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Download Patient Intake WC - WillmarChiropractic.com
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CONFIDENTIAL HEALTH INFORMATION QUESTIONNAIRE This information is needed so we can better serve you. Please fill in all areas of the form. Let us know of any questions. Name: _______________________________________________! Date: ___________ Address: ______________________________________________________________ City: _____________________________ State: _______________ Zip: ____________ Home Phone: _____________________________ Cell:_________________________ Sex: M F Age: _____ Date of Birth: ________ SS#: _______________________ Email: ___________________________ Is your visit due to an accident? Yes No Martial Status: M S D W! Drivers License #: _____________________ Your Occupation: ______________________ Employed by: _____________________ Work Phone: ___________________ Address: _______________________________ Are you a Medicare Patient? Yes ! No ! Medicare #: ______________________ Your Spouses Name: ____________________________________________________ Spouses Employer: ___________________ Spouses Work Phone: ________________ Name of person to contact in case of an emergency: ___________________________ Contacts Phone: _______________________________________________________ Name of nearest relative not living with you: _________________________________ Relatives Phone: _______________________________________________________ How did you hear about Willmar Chiropractic? ! Insurance website ________________________________________________ ! Google ! WillmarChiropractic.com ! Referral, who can we thank? ________________________________________ ! Referring Physician: _______________________________________________ In order to determine if care can be of benefit to you, we offer a courtesy initial consultation without charge. If Dr. Goebel can help your condition, are you interested in seeking care? Yes Unsure THERE WILL BE NO CHARGED SERVICES WITHOUT YOUR INFORMED CONSENT I attest that the above information is true and correct to the best of my knowledge. I further understand that any charges incurred by me in this office are my sole responsibility despite any insurance plan, legal involvement, or settlement. Patients Signature: _________________________________ Date: ________________ Parent or Guardian: _____________________________________________________ Signature: ________________________________________ Date: ________________ Willmar Chiropractic • 1950 19th Avenue SW • Willmar, MN 56201 320-235-7347 telephone • 320-222-2826 fax • www.WillmarChiropractic.com page 1 PATIENT CONSENT AUTHORIZATION CONSENT FOR TREATMENT: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures. I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physician(s). ASSIGNMENT OF BENEFITS: I hereby assign payment directly to the physician(s) accepting this assignment of medical benefits applicable and otherwise payable to me but not to exceed the physicianʼs regular charges. I understand that I am financially responsible for charges not covered by this assignment or for any and all charges that the insurance carrier declines to pay. RELEASE OF INFORMATION: The physician(s), may disclose all or part of the patientʼs record to any person or corporation which is or may be liable under a contract to the physician(s) or to the patient or to a family member or employer of the patient for all parts or part of the physician(s) charges, including but not limited to insurance companies, workers compensation carriers, welfare funds, or the patientʼs employer. H.M.O. DISCLAIMER: I certify that I am not presently enrolled in any Health Maintenance Organization (H.M.O). Subsequent rejection of a claim as a result of this admission due to current enrollment in an H.M.O. plan will constitute responsibility for payment of claim on my part. MEDICARE AND MEDICAID PATIENT CERTIFICATION. PATIENTS CERTIFICATION AUTHORIZATION TO RELEASE INFORMATION AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVII and or Title XI of the Social Security Act is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers any information needed for this or related Medicare or Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician(s) services. I understand that I am responsible for my health insurance deductibles and coinsurance. X ______________________________! ! Print Patients Name! ! ! Other than patient. Print name & relationship. X ______________________________! ! X ______________________________ Patientʼs Signature! ! ! ! ! ! ! X ______________________________ ! ! Witness Signature Willmar Chiropractic • 1950 19th Avenue SW • Willmar, MN 56201 320-235-7347 telephone • 320-222-2826 fax • www.WillmarChiropractic.com