low Back pain Hyperactivity Frequent colds/flu Mid-back Pain Arthritis Heartburn/Reflux Disc Problems Stomach Problems Low energy/Tired /Fatigue Insomnia Depression Unexpected Weight Gain Ringing/Buzzing in Ears Bed Wetting Loss of Memory High Blood Pressure Menstrual Problems Excess Gas/Bloating Low Blood Pressure Thyroid Trouble Multiple Sclerosis Fibromyalgia Blood Circulatory Problems High Cholesterol Shortness of breath Nausea Bladder Problems Cancer Circulatory/Vascular Disorder Digestive Problems Indigestion Heart Condition Infertility Kidney Disease Mood Swings Osteoporosis Sinus Trouble Urinary Difficulty Other:________________ Chemical Stress Physical Stress Emotional Stress/Anxiety Attention Disorders Sciatica Numbness/Tingling Leg pain (right or left) Arm pain (right or left) Vertigo Ulcers Autoimmune Disease Diabetes Swollen Ankles Skin Conditions/Acne Diarrhea Immune System Disorder *****Vertebral Subluxations can cause your pain***** Which pain or condition you have marked is the worst for you? ____________________________________ How long has it bothered you? ___________________________________________________________ Vertebral Subluxations can cause irritation to different fibers within nerves. Is your pain sharp or dull? _______________________________________________________________ Subluxations can put pressure on the spinal cord which can be constant or occasional. Which do you feel? ________ Pressure on the spinal cord or nerves can be worse in the AM or the PM. Which one is harder for you? __________ Does this radiate into an extremity or stay in one area? ________________________________________ 5a. Are any of the above symptoms linked to a current car accident or workers compensation case?____________________________ 5. Other doctors you have seen for this condition: a. “Limited Scope” Chiropractor (focuses mainly on neck and back pain) b. Holistic Chiropractor (focuses on health and well being as well as underlying cause of pain and health concerns) c. Medical Doctor Doctor’s Details: Name:______________________________________________________________________ When did you see them?_______________________________________________________ What did they say was wrong?___________________________________________________ Did it help?__________________________________________________________________ What did they do?____________________________________________________________ Have you been “forced” or “felt the need” to make any “positive” changes in your life due to this pain, illness, condition, etc? (i.e., eat better, less alcohol or drugs, meditate or breathe more, less destructive sports, activities, etc.) If so, what? _______________________________________________________________________________________________ 6. Please indicate which aspects of your life are compromised by your current level of health: Bending Lifting Walking Sitting Climbing Stairs Standing Running Exercise Sleeping Lying in Bed Lifting Children Sports Recreational Activities Getting in/out of Car Housework Yardwork Travel Grooming Job Activities Emotional Well-Being 6b. Circle the two areas of your life are most affected by your current level of health? Family Relationships Job Finance Health Emotional Well-Being Career Time Leisure Communication Knowledge 7. a. Do you have trouble with? (Check what applies) ____Anxiety ____Depression ____Irritability 8. Check all TRUE statements: ___Previous methods ineffective ___I want answers and/or results b. What methods have you tested? ____Exercise ____Physical therapy ____Prescription drugs ____Massage ____Nothing ___My problems could get worse ___I want to be healthy Spirituality ___I want to be energetic again 9. How long have you been living this way? 10. What results do you want for yourself? Weeks(#)_____ Reduce Pain 11. What excuse has stopped you from being well? Money Months(#)_____ Restore Health Time Years(#)_____ Maintain Health Wellness Other____________ 12. Check all statements that apply to you: ___I don’t think anything can help me anymore ___I know I am in the right place ___I’m giving it a try but I doubt it will work ___I’m just here to inquire ___I’m giving it a try and I think it will work ___With the help of God anything is possible 13. How would you be convinced that something ‘works”? (only choose ONE) Seeing it Hearing it Feeling it Understanding it Other_____________________________ 14. Stress History Please indicate whether you have ever experienced stress in any of the following areas. Your answers will enable us to determine which factors have contributed to your present health concerns. 