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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