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:_______________
................
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