CHIROPRACTIC REGISTRATION AND HISTORY PATIENT INFORMATION Patien Address Sex: Dm F Age BIrthdate Single Married Widowed Separated Divorced Patient SS# Occupation Employer Employer Address Employer Phone Spouse's Name BIrthdate SS# Occupation Spouse's Employer Whom may we thank for referring you? iK INSU^NCE Who Is responsible for this account? Relationship to Patient Insurance Co.^ Group # Is patient covered by additional insurance? Yes No Subscriber's Name BIrthdate SS# Relationship to Patient^ Insurance Co Group # ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Responsible Party Signature Relationship Date PHONE NUMBERS Best time and place to reach you IN CASE OF EMERGENCY, CONTACT Home Phone. _ Relationship. Work Phone ACCIDENT INFORMATION Is condition due to an accident? Yes No Date Type of accident Auto Work Home Other To whom have you made a report of your accident? Auto Insurance Employer Worker Comp. Other Attorney Name {If applicable) PATIENT CONDITION Reason for Visit When did your symptoms appear? Is this condition getting progressively worse? Yes No Unknown ( Mark an X on the picture where you continue to have pain, numbness, or tingling. j k A I I * i Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) / \V\ /// Type of pain: Sharp Dull Throbbing Numbness Aching Shooting T IHt Burning Tingling Cramps Stiffness Swelling Other \ J / \ I I How often do you have this pain?^ / \ / . Is It constant or does It come and go?^ \ / \ / Does it interfere with your Work Sleep Daily Routine Recreation Activities or movements that are painful to perform Sitting Standing Walking Bending Lying Down
Transcript
CHIROPRACTIC REGISTRATION AND HISTORY
PATIENT INFORMATION
Patien
Address
Sex: Dm F Age BIrthdate
Single Married Widowed Separated DivorcedPatient SS#
Occupation
Employer
Employer Address
Employer Phone
Spouse's Name
BIrthdate SS#
Occupation
Spouse's Employer
Whom may we thank for referring you?
iK INSU^NCE
Who Is responsible for this account?
Relationship to Patient
Insurance Co.^
Group #
Is patient covered by additional insurance? Yes NoSubscriber's Name
BIrthdate SS#
Relationship to Patient^
Insurance Co
Group #
ASSIGNMENT AND RELEASEI, the undersigned certify that I (or my dependent) have insurance coveragewith and assign directly toDr. all insurance benefits, if any,otherwise payable to me for services rendered. I understand that I am financiallyresponsible for all charges whether or not paid by insurance. I hereby authorizethe doctor to release all information necessary to secure the payment ofbenefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature
Relationship Date
PHONE NUMBERS
Best time and place to reach you
IN CASE OF EMERGENCY, CONTACT
Home Phone.
_ Relationship.
Work Phone
ACCIDENT INFORMATION
Is condition due to an accident? Yes No Date
Type of accident Auto Work Home Other
To whom have you made a report of your accident?
Auto Insurance Employer Worker Comp. Other
Attorney Name {If applicable)
PATIENT CONDITION
Reason for Visit
When did your symptoms appear?
Is this condition getting progressively worse? Yes No Unknown (Mark an X on the picture where you continue to have pain, numbness, or tingling. j k A I I * iRate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) / \V\ ///Type of pain: Sharp Dull Throbbing Numbness Aching Shooting T IHt
Burning Tingling Cramps Stiffness Swelling Other \ J / \ I IHow often do you have this pain?^ / \ / .Is It constant or does It come and go?^ \ / \ /Does it interfere with your Work Sleep Daily Routine RecreationActivities or movements that are painful to perform Sitting Standing Walking Bending Lying Down
HEALTH HISTORY
What treatment have you already received for your condition? D Medications D Surgeiy Chiropractic Services None Other
Name and address of other doctor(s) who have treated you for your conditionDate of Last: Physical Exam Spinal X-Ray
Spinal Exam Chest X-RayDental X-Ray MRI, CT-Scan, Bone Scan
Place a mark on 'Yes" or "No" to indicate if you have had any of the following:
Physical Therapy
Blood Test.
Urine Test
AIDS/HIV DYesDNoAlcoholism^ Yes NoAllergy Shots Yes NoAnemia O Yes NoAnorexia Yes Q NoAppendicitis Q Yes Q NoArthritis Yes O NoAsthma D Yes O NoBleeding
Disorders Yes NoBreast Lump O Yes Q NoBronchitis Q Yes NoBulimia D Yes Q NoCancer Yes NoCataracts Yes D NoChemical
Dependency Yes No
EmphysemaEpilepsyFractures
Glaucoma
Goiter
Gonorrhea
Gout
Yes No Yes No Yes Non Yes O No Yes No Yes No Yes No
By signing below, I give my consent for examination and the performance of any tests orprocedures needed. The treatment may include chiropractic adjustments and other proceduresconsidered therapeutically diagnostic and appropriate.
Doctors of Chiropractic who use manual therapy techniques are required to advise patients thatthere may be some risks associated with such treatment. While rare, some patients mayexperience short term aggravation of sjmiptoms or muscle soreness as a result of manual therapytechniques.
I consent to the chiropractic treatments offered or recommended to me by my chiropractor,including spinal adjustment. I intend this consent to apply to all my present and futurechiropractic care. I wish to rely on Advanced Physical JHealth PC and its doctors to make thosedecisions about my care, based on the facts then known, that they believe are in my best interest.If the patient is a minor, by signing I give consent for examination, tests and procedures for theabove minor patient.
ASSIGNMENT & RELEASE
Assignment & release- by signing below, I authorize Advanced Physical Health PC to releasemedical records required by my insurance company(s). I authorize my insurance company(s) topay benefits directly Advanced Physical Health PC and I agree that a reproduced copy of thisauthorization will be as valid as the original. I understand that I am responsible for any amountnot covered by my insurance, or any amount for a patient for which I am the guarantor. I agreethat I will be responsible for any collection agency or attorney fees incurred. I understand that by '*signing below, I am giving written consent for the use and disclosure of protected healthinformation for treatment, payment, and health care operations.
Patient Name Printed
Signed
Signature of Parent (or Guardian) if minor
Date
ADVANCED PHYSICAL HEALTH
1511 Chapel Hill RoadColumbia, MO 65203
Electronic Health Records Intake FormIn compliance with requirements for the government EHR incentive program
First Name: Last Name:
EmaM'address: (®
Preferred method of communication for patient reminders (Circle one): Email / Phone / Mail
Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked
CMS requires providers to report both race and ethnicity
Race (Circle one): American Indian or Alaska Native / Asian / Blackpr African American / White (Caucasian)Native Hawaiian or Pacific Islander / Other /1 Decline to Answer
Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino /1 Decline to Answer
Are you currently taking any medications? (Please include regularly used over the counter medications)
Medication Name Dosage and Frequency (i.e.' Smg once a day, &tG>)
Do you have any medication allergies?
Medication Name Reaction Onset Date ^ ^ Additionaf Comments
I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a
result of the nature and frequency of chiropractic care.)
Patient Signature: Date:
For office use only
Height: Weight:, Blood Pressure:
If your concern involves lower hack pain, please fill out thefollowing questions:Oswestry Low Back Disability Questionnaire
Instructions: Please circle the ONE NUMBER in each section which most closely describes your problem.
Section 1 - Pain Intensity0 I have no pain at the moment.1 The pain is very mild at the moment.2 The pain is moderate at the moment.3 The pain is fairly severe at the moment.4 The pain is very severe at the moment.5 The pain is the worst imaginable.
Section 2 - Personal Care (Washing, Dressing, etc.)0 I can look after myself normally without causing
extra pain.1 I can look after myself normally but it causes extra
pain.2 It is painful to look after myself and I am slow and
careful.
3 I need some help but manage most of my personalcare.
4 I need help every day in most aspects of self-care.5 I need help every day in all aspects of self-care.
Section 3 - Lifting0 I can lift heavy weights without causing extra pain.1 I can lift heavy weights but it gives extra pain.2 Pain prevents me from lifting heavy weights off the
floor.
3 Pain prevents me lifting heavy weights off the floor,but I can manage if they are convenientlypositioned on a table.
4 Pain prevents me lifting heavy weights but I canmanage light to medium weights if they areconveniently positioned.
5 I cannot lift or carry anything at ail.
Section 4 - Walking0 Pain does not prevent me walking any distance.1 Pain prevents me from walking more than 1 mile.2 Pain prevents me from walking more than Vi mile.3 Pain prevents me from walking more than 100
yards.4 I can only walk using a stick or crutches.5 I am in bed most of the time.
Section 5 - Sitting
0 I can sit In any chair as long as I like.1 I can only sit in my favorite chair as long as I like.2 Pain prevents me sitting more than one hour.3 Pain prevents me from sitting more than 30
minutes.
4 Pain prevents me from sitting more than 10minutes.
5 Pain prevents me from sitting all.
Section 6-Standing0 I can stand as long as I want without extra pain.1 I can stand as long as I want but it gives me extra
pain.
2 Pain prevents me from standing more than 1 hour.3 Pain prevents me from standing more than 30
minutes.
