New Patient Form-March
advertisement
Confidential Patient Health Record Haley Chiropractic Center Date_________________________ Patient Name: _____________________________________________________________________________ WHAT CAUSED YOUR PAIN? ______________________________________________________________ CHIEF COMPLAINTS _____________________________________________________________________ _____________________________________________________________________________________________ WHEN DID YOUR PAIN BEGIN? _____________________________________________________________ A=ACHE B=BURNING N=NUMBNESS S=STABBING P=PINS AND NEEDLES USING THE ABOVE LETTERS: INDICATE ON THE FIGURE THE LOCATION OF ALL YOUR COMPLAINTS. For Doctors Use: Blood Pressure __________/_________ Height _________ Weight _________ Smoking: Everyday Former Never Contraindications: ________________ _______________________________ __________________________________ PLEASE COMPLETE THE FOLLOWING: ____________________________ Level of Pain Due to Symptoms, Area: __________________________ FIRST COMPLAINT 0 1 2 3 4 5 6 7 8 9 10 Level of Pain Due to Symptoms, Area: _________________________ SECOND COMPLAINT 0 Timing: Overall Severity: __Mild 1 2 __Constant 3 4 5 6 __Intermittent __Mild to moderate 7 8 __Frequent __Moderate 9 10 __Occasional __Moderately severe __Severe Patient Name: ______________________________________________________________ Pain Types: __Achy __Burning __Dull __ Pounding __Sharp __Stabbing __Excruciating __Shooting __Numb ache type __ Stinging __Throbbing Check all situations that aggravate your pain: __Coughing __Sneezing __Straining at BM’s __Arising from a chair __Bending __Breathing __Looking down __Looking up __Repetitious movements __Sleeping __Turning the head left __Turning the head right __Flashing lights __Carrying __Climbing a ladder __Climbing stairs __Driving __ Exercising __ Getting out of bed __Getting in and out of the car __Lifting __Pulling __Pushing __Reclining __Sitting __Standing __Stooping __Walking uphill __Walking __Emotional upset __ Stress Does anything relieve your pain? If so, please list: __________________________________________ Have you been told you have arthritis of the spine or disc degeneration? __Yes __No Have you had spinal X-Rays or an MRI? ___Yes ___ No If yes, what area of the spine: Neck/Cervical __ Mid Back/Thoracic __ Low Back/Lumbar __ Name and phone number of Doctor that diagnosed the arthritis of the spine or disc degeneration: _________________________________________________________________________________ Family History: No, I do not have any significant history of family illnesses. Yes, members of my immediate family suffer from the following conditions:________________ ______________________________________________________________________________ MEDICATIONS I am currently not taking any medication, OR please list ALL medications you are currently taking: ______________________________________________________________________________________ ______________________________________________________________________________________ I have no medication allergies, OR please list ALL medications that you are allergic to: ______________________________________________________________________________________ ______________________________________________________________________________________ Patient Name: First ____________________ Last______________________ M _______ Address: _____________________________________________ Birth date: _____/_____/_________ Age: ____ City: _______________________________________________________________State: ____Zip:____________ Home Phone Number: ____________________________Cell Phone Number: ___________________________ Email Address to receive newsletter: _____________________________________________________________ Gender: Male/Female # of Children: ___ Referred by: ________________________________________ __Single __Married __Widowed __Separated __Divorced Spouse: _____________________________ Name of Insurance Company: _______ Social Security Number (required for insurance): _____________________ Are you employed? __Yes __No __Retired Employer: ___________________________________________ Do you eat a well balanced diet? __never, __rarely, __occasionally, __usually, __regularly Do you exercise? Do you drink alcohol? __never, __rarely, __occasionally, __usually, __regularly __never, __occasionally, __frequently (more than 3 days a week), __daily Do you use tobacco products? __never, __occasionally, __frequently (more than 3 days a week), __daily Have you experienced any past or present medical problems? Name: __________________________ No, I do not have any significant past medical problems. Yes, I have experienced the problems indicated below: Please circle. GENERAL: Allergies Anorexia Bladder dysfunction Arthritis Bulimia Dislocated joints Dizziness Epilepsy Fainting Gout HIV/Aids Kidney disease Liver disease Migraines Obesity Osteoarthritis Osteoporosis Painful Urination PMS Rheumatoid arthritis Seizures Sexually transmitted disease Stroke Weight loss SPINE: Kyphosis Lordosis Lower back pain Multiple sclerosis Neck pain Scoliosis Spinal disc disorder Upper back pain Abdominal pain ENDOCRINE: Addison’s disease Diabetes Hyperthyroidism Hypothyroidism Insulin dependent diabetes Non-insulin dependent diabetes Osteoporosis Parathyroid disease RHEUM: Fibromyalgia Lupus Osteoarthritis Polymyalgia rheumatica Rheumatoid arthritis KNEE: ACL tear LCL tear MCL tear PCL tear Degenerative osteoarthritis Meniscal tear Patella femoral syndrome Pre-patellar bursitis Pesancerine bursitis Tibial plateau fracture PULMONARY: Asthma Emphysema COPD Lung cancer CARDIAC: Angina Aortic aneurysm Aortic regurgitation Aortic Stenosis Atrial fibrillation Autonomic dysfunction Cardiac disease Hypertension Myocardial infarction Mitral valve prolapsed Tricuspid regurgitation Peripheral vascular disease GASTROINTESTINAL: Appendicitis Barrett’s esophagus Bowel dysfunction Crohn’s disease Colon cancer Diverticulitis Diverticulosis Dysphagia HAND: Carpal tunnel syndrome HEME/ONC: Anemia Bladder cancer Bone cancer Bladder cancer Hemophilia Hypercoagulability Leukemia Prostate cancer Stomach cancer Thallesemia SHOULDER: Arthritis Bicipital tendonitis Rotator cuff syndrome Rotator cuff tear Subacromial bursitis HIP: Avascular necrosis Degenerative osteoarthritis Femur fracture Fracture of the femoral head Fracture of femoral neck Greater trochanteric bursitis PLEASE INDICATE ANY PROBLEMS NOT LISTED ABOVE: _________________________________ _______________________________________________________________________________________ Name: ________________________________________________________________________________ Review of Systems IF YOU HAVE ANY OF THE ISSUES LISTED BELOW, PLEASE CIRCLE. IF NOT, CHECK “NO PROBLEMS”. chills CONSTITUTIONAL difficulty concentrating dizzy spells weakness fainting nausea night sweats recent weight change (over 10 pounds) perfumes fatigue ALLERGIES smoke pollen __NO PROBLEMS difficulty sleeping __NO PROBLEMS paint hay grasses dairy plantar warts psoriasis INTERGUMENTARY rashes sores itching hives dandruff bruising boils back injuries back pain MUSCULOSKELETAL frequent foot cramps heel spurs joint pain joint stiffness leg cramps during the day hair changes dust neck pain confusion convulsions double vision fainting spells joint swelling muscle cramps muscle pain muscle weakness pain between the shoulders hand trembling PSYCHIATRIC suicidal thoughts crying often drug addiction or dependency eat when nervous feeling angry feeling blue nail biting stuttering hallucinations painful feet headaches loss of memory seizures weak grip __ NO PROBLEMS depression extreme worry frequent bad dreams HEART AND VASCULAR __NO PROBLEMS blood clots blue extremities lightheaded while standing difficulty breathing scoliosis NEUROMUSCULAR __ NO PROBLEMS difficulty of speech dizziness/vertigo anxiety asthma course bumpy skin __NO PROBLEMS general muscle tension alcoholism low blood pressure nail bed changes mole with changes in color or size paralysis angina animal dander excessive perspiration muscle jerking/twitching/tics unusually slow pulse mold __NO PROBLEMS nail fungus acne osteoarthritis memory trouble certain foods dryness eczema leg cramps at night neck injuries fever heart murmur heart condition cold hands/feet high blood pressure heart skipping beats rapid heartbeat swollen ankles RESPIRATORY SYSTEM __NO PROBLEMS chronic cough congestion varicose veins hay fever productive cough non-productive cough phlegm NAME: ______________________________________________________________________________________ EAR, NOSE, & THROAT blisters/cold sores __NO PROBLEMS dental problems loss of smell bleeding gums ear pain ears ringing frequent colds gum disease halitosis hearing loss dentures nasal drip nasal polyps nose bleeds recurrent ear infections sinus infections mouth sores/ulcers deviated septum punctured ear drum tonsillitis vertigo burning eye injury EYES blurred vision __NO PROBLEMS cataracts dry/gritty eyes itching redness tearing vision headaches loss of appetite jumpy/nervous tired excessive thirst extreme thinness ENDOCRINE __NO PROBLEMS changes in hair growth cold intolerance diabetes heat intolerance glaucoma excessive hunger unexplained weight gain unexplained weight loss abdominal gas abdominal pain GASTROINTESTINAL __NO PROBLEMS acid reflux belching after meals black or bloody stools constipation diarrhea frequent indigestion hemorrhoids liver trouble nausea pain/indigestion after eating greasy foods bladder control problems dribbling burning needing stool softeners/laxatives stomach ulcers vomiting blood straining during bowel movements getting up at night to urinate kidney stones urgency FEMALE-GYNECOLOGICAL __NO PROBLEMS chronic yeast infections diminished sexual drive birth control pills/injections hair growth hot flashes increased acne during period menopause cramps painful intercourse cancer impotency tender lymph nodes heartburn GENITO-URINARY __NO PROBLEMS difficulty starting a stream kidney/bladder infections frequent urination painful urination frequent vomiting MALE-REPRODUCTIVE lumps in testicles use of steroids heavy flow irregular period spotting tender breasts __NO PROBLEMS painful genitals cramps Haley Chiropractic Center Patient Authorization Patient Name__________________ Social Security Number___________Date of Birth___________ AGREEMENT TO ACCEPT CARE I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that the Doctor’s Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I hereby authorize the Doctor to examine and treat my condition as he/she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. The patient also agrees that he/she is responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. X________________________________________ __________ Patient signature or authorized person acting on patient’s behalf Date AUTHORIZATION AND ASSIGNMENT In consideration of you providing care for me, I agree to the following: 1. You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred by me or my dependent for services rendered by you. 2. I authorize and assign the direct payment to you of any sum I now or hereafter owe to you by my insurance company, attorney, or out of the proceeds of any settlement of my case. 3. I understand that I am financially responsible for any balance not covered by my insurance carrier. 4. A copy of this signature is as valid as the original and I further agree that this Authorization and Assignment is irrevocable until all monies owed to Haley Chiropractic Clinic are paid in full. X_____________________________________________ ____________ Patient signature or authorized person acting on patient’s behalf Date RELEASE OF RECORDS I hereby authorize Dr. Sam Haley and Haley Chiropractic to send my patient notes to the following doctors: Name Address Telephone Number __________________________________________________________________ __________________________________________________________________ X_________________________________________________________________ Patient signature or authorized person acting on patient’s behalf Date
