PATIENT NAME Last Name: _____________________________________ First Name:_________________________ MI: __________ Gender: M F Date of Birth _______/_______/_______ Age: __________ SS#:________________________ Home Address: ________________________________________________________ Apt #: ____________________ City: ______________________________________ State/Zip: ____________________________________________ E-mail Address: _________________________________ Who referred you to our office? _______________________ Home Phone#: _________________________________ Work Phone #: _____________________________________ Employer Name: ________________________________ Occupation: ______________________________________ Employer Address: ____________________________________ City: ___________________ State/Zip: ___________ SPOUSE OR GUARDIAN Last Name: _____________________________________ First Name:_________________________ MI: ___________ Employer Name: ________________________________ Work Phone #: ____________________________________ Date of Birth _______/_______/_______ SS#:__________________________________________________________ EMERGENCY (Name and address of nearest relative or friend not living with you) Last Name: _____________________________________ First Name:_______________________________________ Home Phone #: __________________________________ Work Phone #: ____________________________________ Relationship to Patient: _____________________________________________________________________________ What are your presenting complaints? _________________________________________________________________ _________________________________________________________________________________________________ MY CERTIFICATION I certify that the above information is correct and I request services. x_____________________________________________________________________ Date: ______________________ Signature of patient or person acting on patient’s behalf. MY PRIVACY I have received a copy of the Notice of Privacy Practices. I understand that I have certain rights to privacy regarding the protection of my health information. I understand that this information can be used to: Conduct, plan & direct my treatment and follow-up among the healthcare providers who may be directly and indirectly involved in providing my treatment; Obtain payment from third-party payors; Conduct normal healthcare operations, such as quality assessment and accreditation. x_____________________________________________________________________ Date: ______________________ PATIENT INFORMATION Page 1
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patient information - Ironwood Chiropractic Center Has ... · PDF filePATIENT NAME Last Name: ... Conduct, plan & direct my ... Tonsilitis GASTROINTESTINAL Belching or Gas Colitis
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PATIENT NAME
Last Name: _____________________________________ First Name:_________________________ MI: __________
Gender: M F Date of Birth _______/_______/_______ Age: __________ SS#:________________________
Home Address: ________________________________________________________ Apt #: ____________________
I certify that the above information is correct and I request services.
x_____________________________________________________________________ Date: ______________________Signature of patient or person acting on patient’s behalf.
MY PRIVACYI have received a copy of the Notice of Privacy Practices. I understand that I have certain rights to privacy regarding the protection of my health information. I understand that this information can be used to: Conduct, plan & direct mytreatment and follow-up among the healthcare providers who may be directly and indirectly involved in providing mytreatment; Obtain payment from third-party payors; Conduct normal healthcare operations, such as quality assessmentand accreditation.
AUTO INSURANCE (Please note: In Idaho, we are required to bill your auto insurance if you have a personal injuryprotection on your policy, even if the third person is at fault).
MY FINANCIAL RESPONSIBILITYI certify that the above information is correct. I understand that I am personally financially responsible for allservices. I am also responsible for any annual deductibles applicable, co-payments, or non-covered servicesas may be required by my insurance plan.
x_____________________________________________________________________ Date: ______________________Signature of patient or person acting on patient’s behalf.
MY AUTHORIZATIONI authorize the release of any medical records or other information to process my claims. I also request payment of government or private benefits, either to myself or to the party who accepts assignment. This is a permanent authorization that I may revoke at any time by written notice.
x_____________________________________________________________________ Date: ______________________Signature of patient or person acting on patient’s behalf.
INSURANCE INFORMATION
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Please check the degree of all conditions you currently have or have had. To be responsible for your case, we need your complete health history. O= Occasional F=Frequent C=Current O F C MUSCLE / JOINT Arthritis
Bursitis
Foot Trouble Hernia Low Back Pain
Neck Pain, Stiffness
Pain Between Shoulders
GENERAL Allergies
Chills
Convulsions
Dizziness
Fainting
Headaches
Loss of Sleep
Loss of Weight
Nervousness, Depression Neuralgia Numbness
Sweats
TremorsCARDIOVASCULAR Hardening of Arteries High Blood Pressure Low Blood Pressure
Pain Over Heart
Poor Circulation
Rapid Heartbeat
Slow Heartbeat
Swelling of AnklesGENITOURINARY Bed-wetting Blood in Urine
Lack of Bladder Control
Painful Urination
Prostate Trouble
Please list any other conditions youhave not listed above______________________________________________________________________________
Please list the drugs you now take:________________________________________________________________
SYSTEMS REVIEW
O F C EYE, EAR, NOSE & THROAT Asthma
Colds
Crossed Eyes Deafness Dental Decay
Earache
Ear Noise Enlarged Glands
Enlarged Thyroid
Eye Pain
Failing Vision
Far Sightedness
Gum Trouble
Hay Fever
Hoarseness
Nasal Obstruction
Near Sightedness
Nose Bleeds
Sinus Infection
Sore Throat
Tonsilitis
GASTROINTESTINAL Belching or Gas Colitis Colon Trouble
PLEASE CIRCLE “YES” or “NO” TO THE FOLLOWING QUESTIONSDo you think you need minerals, herbs or vitamins? Yes NoDo you have any drug allergies? If yes, what is it to? Yes No _______________________________Have you had a spinal X-ray? If yes, when? Yes No _______________________________________Have you had a spinal examination? If yes, when? Yes No __________________________________Have you had a physical examination? If yes, when? Yes No ________________________________
PLEASE LIST ANY OTHER HEALTH CONDITIONS THAT YOU HAVE HAD IN THE LAST 5 YEARS__________________________________________________________________________________
INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legallyresponsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who nowor in the future treat me while employed by, working or associated with, or serving as back-up for the doctor ofchiropractic named below, including these working at the clinic or office listed below or any other office or clinic.
I have had the opportunity to discuss with the doctor of chiropractic named below and /or with other office or clinicpersonnel the nature and purpose of chiropractic adjustments and other procedures. I understand that the results are notguaranteed.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment,including, but not limited to, fractures, disc injuries, strokes, dislocations, and sprains. I don not expect the doctor to be ableto anticipate and explain all risks and complications, and wish to rely on the doctor to exercise judgment during the courseof the procedure, which the doctor feels at the time, based upon the facts known, is in my best interest.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, andby signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatmentfor my present conditions and for any future conditions for which I may seek treatment.
To Be Completed by Patient To Be Completed by patient’s representative
_____________________________________________________ _________________________________________________Print Patients Name Print Patients Name
_____________________________________________________ _________________________________________________Signature of Patient Print Name of Patient’s Representative
_____________________________________________________ _________________________________________________Date Signed Signature of Patient’s Representative _________________________________________________Ironwood Chiropractic Center / Dr. Bradley S. Reed Date Signed2201 N. Government Way, Suite D Coeur d’Alene, ID 83814Tel: 208-667-0823 Fax: 208-664-5251 Page 4