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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Date______________ File No:___________ Welcome to Kobler Chiropractic and Acupuncture! We look forward to working with your family to achieve optimum health. A patient’s health is not based on symptoms or lack of symptoms. For instance, a tooth is not considered healthy when it has decay even though there is no pain felt. A dentist checks for these “painless” cavities just as a chiropractor checks for spinal misalignment to maintain spinal health. Chiropractic does not cure any disease or treat symptoms alone. Rather, our chiropractic analysis will focus on removing nervous system interference, caused by physical, chemical, and/or emotional stressors, allowing the child’s body to properly express health. To help us serve you better, please complete the following: Patient Information Name: Last First MI Mailing Address:________________________________________________City_____________________ State____ Zipcode__________ Phone #(H)____________________________ (C)_______________________ (Other) Email address:_______________________________________________________________________________ Sex: Male Date of Birth: Marital Status: Single Married Divorced Occupation: Female SS#: Widowed Separated Minor Employer: Employer Address: Phone: How did you hear about our practice? Emergency contact: Phone #: Name: Relation: (H) (W) (Other) Accident Information Is this visit due to an accident? Has it been reported? Yes Yes No No If yes, what type? Auto Work Other If yes, to whom? Financial Information Name of person responsible for this account: Relationship to patient (if other than self): Phone # Do you have health insurance? Yes No Name of Carrier: Do you have secondary insurance? Yes No Name of Carrier: PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S) Assignment and Release (insured patients) I certify that I (or my dependent) have insurance coverage with and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions. SIGNATURE (X) DATE Health History Who is your primary care physician? (doctor and/or practice) Please check to indicate if you are currently experiencing any of the following conditions: Neck Pain/Stiffness Pins/Needles in Arms Light Bothers Eyes Sudden Weight Loss Nausea Back Pain/Stiffness Pins/Needles in Legs Depression Loss of Taste Cold Feet Arm/Hand Pain Fatigue Nervousness Loss of Memory Chest Pain Leg/Knee Pain Sleeping Difficulties Tension Jaw Problems Fever Headaches Loss of Smell Cold Sweats Constipation Fainting Dizziness Allergies Stomach Problems Shortness of Breath Asthma Blurred Vision Night Pain Bowel/Bladder Changes Please check to indicate if you have ever had any of the following: Aids/HIV Alcoholism Allergy Shots Anemia Anorexia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Bulimia Cancer Cataracts Chemical Dependency Chicken Pox Diabetes Emphysema Epilepsy Fractures Glaucoma Goiter Gonorrhea Gout Heart Disease Hepatitis Hernia Herniated Disc Herpes High Cholesterol Kidney Disease Liver Disease Measles Migraines Miscarriage Mononucleosis Multiple Sclerosis Mumps Osteoporosis Pacemaker Parkinson’s Disease Pinched Nerve Pneumonia Polio Prostate Problems Prosthesis Psychiatric Care Rheumatoid Arthritis Rheumatic Fever Scarlet Fever Other Stroke Suicide Attempt Thyroid Problems Tonsillitis Tuberculosis Tumors/Growths Typhoid Fever Ulcers Vaginal Infections Venereal Disease Whooping Cough Are you currently under drug and/or medical care? Yes No If yes, explain Please list any medications you are currently taking: Please list any surgeries and/or hospitalizations you have had (type & date): Please list any allergies: Please list any supplements you are currently taking (vitamins/herbs/minerals): Is there a family history of any of the following conditions? (indicate family member including parents, grandparents & siblings) Heart Disease Cancer Diabetes Arthritis Do you exercise: Frequently Moderately Do your work activities mostly involve: Do you sleep on your: Back Other Sitting Side Occasionally Standing Stomach None Light Labor Heavy Labor Do you use a cervical pillow? Yes No What is your daily/weekly intake of the following: Caffeine cups/day Alcohol drinks/week Cigarettes packs/day I certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my health. SIGNATURE (X) DATE : TERMS OF ACCEPTANCE When a person seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is specific adjustment of the spine. Health: A state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. CONSENT TO CARE I do hereby authorize the doctors of Kobler Chiropractic and Acupuncture LLC to administer such care that is necessary for my particular case. This care may include consultation, examination, adjustments, or any other procedure which is advisable and necessary for my health care. l further understand that a fee for services rendered will be charged and that l am responsible for this fee whether results are obtained or not. I also understand any sum of money paid under assignment by any insurance shall be credited to my account, and l shall be personally liable for any and all of the unpaid balance to the doctor. I ________________________, have read, understand, and hereby request chiropractic care based on the terms of acceptance and the consent to care. Signature: _____________________________________________ Date: _______________________ signature of parent or guardian if minor Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name:_________________________ Last Name:_________________________ Email address: __________________________@_________________________ Preferred method of communication for patient reminders (Circle one): Email / Phone / Mail DOB: __/__/____ Gender (Circle one): Male / Female Preferred Language: _______________ Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked CMS requires providers to report both race and ethnicity Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) / Native Hawaiian or Pacific Islander / Other / I Decline to Answer Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer Are you currently taking any medications? (Please include regularly used over the counter medications) Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.) Do you have any medication allergies? Medication Name Reaction Onset Date Additional Comments I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.) Patient Signature: __________________________________________Date: ________________ For office use only Height: _________ Weight:____________ Blood Pressure:______ /______