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PATIENT INTAKE FORMDate: _____/_____/_____Email: __________________________________________________________Referred by: ____________________________________________________________Name: _____________________________ Home phone: ( ) __________________ Cell phone: ( ) __________________Address: ___________________________________________ City: __________________ State: ______ ZIP: _________Age: ________ DOB: _____/______/______ Marital Status (M, S, W, D) No. of Children________Occupation: _____________________ Employer: ____________________________ Phone: ( )______________________Employer address: ________________________________________ City: __________________ State: ______ ZIP:_________In case of Emergency contact: Name: _______________________________ Phone: ( ) _______________________Name of spouse: ___________________________________ DOB: _____________________Name of Parent/Guardian (If patient is a minor): ________________________________________________________________Primary Care Doctor: ______________________________ Date last seen/Reason: ____________________________Address: __________________________ City: __________ State: _____ ZIP: ________ Phone: ( )_________________Other Specialist you see: ___________________________________________________________________________________Women: Gynecologist:_____________________________________________________________________________________Have you ever had Chiropractic care before? Yes / No Doctors Name: __________________________________Purpose of this appointment: _______________________________________________________________________________Is this condition due to a(n) auto accident? ________ Work injury: ________ Other: _________ Date: ___________ If this is a result of the above, do you have a lawyer? Yes / NoLawyer’s Name: ______________________________________________ Phone: ( ) ______________________ Address: ___________________________________________ City: _________________ State: ______ ZIP: _________Are you currently employed? ___Yes ___No ___Retired Give last date of work: _____________ Number of days lost due to injury: ____________Insurance Company: _____________________ Address: ____________________ Phone: ( ) ___________________ Name of the Policy Holder: _____________________________________________ Date of birth: __________________ID # _____________________________________________________ Group Number: ______________________________Patient Signature: __________________________________Patient History and Review of SystemsHave you ever experienced the following:Please circle that which you are CURRENTLY experiencingYNRheumatic/Scarlet FeverYNPersistent Constipation DiabetesVomiting Blood MeaslesBlood in StoolRubella Yellow Jaundice/Liver DiseaseChicken PoxUnusual DischargeMumpsKidney Disease/InfectionPolioUlcersShortness of BreathGallstonesChest Pain/PressureDental ProblemsIrregular Heart Beat/Murmur/ArrhythmiaClicking Jaw/TMJSwelling of FeetSnoringLeg/Arm PainAppetite Changes Abnormal Bleeding Night Time UrinationHigh Blood PressureChanges in Urination/Frequency ___per dayPhlebitis Changes in bowel functions ___per dayStroke Changes in Breast Palpitations Changes in Skin (Mole, Wart, Etc.)Muscle Cramps/Ache while Walking/at RestPneumonia Headaches Tuberculosis/Lung DiseaseVision ProblemsCancerDizzinessThyroid Trouble NumbnessVenereal Infection/Syphilis/Herpes/GonorrheaParalysisHepatitis Slurred SpeechHIV/AIDSHearing Loss/RingingBlood Transfusion ConvulsionPainful/Swollen JointSexual DysfunctionBackacheSeizuresBroken/Fractured Bones Memory LapseTrauma/Accidents Difficulty SwallowingBad Sprains/StrainsPersistent HoarsenessArthritis/GoutPersistent NosebleedsDepression/Anxiety Persistent CoughSmoke/Chew Tobacco _______per dayBloody SputumExposed to Smoke or Chemicals- Home/ WorkWheezingLife Stress Home/WorkWeight ChangesRegular Exercise Painful Urination/ Bladder problems?Use of Alcohol ________ per dayBlood in UrineUse of Recreational Drugs/SteroidsBlood in UrineUse of Caffeine __________ per dayPersistent Nausea/ Vomiting?Vitamins? (List)AllergiesOTHER?Persistent Indigestion/ Abdominal Pain?Sleeping Positions? BACK? STOMACH? SIDE? R L Current MedicationPain Blood PressureHormonesMuscle RelaxerHeart Birth ControlAnti-Inflammatory Thyroid AntidepressantsSteroids Insulin/DiabetesAntibioticsOther Have you ever had any of the following surgeries?YNDateProcedure YNDate ProcedureAppendix (Appendectomy)HeartHysterectomy C-Section, Miscarriages, D & CTonsils (Tonsillectomy)Spine Gallbladder (Cholecystectomy)OrthopedicBreast/ProstateHemorrhoidPlastic/Cosmetic/SkinOtherFamily History RelationDeceased Age State of Health Cause of DeathFather Mother Brother/SisterSpouse ChildrenDo you have a family history of (parents, grandparents, brothers, sisters, children):Heart DiseaseYNCancer (location)YNHigh Blood PressureThyroids Disease Diabetes Bleeding Disorder StrokeArthritisNeurological DisorderOther For Women Only (Menstrual History)Age of OnsetExcessive Flow?Length of Cycle/Regularity Vaginal Discharge? Number of Days Date of Last Period Endometriosis?Are you currently pregnant? (IF YES HOW MANY WEEKS GESTATION?) __________________________Number of vaginal deliveries?_______________ Number of C-sections? _______________________Are you considered high risk for this pregnancy and Why? _____________________________________________________________________________________________Is this a VBAC? _____________________________________ IF so tell me about your previous birth experiences ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I prefer working as a team to help coordinate the best birthing or postpartum experience. Please write the name of the individual or organization and their contact information if you give me permission to share pertinent findings during your care with me: OB/ MIDWIFE: ________________________________________________________________________________DOULA: ______________________________________________________________________________________POST PARTUM DOULA__________________________________________________________________________BREAST FEEDING CONSULTANT___________________________________________________________________OTHER _______________________________________________________________________________________ PATIENT PAIN DRAWINGNAME: ____________________________Date: ____________CIRCLE areas of complaint. Mark 1 for primary, 2 for seconday and 3 for tertiary complaint.Draw an ARROW if the pain is traveling/radiating.Pain Scale Below: (Please cicle corresponding pain to number on scale. Note the area of pain) Pain Free Worst Pain ____________________________________________________________________________Imaginable 0 1 2 3 4 5 6 7 8 9 10HISTORY OF COMPLAINTName: _______________________Date: ______________Case # ____________Primary Complaint: ___________________________________________________________________________________________________________________________________________Secondary Complaint: ___________________________________________________________Tertiary Complaint: _____________________________________________________________Details of Complaints Doctor’s Notes Did anything cause or contribute to the onset? Yes NoWhen did the most recent episode begin? Date: __________________ Yes NoHave you sought other care for this condition? Who _______________ Yes NoCan you point to the exact location of your symptom(s) ____________ Yes NoHow would you describe the intensity of your pain scale of 1 to 10? __ Yes NoCan you describe the sensation? (Dull, sharp, burning, aching, Yes No gnawing, throbbing, shooting, constricting, and other) _____________ Has your condition been constant or intermittent though it’s Yes No duration? Explain ___________________________________________ Does it radiate/ travel to any other part of your body? Where _______ Yes NoHas there been changes in any bodily functions? (urination, bowel, Yes No respiration, digestion, vision, sexual, other) ________________________Has your condition been getting better, worse or about the same? Yes No ___________________________________________________________Has your condition affected your daily activities in any way?Yes No How? ______________________________________________________Is there anything that makes it worse? ___________________________ Yes NoHave you found anything that makes it better? What? _______________Yes NoHave you tried store bought or home remedies? What? ______________Yes NoPatient Signature __________________________________HIPAA Office Policy I understand that this office operates under the HIPAA compliance act and I don’t need to read that act.I understand that this office operates under the HIPAA compliance act and I have been able to read the act on file in the office.Office Policy(PLEASE READ AND SIGN BELOW)We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient. Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with Dr. Young.If your account is not paid within 30 days of the date of service and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account. Balance older than 30 days will be charged a monthly service fee of $8 and accrue monthly interest of 5.5% . You also accept the responsibility to pay any attorney fees, court cost and collection fees that are used to collect the debt.I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand that it is my responsibility to inform this office of any changes in my medical status. Our office I agree to have a likeness or my name posted for the sake of education and or marketing (please initial for YES or write NO) In the office__________ cc&w facebook or instagram_________ cc&w website _______Failure to cancel appointment 24 hours before scheduled time will be charged with a missed appointment/late cancellation fee of $50. A second late cancel/missed appointment will incur an $85 fee and probable release from our practice as a patient. Signature: ____________________________________________________ Date:__________________________SIGNATURE ON FILEI authorize use of this form on all my insurance submissions. I authorize release of information to all my Insurance CompaniesI understand that I am responsible for my bill.I authorize my doctor to act as my agent in helping me obtain payment from my Insurance Companies.I authorize payment directly to my doctor.I permit a copy of this authorization to be used in place of the original.I am responsible for any bank fees incurred to Dr. Young due to depositing a check with insufficient funds Name (Print Please): ________________________Medicare # _______________ I (If applicable) Signature: _________________________________ Date: ___________________ Core Chiropractic & Wellness may keep my credit card information on file in a secure location to pay my balance: Name on card:________________________________________________Card number:_________________________________________________Exp Date : _____________ CSV__________ Billing ZIPCODE_________If the bill is greater than $100, where would you like us to contact you for prior authorization?_________________________________________________________________________Do we have permission to text this phone number? __________ (this may incur a charge with your carrier) Do we have permission to leave a phone message?___________(Note: After 2 failed attempts, our office has implied permission to charge the balance due in full. It is the patient responsibility to keep their demographic and billing information current with our office. ) Name:________________________________________Date :_____________ ................
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