stull chiropractic center 2224 woodman drive, kettering ... · stull chiropractic center 2224...
Post on 29-May-2020
10 Views
Preview:
TRANSCRIPT
STULL CHIROPRACTIC CENTER 2224 Woodman Drive, Kettering, OH 45420
(937) 259-8850 (p) (937) 259-8224 (f)
Please print clearly and complete all applicable items.
Date: ___________________________________________ Patient # _________________________________________
First Name: __________________________________ M.I. _____________ Last: _______________________________
Address: ______________________________________ City: _______________________ State: _______ Zip: _______
Birth Date: _____/______/________Sex: M F SS# ____________________ Work #: _________________________
# of Children: _____________ Home #: ______________________ Cell #: ________________ Work #: _____________
Email Address: _____________________________________ Occupation: _____________________________________
Employer: ________________________________ Employer’s Full Address: ___________________________________
Who referred you to our office? ______________________________ Family Doctor: ___________________________
INSURANCE INFORMATION
Primary Insurance Company: _____________________________________ Secondary: __________________________
Subscriber’s Name (if you are a dependent): _______________________________ Relationship: __________________
Subscriber’s Date of Birth: ______________________________
MEDICAL INFORMATION Purpose of today’s visit/major complaint? _______________________________________________________________
Date symptoms appeared: _________________________ Have you ever had the same or similar condition? YES NO
Dates of serious illnesses: ____________________________________________________________________________
What surgeries have you had (dates): ___________________________________________________________________
Do you smoke? _____ Y _____N In the past? _____Y ______ N How many per day? ________ Since When? _______
List of supplements or medications you take: ____________________________________________________________
Circle the severity (0 = No Pain to 10 = Very Severe Pain) and Frequency of Pain (of the week you experience the pain).
Condition / Problem Severity Minimal Severe
Frequency (of week)Constant
a. ____________________________b. ____________________________c. ____________________________d. ____________________________e. ____________________________
1. Please mark the figures where you experience pain
2. Symptoms are worse in the (check what applies)
Morning Increase during the day
Afternoon Same all day
Night Decrease during the day
Burning Aching Throbbing Numbness Tingling Pins & Needles3. Symptom (a) is: Sharp Dull 4. Symptom (b) is: Sharp Dull Burning Aching Throbbing Numbness Tingling Pins & Needles
Occasional
5. Is this condition interfering with _______ Work _______ Sleep _______ Daily Routine _______ Recreation
6. Any other Musculoskeletal problems? ______ No _______ Yes Neurological problems? _______ No ______ Yes
CONDITIONS YOU HAVE OR HAVE HAD: Please check all that apply
AIDS/HIV Depression High Blood Pressure Prostate Problem Alcoholism Diabetes High Cholesterol Prosthesis Allergies Digestive Disorders Hypoglycemia Rheumatic Fever Anemia Dizziness Neck Pain Sinus Troubles Anorexia Epilepsy Nervousness Stroke Arthritis/Joint Pain Fatigue Neuritis Tuberculosis Asthma Gout Numbness Ulcer Backaches Headaches Osteoporosis Urinary Trouble Bleeding Disorders Heart Trouble Pacemaker Venereal Disease Breathing Problems Hepatitis Parasites Weight Loss Bulimia Cancer
Hernia Herniated Disc
Pinched Nerve Poor Circulation
Yeast/Candida
Check each box that applies or enter age
LIVI
NG
OTHER DISEASES, ABNORMALITIES, COMPLICATIONS?PLEASE DESCRIBE
FATHER
FATHER’S Family
MOTHER
MOTHER’S FAMILY
YOUR SIBLINGS
BROTHER/SISTER
BROTHER/SISTER
YOUR CHILDREN
SON/DAUGHTER
SON/DAUGHTER
MANDATORY FOR PATIENTS WITH MEDICARE Date of last X-ray? _____________________________________
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 for 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 fee 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 rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of you 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: ____________________
AGE
OR
RAN
GE O
F DE
ATH
ALLE
RGIE
S
ARTH
RITIS
ALCO
HOLISM
CANCE
R
DEPR
ESSION
DIAB
ETES
HIGH
BLO
OD
PRES
SURE
HEAR
T DI
SEAS
E
HIGH
CHO
LESTER
OL
STRO
KE
STULL CHIROPRACTIC CENTER 2224 Woodman Drive, Kettering, OH 45420
(937) 259-8850 (p) (937) 259-8224 (f) Patient Name: _____________________________________________ Date: ___________________________
Terms of Acceptance The goal of our office is to enable patients to gain control of their health. To attain this we believe communication is
the key. There are often topics that are hard to understand, and we hope this document will clarify those issues for you.
Please read the below and if you have any questions, please feel free to ask one of our staff members.
Informed Consent:
A patient, in coming to the chiropractic doctor, 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/she 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 what he/she is suffering from: latent pathological defect5s, illnesses or deformities which would otherwise not come to the attention of the chiropractic
physician. The chiropractic doctor provides a specialized, non-duplicating 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 Stull Chiropractic, I am authorizing them to
proceed with any treatment that they deem necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request.
WOMEN ONLY:
To the best of my knowledge I am / am NOT pregnant and (give my permission / don’t give permission) to X-ray me for diagnostic interpretation. (circle one above) (circle one above)
Missed Appointments
There is a possible fee charged for all appointments that are not canceled prior to scheduled visit. Any massage appointment that is not canceled 24 hours prior to scheduled appointment will be charged $35 - $70
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.
Communications
In the event that, we would need to communicate your healthcare information, to whom may we do so? Spouse: __________________________________________ Children: _________________________________________ Others: __________________________________________ No One: ___________
May we leave messages regarding your personal healthcare information on any answering device, i.e. home answering machines or voicemails? Yes ____ No _____
Acknowledgement
I have read and fully understand the above statements. I have reviewed the notice of privacy practices (HIPAA) and have
been provided an opportunity to discuss my right to privacy. Upon request I will be given a copy.
Print Name: ______________________________________________________________
Signature: ____________________________________________________________ Date: ___________________
top related