CHIROPRACTIC REGISTRATION AND HISTORY

Transcription

1 CHIROPRACTIC REGISTRATION AND HISTORY 229 N Andover Rd Suite 200Andover, KS (316) PATIENT INFORMATION Date / / SS # - - Patient Name Last Name First Name Middle Initial Address City State Zip Sex M F Age Birth Date / / Married Widowed Single Divorced Minor Patient Occupation Employer/School Employer/School Phone ( ) Employer/School Address City State Zip Responible party Name Relationship to patient Phone ( ) Address City State Zip Occupation Employer/School Whom may we thank for referring you? PHONE NUMBERS Cell Ph.( ) Home Ph.( ) Cell Phone carrier: ATT VERIZON SPRINT OTHER IN CASE OF EMERGENCY, CONTACT Name Relationship Home Ph.( ) Work Ph.( ) Physician s name Physician s phone ( ) INSURANCE INFORMATION Policy Holders Name Relationship to Patient DOB / / Subscriber s SS # - - Male / Female Primary Insurance Co. Policy # Group # Is patient covered by additional insurance? yes no Policy Holders Name Relationship to Patient DOB / / Subscriber s SS # - - Male / Female Second Insurance Co. Policy # Group # ASSIGNMENT AND RELEASE I Certify that I, and /or my dependent's), have insurance coverage with above Insurance Company(ies) and assign directly to Dr. Kevin D. Allen all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. I understand that I am Financially responsible for all charges whether or not paid by insurance. I agree to pay for services not covered by insurance and understand that I am responsible for payment in full. The above named doctor may use my health care information and may disclose such information to the above named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will apply to all services until it is revoked in writing. X Date / / Signature of Patient, Parent, Guardian or Personal Representative Please print name of Patient, Parent, Guardian or Personal Representative ACCIDENT INFORMATION Is Condition due to an accident? Date Type of accident Auto Work Home Other To whom have you made a report of your accident? Auto Insurance Employer Works Comp Other Attorney Name (if applicable) PATIENT CONDITION Reason for visit When did your symptoms appear? Is this condition getting progressively worse? Unknown Mark an X on the picture where you continue to have pain, numbness, or tingling. Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain: Sharp Dull Throbbing Numbness Aching Shooting Burning Cramps Tingling Stiffness Swelling Other How often do you have this pain? Is it consistant 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 Other

2 Patient Name HEALTH HISTORY Date 229 N Andover Rd Suite 200 Andover, KS (316) What treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic Services None Other Name and address of other doctor (s) who have treated you for this condition Date of last: Physical Exam Spinal X-Ray Spinal Exam Chest X-Ray MRI, CT Scan, Bone Scan Place a mark on Yes or No to indicate if you have had any of the following : AIDS/HIV Anemia Appendicitis Arthritis Asthma Bleeding Disorders Breast Lump Bronchitis Cancer Chemical Dependency Diabetes Emphysema Epilepsy Fractures Goiter Gout Heart Disease Hepatitis Hernia Herniated Disk High Cholesterol Kidney Disease Migraine Headaches Miscarriage Mononucleosis Multiple Sclerosis Osteoporosis Pacemaker Parkinson s Disease Yes No Pinched Nerve Yes No Pneumonia Polio Prostate Problem Prosthesis Yes No Psychiatric Care Rheumatoid Arthritis Rheumatic fever Stroke Thyroid Problem Tonsillitis Tuberculosis Tumors, Growths Yes No Yes No Ulcers Other EXERCISE None Moderate Daily Heavy WORK ACTIVITY Sitting Standing Light Labor Heavy Labor HABITS Smoking Alcohol Packs/Day Drinks/Week Coffee/Caffeine Drinks Cups/Day High Stress Level Reason Are you pregnant? Due Date Injuries/Surgeries you have had Description Date Falls Head Injuries Broken Bones Surgeries Auto Accidents CURRENT MEDICATIONS Pharmacy Name Pharmacy Phone ALLERGIES VITAMINS/HERBS/ MINERALS I request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy, rehabilitation, and diagnostic x-rays on myself or the patient named below for whom I am legally responsible, by the doctor of. I understand and am informed that, like any health care related procedure, there are some risk to treatment. Risks include, but are not limited to fractures, disc injuries, strokes, dislocations, and sprains. I understand that chiropractic is not an exact science and that every patient responds to care differently, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatments that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. SIGNATURE:

