Acknowledgment of Receipt of Notice

Transcription

1 Acknowledgment of Receipt of Notice patient acknowledgment I acknowledge receipt of a copy of Maximum Mobility s Notice of Privacy Practices with an effective of January 1, printed name of patient signature of patient OR RESPONSIBLE PARTY If you have signed this document as a responsible party, please indicate your relationship to the patient: Parent or legal guardian of minor patient Legal guardian or conservator of an incompetent patient Beneficiary or personal representative of deceased patient Other (please list below) for office use only We checked the patient s photo identification: = Yes = No initials of employee We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because: = Individual refused to sign = Other (please list below) printed name of witness signature of witness v

2 Case History Questionnaire general information full legal name preferred name street address city state zip code home phone mobile phone address fax of birth age sex Male Female occupation employer work address work phone What is your marital status? Married Single Widowed Divorced Separated name of spouse number of children emergency contact phone Who referred you to Maximum Mobility? health history Have you previously received chiropractic care? Yes No If yes, who was your chiropractor? Who is your primary care physician? v

3 Case History Questionnaire. Page 2 When was your last physical examination? Have you been treated for any health condition by a physician in the last year? Yes No If yes, please explain: What medications are you currently taking? What vitamins/herbs are you currently taking? Please list any medications you are allergic to: Please and describe any past serious illnesses and/or hospitalizations: Please mark and explain if you have experienced: Surgery A fracture A car accident A fall An on-the-job injury Please mark if you have a family history of: Heart disease Cancer Diabetes Arthritis Back problems Other (please list below) If female, are you possibly pregnant? Yes No If female, what is the of your last menstrual period?

4 Case History Questionnaire. Page 3 Please mark any condition you have experienced ( previous ) or are now experiencing ( current ): previous 6 current 6 previous 6 current 6 7 SAMPLE Fainting or convulsions Headaches Arm or shoulder pain Arm or shoulder weakness Neck pain or stiffness Lower back pain or stiffness Pins and needles in arms Pins and needles in legs Numbness in fingers or toes Leg or foot pain Osteoporosis Asthma or emphysema Sinus trouble or allergies Bleeding gums Easy bleeding or bruising Blood in urine or stool Burning or frequent urination Kidney disease or stone Glaucoma Blurred vision Loss of taste Loss of smell Loss of hearing Buzzing or ringing in ears Depression or anxiety Nervousness Fatigue or weakness Loss of energy Sleeping problems Seizures Loss of memory Loss of balance Parkinson s disease Heart trouble or stroke Chest pain High blood pressure Dizziness Poor circulation Leg cramps or swelling Rheumatic fever Anemia Digestive or eating problems Constipation or diarrhea Nausea or vomiting Gout Pain or trouble breathing Tuberculosis Pneumonia Cold, flu or cough Sore throat Difficulty swallowing Skin disease Rashes Hives Gallbladder Liver Hepatitis Ulcers Thyroid problems Diabetes Immunosuppression Abnormal menstruation Breast problems Prostate problems Sexual dysfunction In the last 30 days, please mark if you have experienced: Pain that worsens at night Unexplained weight loss A bacterial infection Loss of bowel or bladder control Surgery Fever or chills Constant pain unrelated to motion Please mark any statement that is true: I have a history of cancer I have a history of HIV I have used steroids I have used IV drugs I have had a blood transfusion

5 Case History Questionnaire. Page 4 CURRENT CONDITION What symptom(s) are you experiencing? What did your symptom(s) begin? If you are aware of what caused your symptom(s) to begin, please explain: What activities negatively or positively affect your condition? aggravating activities alleviating activities Please describe your pain: It is constant It is intermittent How is your condition evolving? It is improving It is the same It is worsening Does your condition: Become worse at certain times of the day? Morning Afternoon Night Other: Interfere with your work duties? Yes No Interfere with your ability to sleep? Yes No Interfere with your daily routine? Yes No Please list any doctor(s) you have seen regarding your condition: Please list any home remedies you have tried to help improve your condition: patient agreement Patients without insurance: I will pay the fee in full for services rendered at the end of each visit. Patients with insurance: I will pay all co-payments or unmet deductible balances at the time of services rendered. I authorize direct payment from my insurance company to Maximum Mobility. I understand that I am personally responsible for any remaining balance Maximum Mobility does not collect from insurance proceeds. In the event of my default, I promise to pay legally allowed interest on my indebtedness, together with collection costs and reasonable attorney s fees. I authorize the release of any information Maximum Mobility deems appropriate to any insurance company. I give permission to Maximum Mobility to perform necessary tests and treatments. signature of patient or responsible party