4 Pain prevents me from standing more than 10minutes.
5 Pain prevents me from standing at all.
Section 7 - Sleeping
0 My sleep is never disturbed by pain.1 My sleep is occasionally disturbed by pain.2 Because of pain I have less than 6 hours sleep.3 Because of pain I have less than 4 hours.4 Because of pain I have less than 2 hours.5 Pain prevents me from sleeping at all.
Section 8 - Sex Life (if applicable)0 My sex life is normal and causes no extra pain.1 My sex life is normal but causes some extra pain.2 My sex life is nearly normal but it is very painful.3 My sex life is severely restricted because of pain.4 My sex life is nearly absent because of pain.5 Pain prevents any sex life at all.
Section 9 - Social Life
0 My social life is normal and gives me no extra pain.1 My social life is normal but increases the degree of
pain.2 Pain has no significant effect on my social life apart
from limiting my more energetic interests.3 Pain has restricted my social life and I do no go out
as often.
4 Pain has restricted my social life to my home.5 I have no social life because of pain.
Section 10-Traveling0 I can travel anywhere without pain.1 I can travel anywhere but it gives me extra pain.2 Pain is bad but I manage journeys over two hours.3 Pain restricts me to journeys of less than one hour.4 Pain restricts me to short necessary journeys under30 minutes.
5 Pain prevents me from traveling except to receivetreatments.
Patient Signature:
TOTAL:
Date:
If your concern involves neck pain, please fill out. the following questions:Oswestry Neck Disability Questionnaire
Instructions: Please circle the ONE NUMBER in each section which most closely describes your problem.
Section 1 - Pain Intensity0 I have no pain at the moment.1 The pain Is very mild at the moment.2 The pain is moderate at the moment.3 The pain is fairly severe at the moment.4 The pain is very severe at the moment.5 The pain is the worst imaginable.
Section 2 - Personal Care (Washing, Dressing, etc.)0 I can look after myself normally without causing
extra pain.1 I can look after myself normally but it causes extra
pain.2 It is painful to look after myself and I am slow and
careful.
3 I need some help but manage most of my personalcare.
4 I need help every day in most aspects of self-care.5 I need help every day in all aspects of self-care.
Section 3 - Lifting0 I can lift heavy weights without causing extra pain.1 I can lift heavy weights but it gives extra pain.2 Pain prevents me from lifting heavy weights off the
floor.
3 Pain prevents me lifting heavy weights off the floor,but I can manage if they are convenientlypositioned on a table.
4 Pain prevents me lifting heavy weights but I canmanage light to medium weights if they areconveniently positioned.
5 I cannot lift or carry anything at all.
Section 4 - Reading0 I can read as much as I want to with no pain.1 I can read as much as I want to with slight pain.2 I can read as much as I want to with moderate pain.3 I cannot read as much as I want to because of
moderate pain in my neck.4 I can hardly read at all because of severe pain.5 I cannot read at ail.
Section 5 - Headaches
0 I have no headaches at all.
1 I have slight headaches that come infrequently.2 I have moderate headaches which come
infrequently.3 I have moderate headaches which come frequently.4 I have severe headaches which come frequently.5 I have a headache almost all the time.
Section 6 - Concentration
0 I can concentrate fully when I want to with nodifficulty.
1 I can concentrate fully when I want to with slightdifficulty.
2 I have a fair degree of difficulty in concentratingwhen I want to.
3 I have a lot of difficulty in concentrating when Iwant to.
4 I have a great deal of difficulty in concentratingwhen I want to.
5 I cannot concentrate at all.
Section 7 - Work
0 I can do as much work as I want to.
1 I can do my usual work, but no more.2 I can do most of my usual work, but no more.3 I cannot do my usual work.
4 I can hardly do any work at all.5 I cannot do any work at all.
Section 8- Driving
0 I can drive my car without neck pain.1 I can drive my car as long as I want with slight pain.2 I can drive my car as long as I want with moderate
pain.3 I cannot drive my car as long as I want because of
moderate pain.4 I can hardly drive at all because of severe pain.5 I cannot drive my car at all.
Section 9 - Sleeping0 I have no trouble sleeping.1 My sleep is slightly disturbed (less than 1 hr
sleepless).2 My sleep is mildly disturbed (1-2 hrs sleepless).3 My sleep is moderately disturbed(2-3 hrs sleepless).4 My sleep is greatly disturbed (3-5 hrs sleepless).5 My sleep is completely disturbed (5-7 hrs sleepless).
Section 10 - Recreation
0 I am able to engage in my recreation activities withno neck pain.
1 I am able to engage in all my recreation activitieswith some pain in my neck.
2 I am able to engage in most, but not all, of my usualactivities because of my neck pain.
3 I am able to engage in a few of my usual recreationactivities because of my neck pain.
4 I can hardly do any recreation activities because ofpain in my neck.
