AMMONS CHIROPRACTIC CLINIC

Chiropractic Case History/Patient Information

Date

Name

Social Security #

Address

Street Address Line 2

CityState

Zip

E mail address

example@example.com

Home Phone

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

Age

Birth Date

Date

Race

Occupation

Employer

Employer's Address

Office Phone

Format: (000) 000-0000.

How were you referred to our office?

Family Medical Doctor Name

Office Name

Spouse

Occupation

Employer

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. The following person(s) have my permission to receive my personal health information:

Name

Phone

Format: (000) 000-0000.

Name

Phone

Format: (000) 000-0000.

Patient's Signature

Date

Guardian's Signature Authorizing Care

Date

PATIENT NAME

DATE

Date

Complaint Questionnaire: (1 complaint per sheet, if you need another sheet request it at the front desk)

In order to better understand your complaint, please fill out all paperwork completely.

Area of complaint/location

What does this prevent you from doing or enjoying

Onset Date

Date

Cause

Has the pain become worse recently

PREVIOUS TREATMENT: (If you need more room write on the back of the page)

Treatment Provider

When

Treatment

Diagnosis

Treatment Provider

When

Treatment

Diagnosis

Other

Pain Level Range 1-10

Are you losing sleep because of the pain?

Yes, if so how many hours?

Does the pain radiate anywhere?

When is the pain worse:

What makes the pain feel worse

When is the pain better:

What makes the pain feel better

Numbness NO YES, Where?

Weakness NO YES,where?

PATIENT NAME

DATE

Date

Do you have a history of stroke or high blood pressure?

Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Woman, please include information about childbirth (include dates)

Have you had any artificial joints, implanted surgical hardware, or implanted electronic devices installed?

What medications or drugs are you taking?

Do you have any allergies to any medications? If yes, describe

Do you have any Congenital Condition?

Women: Are you pregnant?

Have you had or do you now have any of the following: (N=NOW P=PREVIOUSLY

Rows	N :now P : previously
Headaches
Neck pain
Stiff neck
Sleeping problems
Back pain
Chest pains/ Tightness
Dizziness
Shoulder/neck/arm pain
Numbness in fingers
Numbness in toes
High blood pressure
Lights bother eyes
Ears ring
Rheumatoid Arthritis
Excessive bleeding
Osteoarthritis
Pacemaker
Stroke
Loss of balance
Fainting
Unusual bowel patterns
Cold feet
Cold hands
Arthritis
Muscle spasms
Sinus problems
Indigestion problems
Joint pain/swelling
Buzzing in ears
Circulation problems
Seizures/Epilepsy
Low blood pressure
Osteoporosis
Heart disease
Cancer
Weakness in extremities

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