ALLIED HEALTHCARE, PLLC PATIENT INFORMATION
Name:_______________________________________________________ Date:_________________ Address:_____________________________________ City:__________________ State:____ Zip:________ Birthday:____________________ Sex:______ Social Security Number: ________________________ Home Phone:_________________ Cell Phone:__________________ Work Phone:_________________ Email Address:___________________________________ Occupation:______________________________ Hobbies:_________________________________________________________________________________ Emergency Contact:____________________________________ Phone:_____________________________ Marital Status: Single Married Widowed Divorced
WHO IS RESPONSIBLE FOR THE BILL Responsible Party Name:__________________________ Responsible Party Birthday:_________________ Insurance Company:______________________________ Policy Number:___________________________ Who referred you to our office? How did you hear about us?_______________________________________ Who is your Primary Care Physician?__________________________________________________________ Are you pregnant: YES NO If so, (congrats!) please list your due date:_______________________ CURRENT CONDITION Your present complaint/describe your symptoms:_________________________________________________ Is your visit due to an auto or work-related accident? YES NO Date of accident:________________ How long have you had this condition?_________________________________________________________ Have you had this or similar conditions in the past?_______________________________________________ Does anything make it feel worse?_____________________________________________________________ Does anything make it feel better?_____________________________________________________________
Is this condition: Improved Unchanged Getting Worse Is this condition interfering with: Work Sleep Daily Routine Other:________________________ Other doctors or therapists who have treated THIS condition:_________________________________________ __________________________________________________________________________________________
What do you think caused this condition? ________________________________________________________ Have you had an x-ray or CT scan or MRI in the past 28 days? YES NO If Yes, Where?_____________________________________________________________________________ HEALTH HISTORY Exercise: None Moderate Daily Heavy Work Activity: Sitting Standing Light Labor Heavy Labor Habits: Smoking-packs/day____ Alcohol-drinks/week____ Coffee/Caffeine Drinks-cups/day____ List Medications, Including dosage and frequency if known. If no medications, check here: __________________________________________________________________________________________
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List any known allergies you have had to any medications. If no allergies are known, check here: __________________________________________________________________________________________
List any surgical operations and years: __________________________________________________________ __________________________________________________________________________________________
Signature:____________________________________________ Date:___________________
Parent / Guardian Signature:_________________________________________
INFORMED CONSENT FOR EXAMINATION AND TREATMENT I (we) hereby consent to the performance of examination and treatment on me or on ________________________________, by the licensed doctors of chiropractic, medical doctors, and/or licensed physical therapists who may be employed by or engaged in practice in this clinic. I have had an opportunity to discuss with the doctor(s) or other clinic personnel the nature and purpose of the different physical therapy procedures and chiropractic treatment (manipulation/adjustment). I understand that neither chiropractic nor medical treatment is an exact science and that my care may involve judgments based upon facts and information known to the doctor. The doctor uses this judgment to attempt to anticipate or explain risks and complications and an undesirable result does not necessarily indicate an error in judgment. No guarantee for results can be made or expected but rather I wish to rely on the doctor to choose and recommend a best course of treatment based upon facts known that are in my best interests. I further understand that there are certain degrees of risk associated with chiropractic health care and physical therapy, which includes rarely, but not limited to fractures, disc injuries, strokes, and strain/sprains and am therefore willing to accept and consent to the risk associated with the care that I am about to receive. I have read, or the above information has been explained regarding consent. I have had an opportunity to ask questions about my examination and treatment. By signing below, I agree and intend this consent form to cover the procedures prescribed for my condition and for any future conditions for which I seek treatment. Female Patients: By my signature of this form I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. Date of last menstrual period: ______________ Patient’s Name (Print): ________________________________ Date: ____________________
Patient’s Signature: _____________________________________________________________
Relationship or authority if not signed by patient: _____________________________________
Witness: _________________________________
REVIEW OF SYMPTOMS Check only the ones you now have, or have had in the past.
GENERAL NOW PAST Weakness Fatigue Fever Chills Night Sweats Fainting SKIN Color Changes Nail Changes Hair Changes Moles Rashes Sores HEAD Headaches Injuries Bumps Last Eye Exam: ___________ Glasses Contacts Cataracts EARS Hard of Hearing Deafness Ringing Discharge Earache Itching Dizziness Room Spins NOSE Decreased Smell Bleeding Pain Discharge Obstruction Post Nasal Drip Deviated Septum Runny Nose Sinus Congestion MOUTH Bleeding Gums Sores Dental Problems Bad Breath Loss of Taste Dry Mouth Ulcers Blisters
THROAT NOW PAST Soreness Bad Tonsils Hoarseness Pain Trouble Swallowing Recurrent Infections NECK Neck Enlargement Stiff Neck Soreness Lumps Masses BREASTS Discharge Lumps Pain Bleeding Nipple Changes Skin Changes Bloated LUNGS Cough Phlegm Blood Short of Breath Wheezing Pain Congestion Inhalant Exposure HEART Murmur Palpitations Rapid Heartbeat Swollen Extremities Cold Extremities Chest Pain/Pressure Varicose Veins Blood Clots Blue Extremities BLOOD Anemia Low Blood Iron Easy Bruising Easy Bleeding Swollen Nodes Painful Nodes Sugar in Blood Red Spots
GASTROINTESTINAL NOW PAST Abdominal Pain Nausea Bloated Belching Heartburn Indigestion Irregular Bowel Habits Constipation Diarrhea Gas Hemorrhoids Poor Appetite Food Intolerance Bloody Stools Black Stools GENITOURINARY Urgency Incontinence Straining Back Pain Frequent Voiding Stones Burning Bed Wetting Small Stream Discharge Impotence Dribbling Cloudy Urine Urine Color: _________________ Spotting Between Periods Menstrual Cramps Discharge Itching Painful Intercourse Irregular Periods Hot Flashes Contraception Type: ___________ Age at First Period: ____________ Duration of Cycle: _____________ Duration of Flow: ______________ No. of Pregnancies: ____________ No. of Births: _________________ No. of Miscarriages: ___________ No. of Abortions: ______________ Menstrual Flow: Heavy Mod Light Last Period: __________________ Last Pap smear: _______________ Last Vaginal Exam: ____________ Last Mammogram: ____________ Last Prostate Exam: ____________
REVIEW OF SYMPTOMS Check only the ones you now have, or have had in the past.
NEUROLOGIC NOW PAST Seizures Vertigo Dizziness Hand Trembling Loss of Sensation Incoordination Loss of Facial Weak Grip Paralysis Difficulty Speech Tingling Loss of Memory Numbness ENDOCRINE Weight Loss Weight Gain Extremely Thin Heat Intolerance Cold Intolerance Hair Changes Breast Changes IMMUNIZATION / VACCINATION DPT Mumps Smallpox Typhoid Tetanus Measles Pneumococcal Influenza Polio MMR BLOOD TYPE A+ A‐ B+ B‐ AB+ AB‐ O+ O‐ Other: ___________ BLOOD TRANSFUSIONS
Date: _____________
Date: _____________
Date: _____________
Date: _____________
PSYCHIATRIC NOW PAST Hyperventilation Insecurity Depression Troubled Sleep Irritable Undecidedness Timid Hallucinations Loss of Memory Alcoholism Drug Addiction Drug Dependent Suicidal Thoughts Extreme Worry Sexual Problems MUSCULOSKELETAL Muscle Pain Muscle Weakness Muscle Cramps Muscle Twitching Joint Stiffness Joint Pain Date of Last Chest X‐Ray:___________ Results: Normal Abnormal Date of Last TB Skin Test: __________ Results: Normal Abnormal Allergies: _______________________ _______________________________
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PAST MEDICAL HISTORY (Check only the ones you have had in the past)
Hay Fever Mumps Rheumatic Fever Allergies Angina Cancer Tumor Blood Disease Leukemia Heart Trouble Varicose Veins Phlebitis Hypertension Stroke Ulcers Jaundice Skin Trouble Gallstones Liver Trouble Hepatitis Parasites Epilepsy Paralysis Polio Mental Illness Alcoholism Depression Nervous Breakdown Migraine Gout Hemorrhoids Prostate Problems Sexual Problems Gonorrhea Syphilis Diabetes Bladder Trouble Kidney Stones Kidney Infections Dysentery
OFFICE FINANCIAL POLICY Our policy is to extend to you the courtesy of allowing you to assign your insurance benefits directly to Allied Healthcare. This policy reduces your out-of-pocket expense and allows you to place your family under care. 1. If You Do Not Have Insurance: All payments are expected at the time of service or by an authorized payment plan. Your personal balance may not exceed $100 at any time, or care may be terminated. Our payment plans make care an affordable part of your family budget. 2. If You Have Insurance: All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Your co-insurance balance may not exceed $100, or care may be terminated. Our payment plans make care an affordable part of your family budget. You are considered a cash patient until you bring in your complete insurance information, and we qualify and accept your insurance coverage. Our fees are considered usual, customary, and reasonable by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This statement does not apply to companies who reimburse based on an arbitrary schedule of fees bearing no relationship to the current standard and care in this area. If your carrier has not paid a claim within sixty (60) days of submission, you agree to take an active part in the recovery of your claim. If your insurance carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of any outstanding balance and authorize us to use your credit card to collect full payment. You further agree to pay a collection fee of 33% of the principal amount to reimburse Allied Healthcare its collection costs if your account is assigned to a collection agency. Personal Injury Cases: If account balance is not Paid In Full within 6 months of the first Date of Service, the patient will be required to begin making minimum monthly payments toward account balance, regardless of settlement/claim status. If you discontinue care for any reason other than discharge by the doctor, all balances will become immediately due and payable in full by you, regardless of any claim submitted. We bill insurance carriers as a courtesy to our patients. It is not required by law for us to do so. It is ultimately the patient’s responsibility to contact their insurance carrier to determine what services may or may not be covered. It is also your responsibility to contact your insurance company regarding any questions of payment and/or denials of treatment. Patient’s Name (Print): ________________________________ Patient’s Signature (or legal guardian): ___________________________________ Date: __________________
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY
PRACTICES FOR PROTECTED HEALTH INFORMATION I acknowledge that I have received or asked for a copy of Allied Health Care, PLLC’s Notice of Privacy Practices for protected health information. Patient’s Name (Print): _________________________________ Date: ________________ Patient’s Signature (or legal guardian): __________________________________________