Chiropractic Case History/Patient Information Form

Date: __________________                                                                                            Patient #___________                                                                                                                               Doctor: ___________________

Name: __________________________     Social Security #_________________Home Phone: _______________

Address: ____________________________________City:__________________ State: ______ Zip: ___________

E-mail address: _____________________________Fax #________________ Cell Phone: ___________________

Age: _______ Birth Date: ___________ Race: ______ Marital:  M S W D                  

Occupation: _________________________ Employer: _______________________________________________

Employer's Address: __________________________________        Office Phone: ____________________________ Spouse: __________________ Occupation: ________________ Employer: _______________________________

How many children?____________Names and Ages of Children:________________________________________

___________________________________________________________________________________________

Name of Nearest Relative: _______________________  Address:______________________Phone:___________

How were you referred to our office? ______________________________________________________________

Family Medical Doctor: _________________________________________________________________________

When doctors work together it benefits you.  May we have your permission to update your medical doctor regarding your care at this office? ___________

HISTORY OF PRESENT ILLNESS:

Chief Complaint:  Purpose of this appointment: ______________________________________________________

Date symptoms appeared or accident happened: ____________________________________________________

Is this due to:  Auto___   Work____ Other_________________________________________________________?

Have you ever had the same or a similar condition?     Yes  No   If yes, when and describe:______________

___________________________________________________________________________________________

Days lost from work: _________________ Date of last physical examination: ______________________________

PAST MEDICAL HISTORY

Have you ever been diagnosed as having or have suffered from? (Place a check mark by conditions that apply to you)

__Broken or Fractured Bones __Osteoarthritis            __Eating Disorder

__Circulatory Problems          __Epilepsy                   __Alcoholism

__Rheumatoid Arthritis           __Pace Maker              __Drug Addiction

__Seizures/Convulsions          __Strokes                    __HIV Positive

__A Congenital Disease         __Cancer                     __Gall Bladder

__Excessive bleeding              __Ruptures                  __Depression

__High/Low Blood Pressure     __Coughing Blood       __Ulcers

Do you have a history of stroke or hypertension? ___________________________________________________

Have you had any major illnesses, injuries, falls, auto accidents or surgeries?  Women, please include information about childbirth (include dates): _________________________________________________________________

___________________________________________________________________________________________

Have you been treated for any health condition by a physician in the last year?          Yes  No

If yes, describe: ______________________________________________________________________________

What medications or drugs are you taking? _________________________________________________________

___________________________________________________________________________________________

Do you have any allergies to any medications? Yes No

If yes, describe: ______________________________________________________________________________

Do you have any allergies of any kind? Yes No

If yes, describe: ______________________________________________________________________________

Please list any other health problems you have, no matter how insignificant they may be: ___________________________________________________________________________________________

___________________________________________________________________________________________

SOCIAL HISTORY:

Do you drink alcoholic beverages? ___ If so, how much per week? _____________________________________

Do you use any tobacco products? ______Do you smoke? ____ If so, packs per day: ______________________

Do you take vitamin supplements? ________ If so, please list: _________________________________________

Do you consume caffeine? ____ If so, how much per day: _____________________________________________

Do you exercise? __________   If yes, what is the frequency and type of exercise? _________________________

What are your hobbies? _______________________________________________________________________

What percentage of time during the day (at home or at your job away from home) do you spend? 

lifting_____ sitting_____ bending______working at a computer_______

FAMILY HISTORY:

Parents:

Father: living___ deceased____ Current age if still living: ______ Cause of death and age at death if deceased: _______________________________________________________________________________(check one)

Mother: living___ deceased____ Current age if still living: ______ Cause of death and age at death if deceased: _______________________________________________________________________________ (check one)

Check if applicable to you: _________     As an adopted child, little is known of birth parents or family.

