new chiropractic & physical therapy …...i hereby request and consent to the performance of...
TRANSCRIPT
Patient Demographics Today’s Date: __________________
Name: ____________________________________________ Birth Date: _____-_____-_______ Age: ______ Male Female
Address: ___________________________________________________ City: ______________________ State: ______ Zip: ____________
Home Phone: ___________________________ Cell Phone: _________________________ Work Phone: ____________________________
Email: ______________________________________________________________________________@________________________.com
Preferred method of communication for patient reminders: Email Phone Mail
Social Security #: _____________________________________ Driver's License #: ______________________________________________
Marital Status: Married Single Divorced Widowed Other
Is there a possibility of pregnancy? No Yes Maybe
Race: American Indian or Alaska Native Asian African American Caucasian Native Hawaiian or Pacific Islander I Decline to Answer
Ethnicity: Hispanic or Latino Not Hispanic or Latino I Decline to Answer
Spouses Name: _______________________________________________ Occupation: _________________________________________
Children’s Names & Ages: ___________________________________________________________________________________________
Are you: Employed Homemaker Retired Unemployed Full-time Student Part-time Student
Employer: _____________________________________________________ Occupation: _________________________________________
Seasonal Resident: From: ________________ To: ________________ Northern Phone #: _____________________________________
Northern Address: _______________________________________________ City: ___________________ State: ______ Zip: ___________
Name & Relationship of Emergency Contact: ___________________________________________________ Phone #: _________________
Who may we thank for referring you to this office? ______________________________________________________________________
□ 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.)
Financial Responsibility/Insurance Information - Please notify the Front Desk if your visit is related to an accident or injury
Does your insurance have chiropractic, acupuncture, and/or physical therapy benefits?
No, I will be self-pay Yes, I have insurance benefits – PATIENT MUST COMPLETE FOLLOWING (PI patients need not complete)
I. Primary Insurance Company & Plan Name: ____________________________________________________________________________
ID Number: _________________________________________ Grp/Policy #:____________________Effective Date: ___________________
Subscribers Name: ________________________________________________________________ DOB: ____________________________
Subscriber is my: Self Spouse Parent Other
II. Secondary Insurance Company & Plan Name: __________________________________________________________________________
ID Number: _________________________________________ Grp/Policy #:____________________Effective Date: ___________________
Subscribers Name: ________________________________________________________________ DOB: ____________________________
Subscriber is my: Self Spouse Parent Other
NEW CHIROPRACTIC & PHYSICAL THERAPY PATIENTS
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Social History
Smoking: Cigars Pipe Cigarettes How often? Daily Weekends Occasionally Former Smoker Never Smoked
Alcohol Consumption: Daily Weekends Occasion Never Recreational Drug Use: Daily Weekends Occasion Never
Are you currently taking any medications? (Include regularly used over the counter medications) Use a second sheet if necessary
Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.)
Do you have any medication allergies or allergies to shell-fish?
Medication Name Reaction Onset Date Additional Comments
Family History
Does anyone in your family suffer with the same condition(s)? No Yes
If yes, whom: Grandmother Grandfather Mother Father Sister Brother Son Daughter
Have they ever been treated for their condition? No Yes I don't know
Any hereditary conditions the doctor should be aware of? No Yes _______________________________
Family Medical History (Record one diagnosis in your family history and the affected relative)
Diagnosis
Father Mother Sibling:
(___________)
Offspring:
(___________)
History of Complaint
Please identify the condition(s) that brought you to this office:
When did the problem(s) begin? _________________________ When is the problem at its worst? AM Mid-day PM Late PM
How did the injury occur? __________________________________ Is your problem the result of ANY type of accident? Yes No
Condition(s) ever been treated by anyone in the past? No Yes, When: __________ By Whom? ______________________________
Name of previous chiropractor: ________________________________________________________________________________ N/A
How long were you under care? _______________ What were the results? ___________________________________________________
My present problem affects my: Sleep Hobbies Recreational Activities Exercise Regime
Are there any symptoms such as: Headache Difficulty Sleeping Indigestion Urinary or Bowel Changes
