Skinner Chiropractic/Southside Chiropractic/Skinner Wellness 3198 Custer Dr. Ste 100 Lexington, KY 40517

Size: px

Start display at page:

Download "Skinner Chiropractic/Southside Chiropractic/Skinner Wellness 3198 Custer Dr. Ste 100 Lexington, KY 40517"

Tabitha Mason
5 years ago
Views:

1 Skinner Chiropractic/Southside Chiropractic/Skinner Wellness 3198 Custer Dr. Ste 100 Lexington, KY Patient Name : SS #/SIN DO Male Female Home phone Cell Phone Check appropriate ox: Minor Single Married Divorced Widowed Separated Patient s Address City State Zip Employer Name: Spouse or Patient s Guardian name Spouse s Employer Whom may we thank for referring you? Person to contact in case of an emergency Phone Responsible Party Name of The Person responsible for this account Relationship to Patient Address Home Phone Cell Phone Driver s License # of irth: Is the person currently a patient at our office? Yes No Do you have any Medical insurance? Yes No if yes, complete the following: Name of the insured Relationship to patient irthdate SS#/SIN_ Name of Employer Work Phone Address of Employer State Zip Insurance Company Group # Union or local # Ins. Co. Address City State Zip ASSIGNMENT OF HEALTH PLAN ENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND ENEFICIARY I certify that all information is true and correct. I hereby authorize the release of any information required by this office. I also authorize my benefit payments to be made directly to this clinic. If my current policy prohibits direct payment to the doctor, then I hereby also instruct and direct my insurance company to make out the check to me and mail it to this office. I understand that I am financially responsible for all the services rendered. I agree that if my treatment here is suspended or terminated, bills become immediately due and payable. All x-rays are property of Skinner Chiropractic/Southside Chiropractic/Skinner Wellness. I authorize Skinner Chiropractic/Southside Chiropractic/Skinner Wellness to file a written formal complaint to the insurance commissioner, or Department of Labor, on my behalf. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original. X Patient signature

2 Patient Name: DO: : X : Patient name printed X signature of Guardian if applicable

3 Patient Name: DO: : Chief Complaint: History of Present illness: Location: (Where is the pain/problem?) Quality: (Example: normal vs abnormal color, activity, etc..) Severity: (How severe is the pain/problem on a scale of 1-10 with 10 being the most severe?) Duration: (How long have you had this pain/ problem? When did it start?) Timing: (Does the pain/problem occur at a specific time?) Context: (Where were you at the onset of this pain/problem?) Associated Signs/Symptoms: (What other associated problems have you been having?) Aggravating factors: (What makes the pain/problem worse? Have you had previous episodes?) Relieving factors: (What makes the pain/problem better?) Complete this section if due to an accident Type of accident: o Auto o Workers Comp o Fall o Other: of accident: Past Medical History Please check the box if you have had any of the following: Measles/Mumps A C sthma hicken pox W ronchitis hooping Cough A S nemia carlet Fever R lood/plasma heumatic fever Transfusion P neumonia leeding Tendency T U uberculosis lcer I H f yes, last xray? epatitis R ecurrent ladder Infection rief description of accident: K idney Disease A rthritis ack trouble M igraine headaches H igh blood pressure L ow blood pressure M itral valve prolapse P eripheral Vascular disease S troke D iabetes T hyroid Disease G laucoma C ancer Other: Previous Hospitalizations/Surgeries/Serious Illnesses Please include location and date

4 Patient Name: DO: : Health Screenings: Last pap: Last colonoscopy: Last pneumonia shot: Last mammogram: Last PSA/DRE: Last tetanus shot: Last bone density: Last Flu shot:

5 Patient Name: DO: : Allergies: Medications: (include nonprescription) Social History: Occupation: Marital Status: M S W Alcohol Use: Never: Rarely: Moderate: Daily: Type: D Tobacco Use: Never: day x yrs Use of Drugs Never: Type/Frequency: Current: packs per Former: packs per day x yrs Excessive Exposure at home or at work to: Dust: Solvents: Airborne Particles: Noise: Family Medical History: Age Disease If deceased, cause of death Mother Father rother Sister Children Other Fumes: Review of Systems (Check here if no symptoms to report) Please check the box if you have had any of the following in the past 1-2 months Asthma Stuffy nose Hay fever Sore throat Chronic cough Chest congestion Frequent sneezing Itchy/watery Eyes Sinus drainage Earache/ear infection Shortness of breath Wheezing Chest pain Fatigue Malaise Weakness/tiredness Lightheadedness Irritability Constipation Diarrhea urning with urination lood in urine lood in stool Feeling foggy Forgetfulness Headaches Migraines Dizziness Numbness Tinging Pins/needles in hands/feet Muscle aches Joint pain Low back pain Neck pain

6 Patient Name: DO: : Wrist/hand pain Hip pain Ankle/foot pain Elbow pain Pain between shoulder Knee pain blades Shoulder pain

The Vanguard Clinic. Check appropriate Box: Minor Single Married Divorced Widowed Separated

The Vanguard Clinic. Check appropriate Box: Minor Single Married Divorced Widowed Separated The Vanguard Clinic 2108 Schuetz Rd. St. Louis, MO 63146 Patient Name: : Email: SS#/SIN: DOB: Phone Number: E-Mail Check appropriate Box: Minor Single Married Divorced Widowed Separated Address: City: