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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_________ ................
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