page 2 Present Complaints (please circle the appropriate ones) Headache! ! Mental dullness! Loss of Memory! Dizzy! ! ! Neck Pain! ! Fainting! ! Upper back pain! Lower back pain! Neck restriction! Nervousness! ! ! ! ! ! ! ! ! ! ! Difficulty in: ! Cannot lift: ! Pain in the: ! Radiating pain: ! ! ! Feet & hands cold!! Depression! ! ! Constipation!! ! Rib pain! ! ! Neck Stiffness! ! Shortness of Breath! Upper back stiffness! Lower back stiffness! Eye strain/pain! ! Fear! ! ! ! Standing! Light! Foot!! Neck! Right arm! Head seems heavy! Confusion!! ! Tension! ! ! Unbalanced! ! Chest Pain! ! Ears ringing/buzzing! Midback pain! ! Blurred vision! ! Loss of taste! ! Irritability Sitting!! Moderate! Ankle! ! Base of skull Left arm! Bending! Heavy! Knee!! Ribs! ! Right leg ! Pins & needles in arms ! Right / Left Pins & needles in arms ! Right / Left Pins & needles in legs ! Right / Left Midback stiffness Double vision Loss of smell Walking Repetitive Heel spurs Shoulders Left leg Hips OTHER: ______________________________________________________________ Since the time this (these) complaint(s) began, what, if anything have you tried that did not work? __________________________________________________________ Has the problem interrupted your sleep? Yes No How: ___________________ Does anyone in your family have the same or similar condition: Yes No Who: _________________________________________________________________ List any doctors or therapist that you have seen for this complaint: 1. __________________________________________ Speciality: ________________ 2. __________________________________________ Speciality: ________________ 3. __________________________________________ Speciality: ________________ Relevant medical history: (Please circle the conditions you have or had previously) Arthritis! ! ! Asthma! ! ! Anemia! ! ! Back pain or spasm! Cancer! ! ! Concussion! ! ! Convulsion! ! ! Diabetes! ! ! Digestion problems! Dizziness! ! ! ! ! ! ! ! ! ! ! ! ! Epilepsy! ! ! Fibromyalgia! ! Hand or wrist pain! ! Headaches! ! ! Heart problems! ! Hepatitis! ! ! High blood pressure! HIV! ! ! ! Measles! ! ! Multiple Sclerosis! ! ! ! ! ! ! ! ! ! ! ! Muscular Dystrophy Neck pain or spasms Neuritis Numbness Polio Rheumatic Fever Sinus trouble Sciatica TB Venereal disease Patients Name: _________________________________ Date: ________________ Willmar Chiropractic • 1950 19th Avenue SW • Willmar, MN 56201 320-235-7347 telephone • 320-222-2826 fax • www.WillmarChiropractic.com page 3 Present Complaints (continued) List any operations that youʼve had and approximate date: 1. _______________________________ Date: _________ Doctor: ________________ 2. _______________________________ Date: _________ Doctor: ________________ 3. _______________________________ Date: _________ Doctor: ________________ 4. _______________________________ Date: _________ Doctor: ________________ Are you allergic to any medications? Yes No Please list: ____________________________________________________________ Are you taking any medications? Yes No Please list: ____________________________________________________________ Do you wear Orthotics (shoe inserts)? Yes No If yes, what type? _______________________________________________________ Are you pregnant?! Yes No! ! Due date: ________________ Do you:! Smoke?! Yes No! ! Amount per day: ________________ Drink?! Yes No! ! Light Medium Heavy Exercise Never Sometimes Frequently Regularly Does anyone in your family have a similar health related problem? Yes No Who: ___________________________ What condition: _________________________ Care they are receiving: __________________________________________________ Is it helping? Yes No Patients Name: _________________________________ Date: ________________ Height _________ Weight _________ Shoe Size _________ Shoe Width _________ Willmar Chiropractic • 1950 19th Avenue SW • Willmar, MN 56201 320-235-7347 telephone • 320-222-2826 fax • www.WillmarChiropractic.com page 4 Patients Name: _________________________________ Date: ________________ Please be sure to fill this form out extremely accurately. Mark the area(s) on your body where you feel the described sensation(s). Use the appropriate symbol(s). Mark areas of radiating pain and include all affected areas. You may draw on the face as well. Aches ^^^ Numbness ooo Pins/Needles ••• Burning xxx Stabbing /// Indicate the severity of your symptoms by marking an “X” on the lines below: How bad are your symptoms now?! ! ! ! ! ! None! ! ! ! ! Most Severe How bad have they been in the past? At its Worst ! ! ! ! None! ! ! ! ! Most Severe At its Best ! ! ! ! None! ! ! ! ! Most Severe Willmar Chiropractic • 1950 19th Avenue SW • Willmar, MN 56201 320-235-7347 telephone • 320-222-2826 fax • www.WillmarChiropractic.com page 5
