Performance Health Center



Performance Health Center

6268 S. Rainbow Blvd., Suite 105

Las Vegas, NV 89118

Phone: (702) 966-5920

Email: performancehealthcenterlv@

_________________________________________________________________________________________________

Patient Information

Name: __________________________________________________________________________ Date: __________________________

Last First Middle Initial

Address: ________________________________________________________________________________________________________

Street Address Apt # City State Zip Code

Home Phone: ( )_______________________________________ Cell: ( )____________________________________________

DOB: ____/____/____ SSN #:_____-____-_____ Email:_________________________________________________________________

Marital Status: Single ( ) Married ( ) Divorced ( ) Widowed ( ) Separated ( )

Occupation: ________________________________________ Employer: ____________________________________________________

Employer Address: _______________________________________________________________________________________________

Street Address City State Zip Code

Emergency Contact: _____________________________ Phone: ( )______________________ Relationship:_____________________

Whom may we thank for referring you to our office? ____________________________________________________________________

Current Health Conditions

What is your primary health complaint(s)?_____________________________________________________________________________

Date symptoms first appeared? ___/___/___ Describe any related accident or injury: ___________________________________________

_______________________________________________________________________________________________________________

What aggravates your symptoms? ___________________________________________________________________________________

What alleviates your symptoms? ____________________________________________________________________________________

Have you tried anything to get rid of this problem that did NOT work? Yes ( ) No ( )

If yes, please explain. _____________________________________________________________________________________________

What other health practitioners have you consulted for this/these complaints? _________________________________________________

What daily habits do you have that could make this problem worse? ________________________________________________________

When this problem is at its worst, does it interfere with your: Work? ( ) Family Life? ( ) Recreation? ( )

List of current medications and/or supplements: ________________________________________________________________________

_______________________________________________________________________________________________________________

Please mark the areas of pain on the figures below.

[pic]

Type of Pain:

Sharp______ Dull______ Aching______ Burn______ Throb______ Numb______ Other______

Does the pain radiate? Yes______ No______ Where to?_________________________________

How would you rate your pain? 0—1—2—3—4—5—6—7—8—9—10

No pain Unbearable

Medical History

Past Surgeries/Operations:___________________________________________________________________ ______________________

Major accidents or falls since birth:____________________________________________________________ ______________________

Hospitalizations (other than above):__________________________________________________________________________________

Are you currently under the care of a medical physician? If yes, for what condition?___________________________________________

Please list the physicians’ name, phone number, and the approximate last date of treatment:______________________________________

_______________________________________________________________________________________________________________

Have you had previous Chiropractic care? Yes ( ) No ( ) Please list doctor’s name and approximate date of last visit:___________________________________________________________________________________________________________

Are you currently under the care of any other alternative healthcare practitioners?

Acupuncturist______ Massage therapist______ Nutritionist______ Pilates______ Other_____________

Please check any of the following you have had/been diagnosed with in the past:

____Pneumonia ____Measles ____Influenza ____Rheumatic fever ____AIDS/HIV ____Anemia

____Mumps ____Pleurisy ____Polio ____Small pox ____Arthritis ____Eczema/Psoriasis

____Tuberculosis ____Cancer ____Heart Dis. ____Thyroid Dis. ____Whooping cough

Please check any of the following you have had in the past six months:

Musculoskeletal Gastrointestinal Eyes/Ears/Nose/Throat

____Low back pain ____Poor Appetite/Underweight ____Vision problems

____Pain between shoulders ____Excessive Appetite/Overweight ____Dental problems

____Neck pain ____Unexplained weight loss ____Earache/Infections

____Shoulder/arm/wrist pain ____Frequent nausea ____Difficulty hearing

____Hip/knee/ankle pain ____Vomiting ____Ringing in the ears

____Joint pain/stiffness ____Diarrhea ____Cold/Flu

____Difficulty walking ____Constipation ____Sinus problems

____Jaw/Head pain ____Hemorrhoids ____Sore throat

Nervous System ____Liver problems Cardiovascular

____Cold/tingling extremities ____Gall bladder problems ____Chest pain

____Numbness/Loss of sensation ____Abdominal cramps ____Shortness of breath

____Dizziness ____Gas/Bloating after meals ____High blood pressure

____Fainting ____Heartburn ____Irregular heartbeat

____Forgetfulness ____Excessive thirst ____Heart problems

____Depression ____Colitis/Crohn’s/IBS ____Lung symptoms/congestion

____Seizures Genitourinary ____Varicose veins

____Paralysis ____Painful/Excessive urination ____Ankle swelling

____Nervousness ____Discolored urine ____Stroke

____Stress ____Bladder infections Female Only

General ____Urinary leakage ____Menstrual cramps

____Fatigue Male only ____Irregular/absent periods

____Loss of sleep ____Prostate Dysfunction ____Vaginal infection/pain

____Unexplained fevers ____Loss of libido ____PMS

____Headaches ____Sexual dysfunction ____Loss of libido

____Allergies ____Menopausal symptoms

____Pain at night ____Breast pain

____Uterine/Ovarian fibroids

Are you pregnant? Yes____ No____

Is there anything else you would like the doctor to know regarding your health? _________________________________________

_________________________________________________________________________________________________________

Consent to Treatment

I, voluntarily consent to receive medical and health care services that may include diagnostic procedures, examinations, and treatment.

Financial Responsibility and Assignment of Benefits

I agree to pay all charges for medical and health care services not covered by my insurance company.

Missed Appointments

We respect our patient’s time and try to manage appointments as efficiently as possible. For this reason, we ask that you please contact us at least 24 hours prior to your scheduled appointment time for any changes that need to be made. Failure to do so may result in a service charge of $25 to your account.

I certify that I have read this form and understand its contents.

______________________________________ ____________________________________ ____________________

Print Name Signature Date

HIPAA: Notice of Privacy Practices

I have read and understand the HIPAA Privacy Act. **HIPAA information is on laminated sheet on the clipboard**

______________________________________ ____________________________________ ____________________

Print Name Signature Date

-----------------------

[pic]

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

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

Google Online Preview   Download