Susan Addison, DC



Susan Addison, DC

CONFIDENTIAL PATIENT INFORMATION 1340 SW Bertha Blvd., Suite 102

Portland, OR 97219

503-880-9204

Name: _________________________________________________________ Date: ____/____/____

first middle last

Date of birth: ____/____/____ Age: _____ Female___ Male___

Address: _____________________________________________________________________________

street city state zip code

Phone: _(_____)_______________________ Alternate phone: _(_____)_______________________

please circle: home work cell please circle: home work cell

Email: ___________________________________ Referred to us by: ____________________________

Occupation or main life activity: ______________________ Employer: ___________________________

Marital status:  single  married/partner  separated  divorced  widowed

Emergency contact: _______________________(_____)_______________________________________

name phone number relationship

Children names and ages: _______________________________________________________________

Reason for your visit today: ______________________________________________________________

Is this a work-related injury?  no  yes date of injury: ___/___/___

Is this an injury due to a car accident?  no  yes date of accident: ___/___/____

Describe symptoms: achy stiff numb tingling weak sharp electrical other: _________

Cause of symptoms, if known: ____________________________________________________________

When symptoms began: ______________________ Related problem in the past: ___________________

Classify your condition:  minor  involved  fairly severe  serious

Activities that are difficult due to this condition: _____________________________________________

Symptoms are:  getting better  getting worse  staying the same

Symptoms:  are constant  come and go ( describe pattern ____________________________

Medication(s) you take for this condition and dose: ___________________________________________

What helps your symptoms (applying heat or ice? moving or resting? pain-relieving positions?): _____________________________________________________________________________________

Other treatment received for this condition: _________________________________________________

Relevant X-rays, MRI or CT scan: ________________________________________________________

Goals for care: ________________________________________________________________________

____________________________________________________________________________________

HEALTH HISTORY

Major illnesses or conditions you have currently or had in the past: _______________________________

_____________________________________________________________________________________

Hospitalizations:  no  yes, why: ___________________________________________

Surgeries:  no  yes, procedure: _______________________________________

Accidents, injuries, or falls:  no  yes, describe: ________________________________________

Broken bones:  no  yes, describe: ________________________________________

Sprains or strains:  no  yes, describe: ________________________________________

Been struck unconscious:  no  yes, describe: ________________________________________

Allergies:  no  yes, describe: ________________________________________

Previous chiropractic treatment:  no  yes, why: ___________________________________________

_____________________________________________________________________________________

Please check any symptoms you have experienced in the last six months.

O = occasionally F = frequently C = constant

| | | |Check any of the |

|O F C |O F C |O F C |following illnesses you |

|Musculoskeletal |Eye, Ear, Nose and Throat |Skin |currently have or |

|( ( ( Arthritis |( ( ( Blurred vision |( ( ( Bruise easily |have had in the past: |

|( ( ( Bursitis |( ( ( Colds/Congestion |( ( ( Hives or allergy | |

|( ( ( Elbow pain |( ( ( Dental decay |( ( ( Nail fungus |( Alcoholism |

|( ( ( Foot pain/tingling |( ( ( Earache |( ( ( Skin rash |( Anemia |

|( ( ( Hand pain/tingling |( ( ( Ear discharge | |( Appendicitis |

|( ( ( Hernia |( ( ( Ear ringing |Cardiovascular |( Arteriosclerosis |

|( ( ( Hip pain |( ( ( Enlarged glands |( ( ( Chest pain |( Arthritis |

|( ( ( Jaw pain/clicking |( ( ( Enlarged thyroid |( ( ( High blood pressure |( Autoimmune disease |

|( ( ( Knee pain |( ( ( Eye pain |( ( ( Low blood pressure |( Cancer |

|( ( ( Low back pain |( ( ( Far sightedness |( ( ( Poor circulation |( Chicken pox |

|( ( ( Mid back pain |( ( ( Fullness in ears |( ( ( Rapid heartbeat |( Chronic fatigue |

|( ( ( Neck pain, stiffness |( ( ( Gum trouble |( ( ( Slow heartbeat |( Cold sores |