Do you have any family members who suffer from the same condition you do?  If so, please list: ___________________________________________________________________________________________

FAMILY DISEASES (check if applicable and indicate whether family member is Father, Mother, Sister, Brother):

Tuberculosis____                                             Cancer____                             Mental Illness____      

Diabetes ____                                                             Asthma____                            Heart Disease ____

Stroke ____                                                     Kidney Disease____                Lung Disease____

Arthritis_____                                                   Liver Disease ____

Other ________________________________________

Please check any and all insurance coverage that may be applicable in this case:

Major Medical      Worker's Compensation      Medicaid      Medicare      Auto Accident

Medical Savings Account & Flex Plans      Other

Name of Primary Insurance Company: ___________________________________________________________

Name of Secondary Insurance Company (if any):___________________________________________________

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.  If there is anyone you do not want to receive your medical records, please inform our office.

Patient's Signature: _____________________________________________________       Date: _______________

Guardian's Signature Authorizing Care: _____________________________________         Date: _______________

SUMMARY

1.         What is your major symptom? _____________________________________________________

2.         What does this prevent you from doing or enjoying? ____________________________________

3.         If this is a recurrence, when was the first time you noticed this problem? ____________________

            How did it originally occur? ________________________________________________________

            Has it become worse recently?  Yes ___ No ___ Same ___ Better ___ Gradually Worse _______

            If yes, when and how? ___________________________________________________________

4.         How frequent is the condition?   Constant _____ Daily ____ Intermittent ____ Night Only _______

            How long does it last?  All Day _________ Few Hours ___________ Minutes ________________

5.         Are there any other conditions or symptoms that may be related to your major symptom?

            Yes _____   No _____.  If yes, describe: _____________________________________________

            Are there other unrelated health problems?   Yes _____ No _____. If yes, describe ____________

            ______________________________________________________________________________

6.         Describe the pain:  Sharp _____   Dull_____    Numbness _____   Tingling _____   Aching ______

            Burning _____ Stabbing _____ Other ________________________________________________

7.         Is there anything you can do to relieve the problem?  Yes ___ No ___.   If yes, describe _________

            __________________________.  If no, what have you tried to do that has not helped? _________

            ______________________________________________________________________________

8.         What makes the problem worse?   Standing ____ Sitting ______ Lying ______ Bending ________

            Lifting _____ Twisting _____ Other __________________________________________________

9.         List any major accidents you have had other than those that might be mentioned above: ________  

            ______________________________________________________________________________

10.       Have you received any treatment for this condition? Yes___ No___ If yes, where and when, and what

            were your results? _________________________________________________________________

11.       Any Medical Diagnosis of your complaint?_______________________________________________

12.       Any Chiropractor consulted in past? Name_______________________ when?__________________

13.       WOMEN ONLY:  Are you pregnant or is there any possibility you may be pregnant?

            Yes _____     No _____   Uncertain _____

14.       Remarks: ______________________________________________________________________

                 ______________________________________________________________________________

            ______________________________________________________________________________

                           NO                                                                                             EXTREME

                   SYMPTOMS                                                                                   SYMPTOMS   

                 _|______________________________|__________________________________|_

Please place an “X” on the line above to indicate level of problem.

Patient's Signature: __________________________________________    Date: ____________

Patient Health Information Consent Form

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records.  Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

• The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment.  Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 
• The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections.  The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI.  Our office is obligated to agree to those restrictions only to the extent they coincide with state and federal law.
• A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.
• The patient may provide a written request to revoke consent at any time during care.  This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
• Our office may contact you periodically regarding appointments, treatments, products, services, or charitable work performed by our office.  You may choose to opt-out of any marketing or fundraising communications at any time.
• For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office.  We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.
• Patients have the right to file a formal complaint with our privacy official and the Secretary of HHS about any possible violations of these policies and procedures without retaliation by this office.
• Our office reserves the right to make changes to this notice and to make the new notice provisions effective for all protected health information that it maintains.  You will be provided with a new notice at your next visit following any change.
• This notice is effective on the date stated below.
• If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.

____________________________                __________________

Name of Patient                                                        Date

For further information regarding this notice, please contact our Doctor at (770)-562-8590