Dizziness Blurred Vision Ringing in the ears Tiredness Difficulty Breathing Difficulty Concentrating
Fainting Unexplained Weight Loss or Gain Change in Appetite Falling Hot/Cold Flashes Night Sweats
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**Please identify the area on the diagram and answer the questions to describe your PRIMARY symptom:
**Please identify the area on the diagram and answer the questions to describe your SECONDARY symptom:
Previous Surgeries and Illnesses
Identify any other injury(s) to your spine, minor or major, the doctor should be aware of:
__________________________________________________________________________________________________________________
Have you suffered with this or a similar problem in the past? No Yes, How many times? ___________________________________
When was the last episode? ________________________ What brought on the episode? _______________________________________
I have tried other forms of treatment: No Yes, please state what type of treatment: _______________________________________
Who provided this treatment: _______________________________________________________ How long ago? ____________________
Were the results? Favorable Unfavorable, Please explain: ____________________________________________________________
Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:
__________________________________________________________________________________________________________________
If you have ever been diagnosed with any of the following conditions, please indicate a P for Past, C for Current and N for Never
__ Broken Bone __ Dislocations __ Tumors __ Rheumatoid Arthritis __ Fracture __ Disability __ Cancer
__Heart Attack __Osteo Arthritis __Diabetes __ Cerebral Vascular __ other serious conditions: ______________________
Please, identify ALL PAST and any CURRENT conditions you feel may be contributing your present problem:
How Long Ago Type of Care Received By Whom
Injuries
Surgeries
Childhood diseases
Adult diseases
_____________________________________________________________ ___________________
Patient or Parent/Guardian’s Signature Date Completed
_____________________________________________________________ ___________________
Doctor's Signature Date Form Received
Type of discomfort: (Choose all that apply) Sharp Dull Aching Burning Numbing Shooting Tightness Throbbing Diffuse Tingling
Frequency of discomfort through-out the day: Constant (100%-75%) Frequent (75%-50%) Intermittent (50%-25%) Occasional (25%-1%)
Intensity of discomfort (1-least severe, 10-most severe) 1 2 3 4 5 6 7 8 9 10
Discomfort increases with: (Choose all that apply if applicable) Movement Applied Pressure Prolonged Sitting Coughing/Sneezing
Discomfort decreases with: (Choose all that apply if applicable) Rest Chiropractic Care Medication Movement Ice Heat Type of discomfort: (Choose all that apply) Sharp Dull Aching Burning Numbing Shooting Tightness Throbbing Diffuse Tingling
Frequency of discomfort through-out the day: Constant (100%-75%) Frequent (75%-50%) Intermittent (50%-25%) Occasional (25%-1%)
Intensity of discomfort (1-least severe, 10-most severe) 1 2 3 4 5 6 7 8 9 10
Discomfort increases with: (Choose all that apply if applicable) Movement Applied Pressure Prolonged Sitting Coughing/Sneezing
Discomfort decreases with: (Choose all that apply if applicable) Rest Chiropractic Care Medication Movement Ice Heat
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Contact Consent and Medical Information Sharing
At times our staff will need to contact you at the phone numbers provided by you on your intake paperwork. By
filling out the information below, we will be better able to serve you.
UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO, WE WILL NOT:
LEAVE MESSAGES WITH ANYONE EXCEPT THE PATIENT OR LEGAL GUARDIAN
LEAVE INFORMATION ON AN ANSWERING MACHINE, VOICE MAIL OR ANY OTHER
ELECTRONIC RECORDING DEVICE
COMMUNICATE WITH YOU THROUGH EMAIL, FACEBOOK MESSENGER, OR ANY OTHER
ELECTRONIC, INTERNET OR SOCIAL MEDIA MESSAGING SYSTEMS, INCLUDING TEXT
MESSAGES
Please read below and consider carefully whom you want to have access to your medical information.
I, __________________________________, hereby consent and state my preference to have my physician,
Dr. Aaron M. Taylor and other staff at Taylor Chiropractic & Oriental Medicine may communicate with me by email
or standard SMS/text messaging, in addition to or to replace leaving phone messages, regarding various aspects of my
health care, which may include, but shall not be limited to, test results, appointments, and billing. I understand that
email and standard SMS/text messaging are not confidential methods of communication and may be insecure. I
further understand that, because of this, there is a risk that email and standard SMS/text messaging regarding my
medical care might be intercepted and read by a third party. I understand that if I share an email address with
another person, that person will also have access to information sent to me regarding my care.
I give my permission to leave both appointment reminders AND my private health information at the
following (please fill-in the ones you agree to). At this time Taylor Chiropractic & Oriental Medicine only confirms
appointments through phone calls.