6 Pain Location + Rating where is your pain currently located? Using the appropriate symbols below, please mark the area(s) where you feel a sensation. Place an 7 in the one area where your pain is the worst. AchE ^ ^ ^ Numb = = = Pin/Needle o o o Burn z z z Sharp/Stab / / / Stiff/Tight * * * how bad is your pain? Please circle one number on the scale that most accurately reflects your opinion as it pertains to each statement: What is your level of pain right now? no pain extreme pain What is your level of pain on average? no pain extreme pain What is your level of pain at its very worst? no pain extreme pain What is the overall status of your pain? It is improving It is the same It is worsening printed name of patient v

7 Lifestyle Screening How do you rate your health? Excellent Very good Good Fair Poor personal habits Please mark one answer that most accurately describes your habit as it pertains to each question: How much do you smoke per day? For cigars/pipes/chew, please estimate the amount of tobacco used. I do not smoke 1/4 pack or less 1/2 pack or less 3/4 pack or less 1 pack or more How often do you exercise? Exercise is defined as at least 30 minutes of continual activity. 3 to days per week 2 days per week 1 day per week 1 day per month I do not exercise How many servings of fruits and vegetables do you eat? 3 or more per day 2 per day 1 per day 1 to 4 per week I do not eat fruits and vegetables How often do you wear a seatbelt? Always Almost always Occasionally Almost never Never How much alcohol do you consume per week? One drink is equivalent to 12 ounces of beer, 4 ounces of wine, 1 wine cooler, 1 cocktail or 1 shot of hard liquor. I do not drink alcohol 1 drink 2 to 7 drinks 8 to 14 drinks 1 to 21 drinks 22 or more drinks v

8 Lifestyle Screening. Page 2 questionnaire Please circle one number on the scale that most accurately reflects your opinion as it pertains to each statement: I should not perform my normal work duties because of my pain. strongly disagree strongly agree Physical activities make my pain worse. strongly disagree strongly agree When my pain increases, I should stop what I m doing until my pain decreases. strongly disagree strongly agree On an average day, how much are you able to decrease your pain based on the methods you use to cope with it? eliminate completely no decrease at all How happy are you with your home life? extremely happy extremely unhappy How happy are you with your job? extremely happy extremely unhappy In the past month, have you felt depressed or hopeless? Yes No In the past month, have you felt a lack of interest or pleasure in doing things? Yes No In the past two weeks, how often have you felt nervous or anxious? Not at all Several days More than 7 days Nearly every day In the past two weeks, how often have you felt worried? Not at all Several days More than 7 days Nearly every day signature of patient or responsible party

9 Family Health History first name only age state of health age at death cause of death Father Mother Spouse Siblings Children Others please note the relation next to or below name printed name of patient v

10 Financial Policy We are dedicated to providing the best possible care for you, and we want you to understand our financial policy. Most health and accident insurance companies cover chiropractic care. Keep in mind that your insurance policy is a contract between you and your insurance company. If you have insurance, we will call your insurance company to determine your coverage for chiropractic care. However, information provided by phone (or written in an insurance policy book) does not guarantee the payment of benefits. Insurance companies cannot establish whether benefits will be paid until an actual claim is submitted. We cannot take responsibility for knowing which services your insurance company will or will not cover. Not all insurance plans cover all services. Ultimately, you are responsible for payment of all health care services we provide to you at our clinic. As a courtesy to you, we will gladly submit invoices to your insurance company for services we provide to you. We have made in-network arrangements with some insurance companies. For patients who have policies with these companies, we will bill the insurance company and collect the required co-payment or unmet deductible balance at the time of your visit. If you are insured by a company with which we do not have a prior arrangement, we will submit the claim for you. However, payment for your care is due at the time of services. patient agreement I will pay all co-payments or unmet deductible balances at the time of services. I understand that I am personally responsible for any remaining balance Maximum Mobility does not collect from my insurance company. In the event my insurance company does not compensate Maximum Mobility within thirty (30) days after billing, I will pay the remaining balance. I have read and understand this financial policy and agree to be bound by its terms. printed name of patient signature of patient or responsible party v