Do you have insurance? No Yes* Social Security #: Number Driver's License #: Number Employer: Occupation: Spouse's Name First Name Last Name Spouse's Employer Number of children and ages: 1. 2. 3. 4. 5. 6. 7. Name of Emergency Contact: First Name* Last Name*Contact Number: Area Code* Phone Number*Relationship:
Please Identify the condition(s) that brought you to this office: Primary: Secondary: Third: Fourth: On a scale of 0 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling selecting the number
When did the problem(s) begin? When is the problem at its worst? AM PM Mid-Day Late How long does it last? It is constant I experience it on end off during the day It comes and goes throughout the week How did the injury happen? Condition(s) ever been treated by anyone in the past? No Yes If yes, when? by whom? How long were you under care? What were the results? Name of previous chiropractor: First Name Last Name N/A
PLEASE MARK the areas on the body diagram with the following letters to describe your symptoms
R= Radiating B=Burning D=Dull A=Aching N=Numbness S=Sharp/Stabbing T=Tingling
What relieves your symptoms? What makes your symptoms feel worse? Is your problem the result of ANY type of accident? No Yes Identify any other injury(s) to your spine, minor or major, that the doctor should know about:
Have you suffered with any of this or a similar problem in the past? No Yes If yes, how many times? When was the last episode? How did the injury happen? Other forms of treatment tried: No Yes If yes, please state what type of treatment: , and who provided it? How long ago? What were the results. Favorable Unfavorable Please explain: Please Identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:
1.Does anyone in your family suffer with the same condition(s) No Yes If yes, whom? Grandmother Grandfather MotherFather Sister(s) Brother(s) Son(s) Daugther(s)Have they ever been treated for their condition? No Yes I don't know 2.Any other hereditary conditions the doctor should be aware of? No Yes
1.Smoking: No Yes Cigarettes How Often? Daily Weekends 2.Alcoholic Beverage: Consumption Occurs Daily Weekends OccasionallyNever 3.Recreational Drug Use: Daily Weekends OccasionallyNever4.Hobbies - Recreational Activities Exercise Regime How does your present problem affect? (See ADL form)
I hereby authorize payment to be made directly to Covington Family Chiropractic LLC, for all benefilts which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application, or copies thereof, for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Covington Family Chiropractic LLC for any and all services I receive at this office.
ACTIVITIES OF LIFE
Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:
Otherblanks No Effect Painful (can do) Painful (limits) Unable to perform
Please read carefully: Instructions: Please circle the number that best describes the question being asked. Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst.
Covington Family Chiropractic LLC
I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often very minimal, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke-which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.
Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Covington Family Chiropractic LLC have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.
FEMALES ONLY: Please read carefully, check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our front desk staff for further explanationThe first day of my last menstrual cycle was on Date I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic X-ray examination the doctor has deemed necessary in my case.
Patient Initials: blanks*-retaining page 1 of 2
(Covington Family Chiropractic LLC) NOTICE REGRADING YOUR RIGHT TO PRIVACY continued..
I have received a copy of Covington Family Chiropractic LLC Patient Privacy Notice. I understand my rights as well as the practice's duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this "Notice of Privacy Practice" at a time in the future and will make the new provisions effective for all information that it maintains past and present.
I am aware that a more comprehensive version of this "Notice" is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.
Covington Family Chiropractic LLC NOTICE OF PRIVACY PRACTICE
This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled 'HIPAA' on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.
1. Treatment purposes - discussion with other health care providers involved in your care.
2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
4. For workers compensation purposes - to process a claim or aid in investigation.
5. Emergency - In the event of a medical emergency we may notify a family member.
6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner and government benefits purposes.
9. Deceased persons - discussion with coroners and medical examiners in the event of a patient's death.
10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.
11. Change of ownership in the event this practice is sold, the new owners would have access to your PHI.
1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive "Detail Privacy Notice.
3. To request mailings to an address different than residence.
4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.
If you wish to make a formal complaint about how we handle your health information, please call Dr. Jamie Adams at (770) 786-2818 If she is unavailable, you may make an appointment with our receptionist to see her within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:
The Release of information will remain in effect until terminated by me in writing.
Please call (my home) Area Code Phone Number . (my work) Area Code Phone Number .(my mobile) Area Code* Phone Number*.
The best time to reach me is (day) Date between TimeAMPM toTimeAMPM .