CONFIDENTIAL PATIENT HEALTH HISTORY FOR PAIN …



CONFIDENTIAL PATIENT HEALTH HISTORY FOR PAIN TREATMENT CENTER, PC

Name:__________________________________ Home Phone: _________________ Cell Phone: _____________ Work Phone:__________________

Address:____________________________________________________ City_________________________ State_______ Zip:________________

Age:_____________ Date of Birth______-______-______ Marital Status: M S D W Sex M F How many children?______________

Occupation__________________________________________________ Employer_____________________________________________________

Name of partner/spouse_____________________________Employer_____________________________Occupation__________________________

Date of last physical exam?___________________________________ E-Mail address: _________________________________________________

Emergency Contact (someone not living with you) Name: _______________________________________ Telephone no: ______________________

How did your current condition develop? Auto Accident Work Injury Other:_____________________________________________

When was the first time you became aware of this problem?________________________________________________________________________

Have you ever had the same or similar condition? (if yes, explain): __________________________________________________________________

Other doctor's seen for this condition:______________________________________ Family Doctor:_______________________________________

Have you ever been treated by a chiropractor before? Yes No If yes, who?_____________________________________________________

Have you had any surgeries? Yes No. If yes, explain:_________________________________________________________

Have you been treated for any other health condition in the past year? (what):___________________________________________

Have you ever had any bad falls? Yes No If yes, please describe:___________________________________________

Have you ever broken any bones? Yes No If yes, which?______________________________________________________

Have you ever been involved in a car accident? Yes No If yes, when?__________________________________________

What drugs are you now taking?_________________________________*FEMALE ONLY* Are you pregnant? Yes No

PAYMENT IS EXPECTED AT THE TIME OF VISIT (A 1% monthly service fee will be added to all outstanding balances.)

Method of payment: Cash Health Insurance Auto Insurance Work Comp. Other

Insurance Company:________________________________ Address:__________________________

Insurance telephone #:_______________________ Policy #:______________________________

Please note: We will bill your specified insurance company. However you are responsible for all costs incurred for treatment should there be no coverage.

I understand and agree that health and accident insurance policies are an arrangement between the insurance company and myself. I understand that Pain Treatment Center will prepare any reports or forms to assist me in making collection and that any amount authorized to be paid directly to this clinic will be credited to my account. I also give this office power of attorney to endorse checks make out to me, to be credited to my account. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that by signing below, I authorize Pain Treatment Center, P.C. to bill any and all applicable insurance for services rendered to me in this office.

_________________________________________ _______________________________ ______________________ Signature of patient (or guardian) Social Security Number Date

PERSONAL AND FAMILY HEALTH HISTORY:

PATIENT NAME: ____________________________________ DATE: ____/____/_____

HEALTH HISTORY: Please check any of the following conditions that you or a member of your family have had or do have:

Please indicate yourself or the family member, (i.e. Mother, Father, Sister, etc.)

| Scarlet Fever | Myself Family member: ____________________ |

| Heart Disease | Myself Family member: ____________________ |

| Lung Disease | Myself Family member: ____________________ |

| Rheumaic Fever | Myself Family member: ____________________ |

| Diabetes | Myself Family member: ____________________ |

| Difficulty Breathing | Myself Family member: ____________________ |

| Typhoid | Myself Family member: ____________________ |

| Kidney Disease | Myself Family member: ____________________ |

| Asthma | Myself Family member: ____________________ |

| Dysentery | Myself Family member: ____________________ |

| Liver Disease | Myself Family member: ____________________ |

| Allergies | Myself Family member: ____________________ |

| Tuberculosis | Myself Family member: ____________________ |

| Nerve disease | Myself Family member: ____________________ |

| Ulcers | Myself Family member: ____________________ |

| Cancer | Myself Family member: ____________________ |

| Swelling of Ankles | Myself Family member: ____________________ |

| Colitis | Myself Family member: ____________________ |

| Pneumonia | Myself Family member: ____________________ |

| Urinary problems | Myself Family member: ____________________ |

| Diverticulitis | Myself Family member: ____________________ |

| Malaria | Myself Family member: ____________________ |

| Bowel Problems | Myself Family member: ____________________ |

| High blood pressure | Myself Family member: ____________________ |

| Diphtheria | Myself Family member: ____________________ |

| Arthritis | Myself Family member: ____________________ |

| Low blood pressure | Myself Family member: ____________________ |

| Sleep Loss | Myself Family member: ____________________ |

| Nervousness | Myself Family member: ____________________ |

| Headaches | Myself Family member: ____________________ |

| Sinus | Myself Family member: ____________________ |

| Migraines | Myself Family member: ____________________ |

| Hemorrhoids | Myself Family member: ____________________ |

| Backaches | Myself Family member: ____________________ |

| Dizziness | Myself Family member: ____________________ |

| Emphysema | Myself Family member: ____________________ |

OTHER CONDITIONS: ___________________________________________________________________________

Reviewed by: __________________________________

PAIN TREATMENT CENTER

SYMTPOMS FOLLOWING THE ACCIDENT:

PATIENT NAME: ____________________

|HEAD: |ARMS AND HANDS: |LOW BACK: |

| | | |

|Headaches |Pain in upper arm |Low back Pain |

|Entire Head |Pain in Forearm |Lower back pain worse when: |

|Back of head |Pain in Hands |Working |

|Forehead |Pain in fingers |Lifting |

|Temples |Pinched nerve in fingers |Stooping |

|Migraine |Sensation of pins and needles |Standing |

|Head feels heavy |In arms |Sitting |

|Loss of memory |In finger |Bending |

|Light headedness |Fingers go to sleep |Coughing |

|Fainting |Hands cold |Pinched nerve in low back |

|Lights bother eyes |Swollen joints in fingers |Slipped disc |

|Loss of smell |Loss of grip strength |Low back feels out of place |

|Loss of taste | |Muscle spasms |

|Loss of Balance |MID BACK: |Arthritis |

|Dizziness | | |

|Loss of hearing |Mid back pain |WOMEN: |

|Pain in ears |Pain between shoulders | |

|Ringing in ears |Sharp stabling in mid back |Menstrual pain |

|Buzzing in ears |Muscle spasms |Cramping |

| | |Irregularity |

|ABDOMEN: |CHEST: | |

| | | |

|Nervous stomach |Chest Pain |NECK: |

|Nausea |Shortness of breath | |

|Gas |Pain around ribs |Pain in neck |

|Constipation | |Neck pain with movement |

|Diarrhea |HIPS, LEGS AND FEET: |Pinched nerve in back |

| | |Neck feels out of place |

|SHOULDERS: |Pain in buttocks (right or left?) |Stiff neck |

| |Pain in hip joint (right or left?) |Muscle spasm |

|Pain in shoulders |Pain down leg (right or left?) |Grinding sounds in neck |

|Pain across shoulders |Leg cramps (right or left?) |Grating sounds in neck |

|Bursitis (right or left?) |Pins and needles in leg (right or left?) |Popping sounds in neck |

|Arthritis (right or left?) |Numbness of leg (right or left?) |Arthritis |

|Can’t raise arm |Numbness of feet (right or left?) | |

|Over shoulder |Numbness of toes |GENERAL: |

|Overhead |Feet feel cold (right or left?) | |

|Tension in shoulders |Cramps in feet (right or left?) |Nervousness |

|Pinched nerve in shoulder |Swollen ankles |Irritability |

|Muscle spasm in shoulder |Painful joints in toes |Depressed |

| | |Generally run down |

| | |Loss of sleep |

| | |Loss of weight |

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working toward the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

I, ____________________________________(patient name) have read and fully understand the above statements.

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.

I, therefore, accept chiropractic care on this basis.

______________________________ ______________________

Signature Date

PAIN TREATMENT CENTER

2445 4th Avenue So. #112

Seattle, WA. 98134

Privacy: We will protect your personal health information against disclosure to unauthorized entities/persons. With your permission we will share your personal health information only with entities/persons directly related to your health care and insurance payment needs. We will ask for your written permission for any other disclosure of your personal health information.

Access: You have the right to review and amend your personal health care records. Fees for copying your personal health information/records are set by the state regulators annually.

I _______________________________________ hereby give consent and authorization to Pain Treatment Center to release and/or request any and all medical records for myself or dependents to/from whomever necessary in order to collect charges incurred on my account. A photocopy of this authorization will be as valid as the original.

___________________________________________ ______________________

Patient's Signature Date

___________________________________________ _______________________

Witness' signature Date

Pain Treatment Center, P.C.

INSURANCE INFORMATION

Work Injury? ( Yes ( No If yes, date of injury: ____________ Claim number: __________________

Primary Private Health Insurance: __________________________________________________________

Name and Address

Phone #:______________________ Policy#: _____________________ Insured name: ____________________

Secondary Private Health Insurance: _______________________________________________________________

Name and Address

Phone #:______________________ Policy#:______________________ Insured name: ______________________

FOR OFFICE USE ONLY: Date verified: _____________ Verified by: ________________

Primary: Effective date: __________ Chiropractic Coverage? ( Yes ( No

Percentage covered_______% X-rays _____%

Deductible: ___________ Met? ( Yes ( No How much remains? ___________

Referral needed? ( Yes ( No

Visit Limit? __________ Limitations? ______________________________________________________________

Secondary: Effective date: __________ Chiropractic Coverage? ( Yes ( No

Percentage covered_______% X-rays _____%

Deductible: ___________ Met? ( Yes ( No How much remains? ___________

Referral needed? ( Yes ( No

Visit Limit? __________ Limitations? ______________________________________________________________

WORK INJURY:

TYPE: ( L&I ( Self Insured ( Maritime ( Federal

Self-Insured/Federal or Maritime Insurer:____________________________________________________________

Phone no: ___________________

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