3 229 N. Andover Road, Suite 200, Andover, KS (316) Fax (316) FINANCIAL POLICY NOTICE In an effort to maintain compliance with various state and federal regulations, managed care and preferred provider agreements, as well as billing and coding guidelines, we have adopted the following financial policies. 1. Our clinic has established a single fee schedule that applies to all patients for each service provided. 2. You may be entitled to a network or contractual discount under the following circumstances: a. We are a participating provider in your health plan. b. You are covered by a State or Federal program with a mandated fee schedule. c. You are a member of ChiroHealthUSA, or any other Discount Medical Plan Organization we may join. Patients who are uninsured, or underinsured (limited benefits for chiropractic care), may join ChiroHealthUSA in our office and will be entitled to network discounts similar to our insured patients. Membership is $49.00 a year and covers you and your dependents. Ask our staff for more information. d. Patients who meet state and or federal poverty guidelines or other special circumstances outlined in our "Hardship Policy" may be offered a discount for a period of time as determined by the clinic. Verification will be required 3. As part of our compliance plan, as of June 1, 2015, our office will be unable to extend any type of discounts other than those listed above. ACKNOWLEDGED BY: DATE:

4 Patient Acknowledgement and Receipt of Notice of Privacy Practices Pursuant to HIPAA and Consent for Use of Health Information Name Print Patient s Name Date The undersigned does hereby acknowledge that he or she has received a copy of this office s Notice of Privacy Practices Pursuant To HIPAA and has been advised that a full copy of this office s HIPAA Compliance Manual is available upon request. The undersign does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State law and Federal Law. Dated this day of, 20 By Patient s Signature If patient is a minor or under a guardianship order as defined by State law: By Signature of Parent/Guardian (circle one) Allen Family Chiropractic 229 N. Andover Road, Suite 200, Andover, KS (316) Fax (316)

5 PERMISSION TO GIVE MEDICAL INFORMATION I, hereby authorize the physicians and staff of Kevin D. Allen Family Chiropractic, LLC, to give the following people information concerning my health and well being. Spouse Significant Other Any specified person Name: Name: Name: Following forms of communication are ok: home telephone/answering machine, please provide number work telephone/answering machine, please provide number cellular phone, please provide number The following information may be given to the above individuals: Appointment Time Test/Lab Results Medications Procedures Any other information regarding my health I understand I may revoke this consent at any time by giving written notice to the person or organization making this disclosure. This authorization expires upon written notification from the patient to alter the document. Signed: (patient/parent/legal guardian) Date: 229 N. Andover Road, Suite 200, Andover, KS (316) or (316)

6 Explanation of X-ray Risk Regarding Womens Health I, the undersigned patient, understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus. This form hereby advises me that the 10 days following the onset of a menstrual period are generally considered to be safe for x-ray exams. With those factors in mind, I am advising my doctor of the following: YES NO UNSURE I am pregnant I could be pregnant I am late with my menstruation I am taking oral contraceptives I use an IUD I have had a tubal-ligation I have had a hysterectomy I have irregular menstruations I have reached post menopause Other My last menstrual period began on (date) may perform an x-ray examination on me. By signing below, I am giving my consent to said exam. Patient Signature Witness Signature Date Date

7 WHY ICE.. People are reluctant to use ice when experiencing pain of neuromuscloskeletal origin. It s just human nature to be hesitant about utilizing cold therapy. The truth of the matter is however, that icing one area of your body does not cause your entire body to become cold. Placing ice over a painful area is important for a few reasons. First of all, ice slows down the circulation to the painful area, which reduces inflammation the cause of pain. Secondly, ice numbs the area so the pain sensation is greatly reduced. Thirdly, by decreasing inflammation, the ice allows the painful area to heal faster than if nothing were used. While there seems to be much controversy over the use of heat and ice, we make it simple for you. Heat is Bad.. Ice is Good. Heat therapy has an opposite effect by increasing circulation and swelling. Yes, it feels good while being applied, but heat actually make the problem worse and prolongs the healing process up to 6 months. Heat therapy includes such things as hot baths, heating pads, hot water bottles and whirlpools. All these should be avoided as they have negative effects to healing. The effects from ice are the most beneficial within the first 10 minutes. After that, ice starts taking on the characteristics of heat. This is because the body eventually responds to the iced area as if it were freezing. Eventually, the body increases the circulation to that area in the interest of saving the frozen area. Unfortunately, we don t want those final effects of ice, so that is whey we tell you to limit your ice time to 15 minutes for the low back and 10 minutes to the upper back and neck. Next time you feel pain of a neuromuscloskeletal origin, grab an ice pack. Cryotherapy Protocols (Cold Packs) AREA LENGTH OF APPLICATION CERVICAL SPINE (neck) 10 MIN ON 50 MIN OFF THORACIC SPINE (mid-back) 15MIN ON 45 MIN OFF LUMBAR SPINCE (low-back) 15 MIN ON 45 MIN OFF ELBOW 15 MIN ON 45 MIN OFF WRIST / HAND 10 MIN ON 50 MIN OFF PELVIS / THIGH 15 MIN ON 45 MIN OFF KNEE 15 MIN ON 45 MIN OFF SHIN / ANKLE / FOOT 10 MIN ON 50 MIN OFF FREQUENCY OF APPLICATION A. MINIMUM: 2 4 CYCLES PER DAY B. MAXIMUM: CONTINUOUS CYCLES Dr. Kevin Allen, D.C. 229 N. Andover Road, Suite 200 * Andover, KS *