PATIENT INFORMATION



New Patient Information

Name and nickname: ___________________________________________________________________________

Date of Birth: ____________________ Social Security Number__________________________________________

Gender: Male Female

Address: _________________________________________________________________________

City:____________________________________State:_____Zip:____________

Phone Numbers-Home: _________________ Work: __________________ Cell: _______________

Preferred contact: Home Work Cell E-mail:____________________________________

Marital Status: Married Single Widowed Divorced Domestic Partnership

Race: ________________ Ethnicity_____________________ Preferred Language___________

Occupation: _____________________________________________________________________

Employer: _______________________________________________________________________

Emergency Contact person: ________________________________________________________

Emergency contact phone number: __________________________________________________

How were you referred to our office: _________________________________________________

Primary Care Physician: ____________________________________________________________

INSURANCE INFORMATION

Please indicate any and all insurance coverage that may be applicable in this case.

Major Medical Worker’s Comp Medicare Medicaid Auto Accident

Name of primary insurance company _____________________________________________

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 payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I will notify the chiropractic office of any change in my status in regards to insurance information. I consent to the care including diagnostic procedures, examinations and treatment that the chiropractor designates and considers to be necessary to treat my condition. The office may be reached at kuperuschiropractic@ , by phone at 502-426-6715 and by fax at 502-426-6716.

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 your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your 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 signature: _______________________________________ Date: ____________________________

Guardian’s signature authorizing care: _________________________________Date: __________________

Major complaint/symptoms:

1._______________________________________________________________________________________________

2. _______________________________________________________________________________________________ Describe the pain (achy, tender, sharp, numbess, tingling) :_________________________________________________

Symptoms are worse in: morning afternoon night

Symptoms: come and go constant

Date symptoms appeared or accident happened ______________________________________________________

Describe how the injury or symptoms first occurred____________________________________________________

What positions or activities aggravate your condition:

bending reaching coughing sneezing sitting standing

walking lifting lying down turning head bowel movement

What positions or activities relieve your condition:

sitting standing walking bending reaching

lifting turning head lying down

Have you been treated by a medical physician for this condition? _________________________

Have you ever had the same or a similar condition? Yes No

If yes, when and describe _________________________________________________________

Days lost from work ________________

Height ___________ weight ____________

Social habits Past OR present:

smoker __________ alcohol use _________IV Drug use__________ coffee__________ tea __________

Date of last physical_____________________________

Have you ever been in any accidents, auto, fall down stairs, fall from ladder, or other significant trauma (even as a child)?

When? ______________________________________________________________________________________________

Surgeries:

Back/Joint Heart Female Other

spinal fusion angioplasty C-section gall bladder

laminectomy Catheterization hysterectomy appendectomy

disc surgery artery bypass mastectomy hemorrhoidectomy

joint reconstruction pacemaker insertion lumpectomy tonsillectomy

joint replacement defibrillator D&C cosmetic

rotator cuff other ablation hernia repair

knee repair

carpal tunnel Surgery dates___________________________________________________

Other surgeries not listed _________________________________________

Please list all prescription and over-the –counter medications AND supplements.

|Name of Medication |Dosage |Frequency |For what condition |How long have you been taking it? |Prescribing MD |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Do you have medication allergies? (Please list medication and reaction) __________________________________________

_____________________________________________________________________________________________________

Have you gained or lost weight, without trying, in the past year? ________________________________________________

Have you had a bacterial infection in the past 30 days? _______________________________________________________

FOR WOMEN

Is there any possibility you could be pregnant? ______________________________________________________________

When was your last menstrual period? ____________________________________________________________________

Do you take birth control pills? ___________________________________________________________________________

Do you have any unusual bleeding or discharge? _____________________________________________________________

Do you have any thickening in your breasts or elsewhere? _____________________________________________________

Please indicate if you have any of the following conditions:

facial pain/stiffness pins/needles in arms ringing in ears loss of smell nausea

neck pain/stiffness pins/needles in legs depression loss of taste cold feet

back pain/stiffness fatigue nervousness loss of memory chest pain

arm/hand pain sleeping difficulties tension jaw problems fever

leg/knee pain asthma cold sweats constipation fainting

headaches allergies stomach problems shortness of breath problems swallowing

dizziness blurred vision night pain bowel/bladder problems

Family History Self Father Mother Sibling

High Blood Pressure

Heart Problems

Fibromyalgia

Stroke (CVA or TIA)

Emphysema

Asthma

Seizures-Convulsions

Diabetes

Kidney Disease

Thyroid Disease

Cancer

Arthritis

Osteoporosis

QUADRUPLE VISUAL ANALOG SCALE

Please read carefully Please circle the number that best describes the question being asked.

NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for

each complaint. Please indicate you pain level right now, average pain and pain at its best and worst.

What is your pain right now?

no pain ___________________________________________________________________________ worst possible pain

0 1 2 3 4 5 6 7 8 9 10

What is your typical or average pain?

no pain ___________________________________________________________________________ worst possible pain

0 1 2 3 4 5 6 7 8 9 10

What is your pain level at its best? (how close to “0” is your pain at its best)

no pain ___________________________________________________________________________ worst possible pain

0 1 2 3 4 5 6 7 8 9 10

What is your pain level at its worst? (how close to “10” is your pain at its worst)

no pain ___________________________________________________________________________ worst possible pain

0 1 2 3 4 5 6 7 8 9 10

Mark the areas on this body where you feel the described sensations. Use the appropriate symbols. Mark areas of radiation. Include all affected areas.

Numbness Pins & Needles Burning Aching Stabbing

--------------- ooooooooooo xxxxxxx ****** ////////

[pic]

Please use the space below to add anything else you would like the Dr to know.

I verify all information provided is true and correct to the best of my ability.

Signature:___________________________________________________________Date:_______________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download