|( ( ( Pain b/w shoulders |( ( ( Hay fever |( ( ( Swelling of ankles |( Diabetes |

|( ( ( Poor posture |( ( ( Hearing problems |( ( ( Varicose veins |( Drug dependency |

|( ( ( Sciatica |( ( ( Hoarseness | |( Eczema |

|( ( ( Shoulder pain |( ( ( Nasal obstruction |Respiratory |( Edema |

|( ( ( Spinal curvature |( ( ( Near sightedness |( ( ( Asthma |( Emphysema |

|( ( ( Swollen/hot joints |( ( ( Nose bleeds |( ( ( Chronic cough |( Epilepsy |

|( ( ( Tailbone pain |( ( ( Sinus infection |( ( ( Difficulty breathing |( Fibromyalgia |

|( ( ( Walking problems |( ( ( Sore throat |( ( ( Spitting up blood |( Goiter |

| |( ( ( Tonsillitis |( ( ( Spitting up phlegm |( Gout |

|General |( ( ( Vision changes | |( Heart disease |

|( ( ( Anxiety/Nervousness | |Genitourinary |( Hepatitis |

|( ( ( Balance trouble |Gastrointestinal |( ( ( Bladder control prob |( Herpes |

|( ( ( Chills |( ( ( Abdominal pain |( ( ( Bladder infection |( Influenza |

|( ( ( Convulsions |( ( ( Belching |( ( ( Discolored urine |( Lyme disease |

|( ( ( Depression |( ( ( Black/bloody stool |( ( ( Frequent urination |( Malaria |

|( ( ( Dizziness |( ( ( Colon trouble |( ( ( Kidney infection |( Measles |

|( ( ( Fainting |( ( ( Constipation |( ( ( Painful urination |( Multiple sclerosis |

|( ( ( Fatigue |( ( ( Diarrhea | |( Mumps |

|( ( ( Fever |( ( ( Excessive hunger |Women’s health |( Pacemaker |

|( ( ( Forgetfulness |( ( ( Excessive thirst |( ( ( Congested breasts |( Pleurisy |

|( ( ( Headache |( ( ( Gallbladder trouble |( ( ( Cramps or backache |( Pneumonia |

|( ( ( Loss of concentration |( ( ( Gas/bloating |( ( ( Excess menstrual |( Polio |

|( ( ( Numbness |( ( ( Heartburn |flow |( Prostate problems |

|( ( ( Sleep difficulties |( ( ( Hemorrhoids |( ( ( Hot flashes |( Psoriasis |

|( ( ( Sweats |( ( ( Indigestion |( ( ( Irregular cycle |( Psychiatric illness |

|( ( ( Tremors |( ( ( Jaundice |( ( ( Lumps in breast |( Rheumatic fever |

|( ( ( Weight gain |( ( ( Liver trouble |( ( ( Menopause |( Scarlet fever |

|( ( ( Weight loss |( ( ( Nausea |( ( ( Painful menstruation |( Stroke |

| |( ( ( Pain over stomach |( ( ( Vaginal discharge |( Thyroid disease |

| |( ( ( Poor appetite |( ( ( Yeast Infections |( Tuberculosis |

| |( ( ( Vomiting |Are you pregnant? (Yes (No |( Ulcers |

| |( ( ( Vomiting of blood |If yes, how many months?____ |( Venereal disease |

| | | |( Whooping cough |

| | | | |

Are you currently under the care of another doctor? (please provide name of doctor and reason) _____________________________________________________________________________________

Date of last physical exam: ________________ Abnormal findings: ____________________________

Height: ______ Weight: ______ lbs

FAMILY HEALTH HISTORY

Please circle any disease that runs in your biological family and indicate relationship to you:

High blood pressure High cholesterol Heart disease Diabetes Mult sclerosis

Cancer Depression Arthritis Osteoporosis

Other: ________________________________________________________________________

HEALTH HABITS

Medications and supplements you currently take (please include prescription and over-the counter medications as well as vitamins and nutritional supplements): ___________________________________ _____________________________________________________________________________________