Phone number: ___________________________ Email: _______________________________________________
Text: N/A – Taylor Chiropractic & Oriental Medicine will not contact you regarding your chiropractic care by text
message, Facebook, or any other social media system.
~~~~~~~~~~~~~~~~~~~~~~~~~~~
I______________________________________ DO NOT give Taylor Chiropractic & Oriental Medicine my
permission to leave phone messages, email, or text messaging regarding my medical care and test results. Without
consent Taylor Chiropractic & Oriental Medicine will be unable to leave messages for me regarding scheduled
appointments.
NOTE: Appointment reminders and private health information will be communicated to you only in the manners in which you
have given specific written authorization and you have the option to opt out of any of those methods at any time by notifying our
office. I fully understand that this consent will remain in effect until revoked in writing. Email and standard SMS/text
messaging are not confidential methods of communication and may be insecure.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
My medical care may be discussed with the following individuals. The following individuals will also serve as
emergency contacts
Name: ___________________________________________________ Relationship: _____________________
Name: ___________________________________________________ Relationship: _____________________
Signature of
Patient/Parent/Guardian______________________________________________________Date________________
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PLEASE COMPLETE THIS FORM IN OUR OFFICE
Informed Consent to Care
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including
various modes of physical therapy, diagnostic x-rays, and examinations on me (or on the patient named below, for whom I
am legally responsible) by the doctor of chiropractic at Taylor Chiropractic & Oriental Medicine.
I have had the opportunity to discuss with the doctor and/or with other office or clinic personnel the purpose and benefits of
chiropractic adjustments and other treatments. Alternatives to treatment have been reviewed. Though chiropractic adjustments
and treatments are usually beneficial and seldom cause any problem, I understand and am informed that there are some risks to
treatment.
I understand that chiropractic is not an exact science, therefore practitioners cannot guarantee results. I acknowledge that no
guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I
have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to
treatment. Signature of Patient/Parent/Guardian:
X _____________________________________________________________________________Date__________________
Financial Responsibility
I agree to be financially responsible for all charges I incur at Taylor Chiropractic & Oriental Medicine including deductibles, co-
payment, co-insurance and any specific services rejected by my insurance company. I understand that all payments are due at
the time of service and that I am financially responsible for all charges whether or not they are paid by a health insurance policy.
I understand that the office has a 24 hour cancelation policy for scheduled massages and I will be charged a $30 cancelation fee
if I miss or need to cancel a massage appointment less than 24 hours prior. I understand that if I purchase a discounted
chiropractic or massage package and later request a refund; all refunds will be calculated less the full retail price of
appointments already redeemed from the package. Signature of Patient/Parent/Guardian:
X _____________________________________________________________________________Date__________________
Authorization to bill Insurance Company/Assignment of Benefits
I authorize Taylor Chiropractic and Oriental Medicine to release any information pertinent to my care to any insurance
company, adjustor, and/or attorney involved in this case, and hereby releases this office of any consequence thereof.
I agree to be financially responsible for all charges I incur at Taylor Chiropractic and Oriental Medicine including deductibles,
co-payment, co-insurance and any specific services rejected by my insurance company. I understand that verification of my
benefits is not a guarantee of payment by the insurance company; I further understand that verification of my benefits is an
approximation of covered charges and all charges are subject to the insurance company’s approval.
I understand that some third-party payers may require that my medical information, including copies of treatment notes, be
submitted along with requests for payment. I hereby authorize Taylor Chiropractic & Oriental Medicine to release all medical
information necessary to secure payment of benefits from the third-party payers. I understand that this information may include
medical information related to drug and alcohol abuse, sexually transmitted diseases, HIV/AIDS and mental health. I understand
that this authorization shall remain valid without expiration unless expressly revoked by me in writing.
I hereby instruct and direct my insurance company to pay by check/eft made out and mailed directly to Taylor Chiropractic
& Oriental Medicine the professional or medical expense benefits allowable, and otherwise payable to me under my current
insurance policy as payment toward the total charges for services rendered by this office. A photocopy of this assignment
shall be considered as effective and valid as the original.
Signature of Patient/Parent/Guardian:
X _____________________________________________________________________________Date__________________
I have received the Notice of Privacy Practices and I have been provided with an opportunity to review it.
Signature of Patient/Parent/Guardian:
X_____________________________________________________________________________Date__________________
Staff Witness to all Patient/Parent/Guardian signatures
Signature_____________________________________________________________________________Date______________