STEVENS FAMILY CHIROPRACTIC METROPOLIS AVE, SUITE 101 FT MYERS, FL (239) Patient Intake Form. Sex: Male Female.

Transcription

1 Patient Intake Form : Name: Sex: Male Female Address: City: State: Zip: Home Phone: Cell Phone: Preferred Phone: Address: Social Security #: Of Birth: Occupation: Marital Status: Single Married Divorced Widow Name of Spouse/Significant Other: Ethnicity: Not Hispanic or Latino Hispanic or Latino Race: Black or African American White Asian American Indian or Alaska Native Native Hawaiian or Pacific Islander Preferred Language: How did you hear about us? Northern Address: City: State: Zip: Insurance Carrier: Member ID #: Group #: Adjuster Name: Adjusters Phone #: Ext: Who is financially responsible for the bills with our office? In case of emergency, Please notify Name: Phone#: Relationship: Please List any present or past diseases: Do you suffer from any condition other than which you are consulting us? Yes or No (if yes, what condition?) Do you exercise on a regular basis? Yes No How? Do you use: Caffeine? Tobacco? Nicotine? Recreational Drugs? Alchohol Patients Signature

2 Patient Name: : Present Complaints Please mark the areas where you have Pain/Tenderness Please circle all that apply ~ Headache ~ Neck ~ Mid Back ~ Low Back ~ Hips ~ Legs ~ Arms ~ Other How long have you had these conditions? Are these conditions progressively getting worse? Yes No Constant Have you received treatment for these conditions? Yes No (If Yes, with whom?) What makes your condition worse? What makes your condition better? Check the following conditions that apply to you, past or present. Please add your comments to clarify the condition. Musculoskeletal Digestive Other Headaches Nervous Stomach Loss of Appetite Joint Stiffness/Swelling Indigestion Depression Spasms/Cramps Constipation Hearing Impaired Broken/Fracture Bones Intestinal Gas/Bloating Vision Impaired Strains/Sprains Diarrhea Bladder Infection Back/Hip Pain Diverticulitis Diabetes Shoulder, Neck, or Arm Pain Irritable Bowel Syndrome Fibromyalgia Leg, foot pain Crohn s Disease Cancer Chest, Ribs, Abdominal Pain Vomiting Blood Infectious Disease (Please List) Problems Walking Nervous System Jaw Pain/TMJ Numbness/Tingling Eye, Ear, Nose, Throat Tendonitis Fatigue Pain in Eyes Bursitis Chronic Pain Ear Noises Arthritis Sleep Disorders Nose Bleeds Osteoporosis Ulcers Sore Throat Scoliosis Cerebral Palsy Frequent Cough Bone or Joint disease Epilepsy List any Additional comments Other: Multiple Sclerosis Regarding Your Health: Circulatory & Respiratory Parkinson s disease Dizziness Fainting Spinal Cord Injury Shortness of Breath Other: Females Only: By My Signature on This Cold Feet or hands Reproductive System Form, I do Hereby State That I am not Poor Circulation Pregnancy Current Pregnant, nor is Pregnancy Suspected Varicose Veins PMS Hot Flashes at this Time. Blood Clots Menopause Stroke Heart Condition Endometriosis Patients Signature Allergies Hysterectomy High/Low Blood Pressure Prostate Problems Patients Name (Please Print) STEVENS FAMILY CHIROPRACTIC

3 Patients Name: : Please list ALL medications including vitamins/supplements you are currently taking: Medication/Vitamin Name Mg How many times a day started Please list ANY/ALL allergies to medications/foods: Medication/Food Reaction Onset Please list any surgeries/procedures you have had in your lifetime: Surgery/Procedure it was done

4 ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years. Patient Name (PLEASE PRINT) Parent, Guardian or Patient s Legal Representative Patient Signature THIS FORM WILL BE PLACED IN THE PATIENT S CHART AND MAINTAINED FOR SIX YEARS. List below the names and relationship of people to whom you authorize the Practice to release PHI. Name Relationship Name Relationship Name Relationship

5 APPOINTMENTS To ensure that our patients receive the highest quality of care, we limit the number of patients we see each day. Each individual is given the time and attention needed to discuss his/her progress, answer questions, and provided with treatment and instructions. After your initial visit, which usually takes one hour, return visits are scheduled with the doctor for fifteen minutes. We have found this mode of treatment maximizes the benefit of each visit and usually results in less frequent office visits. We realize that your time is valuable and we do our best to stay on schedule. Therefore, we ask that you notify our office at least 24 hours in advance if you are not able to keep an appointment. Your co-operation will help us utilize an appointment for someone else needing care. FINANCIAL POLICY We cannot bill your insurance company unless you give us your insurance information. In the event that your insurance carries a deductible, payment will be required at the time of service until your deductible is met. Your insurance policy is a contract between you and your insurance company. Please be aware that some, and perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare program and/or other medical insurance. In the event that your insurance coverage changes, along with benefits, please be aware that your financial obligations may change with our office. Please understand that you are ultimately responsible for payment of any services rendered within our office. If payment is not received on past due account balances, accounts will be turned over for collection, which will include the full service fee charges, collection service charges, and daily interest. Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read the information above regarding appointments and financial policy and I fully understand and agree. Patient Name (PLEASE PRINT) Patients Signature

6 ASSIGNMENT OF BENEFITS I,, authorize the release of any medical or other information necessary to process my claims. I also request payment of government benefits to the party who accepts assignment of benefits listed below. I authorize payment of medical benefits to the physician or supplier listed below for the services submitted to my insurance company on behalf of all present and future HFCA 1500 forms. Signature of Patient Physician receiving benefits: Linda D. Stevens D. C Metropolis Ave Suite 101 Fort Myers, FL License #: CH7948 Tax ID #: INSURANCE VERIFICATION DISCLAIMER My Chiropractic Insurance benefits have been verified and explained to me. I understand what is covered and not covered under my benefits. Any services not covered by my insurance company will be my responsibility. Signature of Patient Explained By