1) Childhood Repeated/Prolonged Antibiotic Use Car Accident Childhood Illness Fall/Jump from a Height < 3 feet Fall/Jump from a Height > 3 feet Head Trauma Yes Yes Yes Yes Yes Yes No No No No No No 2) Adulthood Alcohol Consumption Repeated/Prolonged Antibiotic Use Car Accident Coffee Drinker Drug Use/Abuse Fall/Jump from a Height Head Trauma Home Environment Stress Inhaler Use Yes No Prescription Medications Yes No Surgery Yes No Vaccination Yes No Youth Sports Yes No Other Traumas (physical or emotional): _____________________________________________ Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Inhaler Use Yes No Prescription Medications Yes No Smoker Yes No Surgery Yes No Contact Sports Yes No Extreme Sports Yes No Workplace Stress Yes No Other Traumas (physical or emotional): __________________________________________ 15. Stressors: Because accumulation of stress affects our health and ability to heal please list your top three stressors (you have ever had) in each category: 1. Physical stress (falls, accidents, work postures, etc.) a. ___________________________________________________________________________________ b. ___________________________________________________________________________________ c. ___________________________________________________________________________________ 2. Bio-chemical stress (smoke, unhealthy foods, missed meals, don’t drink enough water, drugs/alcohol, etc.) a. _____________________________________________________________________________________ b. _____________________________________________________________________________________ c. _____________________________________________________________________________________ 3. Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.) a. _____________________________________________________________________________________ b. _____________________________________________________________________________________ c. _____________________________________________________________________________________ 16. On a scale from 1-10 please grade your present levels of stress (including physical, bio-chemical and psychological or mental/emotional): At work: At home: At play: 17. On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your: Eating habits: Exercise habits: Sleep: General health: Mind set: 18. How many glasses of pure water do you drink per day? (no soda, coffee, or tea)__________ 19. How do you grade your physical health? Excellent Good Fair Poor Getting better Getting worse Poor Getting better Getting worse 20. How do you grade your emotional/mental health? Excellent Good Fair 21. On a 1-10 scale, a. Where would you rate your overall health and well-being? _____ b. Where would you want it to be?____ And how long do you think this process will take?______ 22. On a scale from 1-10(1 being least, 10 being most) rate your interest in the following: a. Correcting the cause of any existing ailment _______ b. Nutrition/herbs to increase overall health______ c. Eliminating negative emotions that may be compromising your health_____ d. Detoxifying your body of pollutants (heavy metals, tobacco, blood clot)_____ e. Massage therapy_____ 23. What do you search for when seeking a healthcare provider? ____________________________________________________ _________________________________________________________________________________________________________ 24. Have you had any experience with chiropractic? YES NO a. Did you like the results? YES NO b. What did you enjoy most and least about your visits there?________________________________________________ 25. Have you attended any of our health talks yet? YES NO 26. Based on your experience, what do you expect from this visit? a. A short and to the point presentation of what you can offer me b. The science and statistics behind what you do c. The clinical experience and background of the Dr. d. An explanation of what I can expect to experience here e. Other: ______________________________________ 27. Is there anything else which may help to better understand you which has not been discussed?__________________________ _________________________________________________________________________________________________________ Medical History List all physicians and practitioners you have seen for your current condition________________________________ _____________________________________________________________________________________ Have you had any surgeries? YES NO If so, when and what?_________________________________________ _____________________________________________________________________________________________ Do you have any scars? YES NO If yes, where?____________________________________________________ Do you currently have any injuries as a result of an auto or work related accident. If yes, please specify.___________ ______________________________________________________________________________________________ Have you ever been hospitalized? YES NO If yes, list reason___________________________________________ ______________________________________________________________________________________________ List any medical conditions you currently have_________________________________________________________ List any medications you are currently on_____________________________________________________________ If there was a way we can help you come off these medications would you be interested? YES NO List any known allergies (food, inhalants, etc.)_________________________________________________________ Have you ever had any of the following diagnostic tests? ___X-rays ___MRI scans ___Bone scan ___Myelogram ___Disco gram ___EMG ___CT scan If any selected, list reason:_____________________________________________________________________ Do you have a history of cancer? YES NO Are you currently pregnant? YES NO Check all that apply: ___Smoker ___Non-smoker ___Drinks Alcohol ___Does not drink alcohol ___Takes drugs ___Does not take drug How were you referred to us_______________________________________________________________________ Employer______________________________________________________________________________________ Occupation (Please be specific. Often times the work that we do greatly affects our health and/or stress level. This information will help the doctor with your course of care). _______________________________________________________________ Circle one: Single Married DivorcedSeparated Widow/ed Name of children and age(s)____________________________________________________________________________ Education completed: High school College Graduate Post-Graduate H e a lt h F ro m W it h in F a m i ly W e l ln e s s C e n t e r 1818 Marron Rd, Ste 103 ~ Carlsbad, CA 92008 (760) 385-8352 www.healthfromwithinCA.com Please read the below and if you have any question please feel free to ask one of our staff members. Informed Consent: I do hereby authorize the doctors of Advanced Chiropractic Healthcare to administer such care that is necessary for my particular case. This may include consultation, examination, adjustments or any other procedure, which is advisable and necessary for my healthcare. In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Health From Within Family Wellness Center, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. I understand that payment plans are mandatory unless balance can be paid in full. Finance charges will be applied to balances 60 days overdue at 1.5% and every 30 days there after. INTEREST AND COLLECTION: I acknowledge and agree that, should my account become more than thirty (30) days overdue, I will incur interest on my past due balance of seven percent (7%) per annum. I further acknowledge and agree that Advanced Holistic Healthcare shall be entitled to reimbursement from me for any legal costs, including attorney fees, for all efforts to collect on any past due account with Advanced Holistic Healthcare. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. A patient, in coming to the chiropractic physician, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give any treatment or care if he is aware that such care may be contra-indicated. Again, it is the responsibility of the patient to make it known, or to learn through healthcare procedures whatever he/she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the chiropractic physician. The chiropractic physician provides a specialized, nonduplicating health care service. Your doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regimen. I understand that if I am accepted as a patient by a physician at Health From Within Family Wellness Center, I am authorizing them to proceed with any treatment that may be necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request. Acknowledgement I have been informed that upon request I can receive a copy of the privacy practices (HIPPA) and I am aware that I have an opportunity to discuss my rights to privacy if I please. Missed Appointments: There will be a $30 fee charged for all appointments that are not canceled within 24 hours prior to scheduled visit. Print Name: ______________________________________________ Signature: ________________________________________ Date: __________________________ H e a lt h F ro m W it h in F a m i ly W e l ln e s s C e n t e r 1818 Marron Rd, Ste 103 ~ Carlsbad, CA 92008 (760) 385-8352 www.healthfromwithinCA.com Consent to Evaluate and Treat a Minor: I, _______________________________ being the parent or legal guardian of _____________________________, have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. Print Name: ______________________________________________ Signature: ________________________________________ Date: __________________________ Communications: In the event that we would need to communicate your healthcare information, to who may we do so? Spouse: ____________________________________________________ Children: ___________________________________________________ Others: _____________________________________________________ May we leave messages on any answering device, i.e. home answering machines or voicemails? Yes [ ] No [ ] Insurance Information (if applicable) Primary Insurance: Policy Holder ____________________Relationship to insured: Self Spouse Child Other Insured address (if different from yours) ___________________________________________ ____________________________________________________________________________ Insured Date of Birth ______________ Insured Gender: M F Policy name: _________________________ Policy #: ________________________________ Secondary Insurance: Policy Holder ____________________Relationship to insured: Self Spouse Child Other Insured address (if different from yours) ___________________________________________ ____________________________________________________________________________ Insured Date of Birth ______________ Insured Gender: M F Policy name: _________________________ Policy #: ________________________________