Dietary restrictions: ____________________________________________________________________

Alcohol:  no  yes, amount: ___________________________________

Smoking:  no  yes, amount: __________________________________

Do you wear:  heal lift  insoles  orthotics

Physical activities in a typical week: _______________________________________________________ _____________________________________________________________________________________

Hobbies: _____________________________________________________________________________

Stress level:  Not a problem  mild  moderate  high

Sleep: average # of hours per night: ______ Quality of sleep:  poor  fair  good

Type of bed: ________________________ Typical sleeping position(s): ________________________

Do you have any other symptoms or concerns the doctor should know about? _____________________________________________________________________________________

_____________________________________________________________________________________

OFFICE POLICIES

Payment is expected at time of service unless other arrangements have been made. We accept payment by cash, check or credit card.

You may be required to have x-rays or other imaging or lab work done outside of this office. Any charges for these services will be handled by the other facility directly.

If you need to cancel an appointment, please provide 24 hours notice. If less than 24 hours notice is given, you will be charged the full appointment fee. Exception will be made in the case of emergency.

Drink extra water after your treatment, at least 1-2 glasses.

Questions are always welcome. Please feel free to call or email me with any questions, concerns or ideas regarding your care.

INSURANCE INFORMATION

Please complete this section if you would like us to bill your insurance company for services:

Insurance plan name: ____________________________________ Phone: _(____)_________________

Claims address: ______________________________________________________________________

street city state zip code

ID# _______________________________ Group# __________________________

Primary insured person is: □ self □ spouse □ parent

NOTICE OF PATIENT PRIVACY

Health Insurance Portability and Accountability Act (HIPAA)

We are dedicated to preserving the confidentiality of your protected health information. We are required by law to protect your health information and to provide you with a notice describing how your medical information may be used and disclosed and how you can access this information. This notice describes your rights and our duties with respect to your protected health information.

We may use or disclose your protected health information for the purpose of diagnosing or providing treatment, obtaining payment for health care bills or to conduct health care operations. We may be required by law to use and disclose your medical information for other purposes without your consent or authorization.

Your protected health information includes your health and demographic information, collected by us, other health care providers, a health care clearinghouse, or an employer. This information relates to your past, present or future physical or mental health or condition and identifies you, or there is a reasonable basis to believe the information may identify you.

You are provided the right to inspect and receive a copy of your medical information that we maintain, amend or correct that information, obtain an accounting of our disclosures of your medical information, request that we communicate with you confidentially, request that we restrict certain uses and disclosures of your health information, and file a complaint if you think your rights have been violated. All requests and complaints must be made in writing.

If you have any questions or concerns, please contact Susan Addison, DC at (503) 236-9609.

Release of Confidential Patient Information

By completing the spaces below, you authorize those listed to have access to any of your medical and billing information retained in this office.

Authorized people:

Name: ________________________________ Name: ________________________________

Relationship: ___________________________ Relationship: ___________________________

PATIENT INFORMED CONSENT

I consent to receiving chiropractic treatment from Susan Addison, DC. Treatment may include chiropractic adjustments, massage, stretching and other soft tissue treatments, and nutritional and home exercise advice. I understand that chiropractic treatment is usually beneficial and rarely causes side effects or injury. As with all healthcare, there are risks. These include, but are not limited to: post-treatment soreness, bruising, sprain, strain, fracture, dislocation and stroke.

I understand that Dr. Addison will gather my health information and perform an exam in order to minimize any risks. However, I do not expect her to be able to anticipate and explain all possible risks and complications. Dr. Addison may decide that chiropractic treatment is not the most appropriate treatment for me, and she may refer me for treatment by another health care provider. Finally, I understand that Dr. Addison gives no guarantee to the results of treatment.

I have read the above consent and have had the opportunity to ask questions about its content.

I understand the above information and have completed this form to the best of my knowledge. I know that it is my responsibility to inform this office of any changes in my health.

____________________________________ _______________________

Patient signature Date

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