mazu - New Patient Intake

New Patient Form
Demographics
Today's Date :

MonthDayYear
Date
Name:

First NameLast Name
Address :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone :
Please enter a valid phone number.
Date of Birth :

MonthDayYear
Date
Age:
Sex:

MaleFemale
Cell Phone:
Please enter a valid phone number.
Email Address:
example@example.com
Cell Carrier for text reminders:
Social Security #:
Circle ALL that apply:

MarriedSingleWidowedDivorcedEmployedRetiredHomemakerStudent
Employment Information
Employer:
Job Title:
City, State:
Name of Spouse:

First NameLast Name
Spouse’s Occupation:
Employer:
Health Insurance
Name/Policy Number
Emergency Contact Information
Name:

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.
Relationship:
Is this visit related to worker’s compensation?

YesNo
Is this visit related to any legal actions?

YesNo
Is this visit related to any sort of motor vehicle accident?

YesNo
Patient Condition Please
Describe the Major Problem That Brings You in Today to See a Chiropractic Neurologist:
When did this condition begin?
Have you ever experienced a similar problem in the past?

YesNo
When:
How long has it beensince your last medical/chiropractic evaluation?
If you follow aspecific diet, please describe:
Please select if you have the pain or difficulty performing the following:

BendingExtended computer useLifting childrenSexual activitiesCarrying GroceriesFeedingPet careSleepingChange position(sit-stand)Household choresReading(concentration)Static SittingClimbing stairsKneelingSelf-care (bathing)WalkingDrivingLiftingSelf-care (dressing)Yard work
By using the key below, indicate on the body diagram where you are experiencing pain:
On average rating from 0-10, how much pain are you experiencing? 0 = no pain and 10= the worst pain imaginable?

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Worst Pain
How are your symptoms changing?

Getting betterNot changingGetting worse
Other:
Family History

Do you have a family member affected with:

Condition

	Yes	Relative
Alcoholism
Diabetes
Depression
Heart Disease
Hypertension
Migraines
Neuromuscular junction disease
Multiple Sclerosis
Neuropathy
Neurological Disorder
Osteoporosis
Parkinson’s disease
Seizures or Epilepsy
Stroke
Thyroid Disease

Any Other Condition
Please list all medications and supplements you take routinely, prescribed or over the counter, along with the dosages:
Review of Symptoms

Do you currently, or have you had a problem with (please check all that apply):
ALLERGIC

Autoimmune disease(i.e., lupus)FoodInhalant (nasal) allergiesSkin Rash
ENDOCRINE:

Breast lumps/ dischargeBleeding/BruisingCancerChange in hair or skinCold extremitiesDiabetesExcessive thirst/urinationHypoglycemiaIrregular MensesPMSSexual DysfunctionSymptoms of menopauseThyroid disease
MUSCULOSKELETAL:

Arm or leg Pain/Weakness/Numbness ArthritisBack painBroken bonesJoint pain or swellingNeck PainPadgett's diseaseRestless LegsTMJ pain
CONSTITUTIONAL:

FatigueFeverHistory of fallsWeight loss >5 lbs
EYES:

CataractsGlaucomaVision problemsWear glasses/contacts
NEUROLOGICAL:

Daytime sleepinessDifficulty with balanceDifficulty with memoryDifficulty with speechDisorientationDizzinessDouble or Blurred visionFainting spells / black outsHeadaches / migrainesInability to concentrateLoss of consciousnessLoss of sensationSeizuresStrokeTeeth grinding/clenching
CARDIOVASCULAR:

Chest pain or anginaCirculation problemsHeart MurmurHigh blood pressureHigh cholesterolIrregular pulseLow blood pressurePacemakerSwelling in hands or feetPalpitations
GASTROINTESTINAL:

Abdominal painBlood in vomitChange in bowel habitsConstipationDiarrheaHeartburnJaundice / liver disease Nausea / vomitingUlcers or gastritis
PSYCHIATRIC:

Anxiety / DepressionPanic Attacks Insomnia
EAR, NOSE, THROAT& MOUTH:

Balance (vertigo, spinning, etc.) Dental problemsEar Pain/InfectionsHearing lossHoarsenessInability to smellNasal congestion/DrainageNose bleedsRinging in earsSinus problemsWear hearing aid(s)
GENITOURINARY:

Bladder control / incontinenceBlood in your urineDifficult starting/stopping streamKidney stonesPainful urinationUrinary tract infections
RESPIRATORY:

AsthmaBreathing difficultyChronic CoughEmphysema / lung diseaseSleep ApneaSnoringWheezing
HEMATOLOGIC/LYMPHATIC:

AnemiaBlood transfusionBruisingFainting spells / blacking outHemophilia
Other:
ALLERGIES/SENSITIVITIES
Please (E.g., medications, foods, latex, iodine, etc.)
Are you taking any blood thinning medications including aspirin?
Surgical History
Please list all operations you have had:
Social History
Hobbies:
Tobacco?

YesNo
How many a day?
At what age did you start?
At what age did you stop?
Do you drink alcohol?

YesNo
If yes, how much daily?
Do you use recreational drugs?

YesNo
Type?
Do you exercise regularly?

YesNo
How frequently?
Female Medical History:
Are you pregnant?

YesNo
If yes, how many weeks?
Age at first menstrual period?
Age at last?
Have you ever used oral contraceptives?
Have you ever used hormone replacement therapy?

YesNo
Most patients that come to our office have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program.
Please check the type of care desired so that we may be guided by your wishes whenever possible.

Relief Care is the care necessary to get rid of your symptoms or pain, but not the cause of it. It is the same as drying a floor that was getting wet from a leak, not fixing the leak, or cause of the symptom.Corrective Care differs from relief care in that its goal is to get rid of the symptoms or pain while correcting the cause of the problem. Corrective care varies in length of time but is longer lasting.Check here if you want the Doctor to select the type of care appropriate for your condition.

FINANCIAL POLICY
We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility.

Financial Agreement

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. If you have Health Insurance; we will bill them as a courtesy and assist you in receiving the maximum reimbursement benefits possible. Furthermore, I understand that Dr. Masulas’ Office will prepare any necessary reports and forms to assist me in making collection from my insurance company and that any amount authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt.

However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable. The patient also agrees that he/she is responsible for all bills incurred at this office.

Please Initial at Each Line Below:
PERSONAL INJURY / WORKERS COMPENSATION
Initial Assignment of Benefits (Personal Injury case or Worker’s Comp case)
I hereby authorize payment directly to the physician of all benefits otherwise payable to me, but not to exceed the total charges for the services rendered.

My signature below indicates that I have read, understand, and agree to all of the above listed information.
Responsible Party/Guardian Signature

Clear
Date:

MonthDayYear
Date
AUTHORIATION TO RELEASE INFORMATION

I authorize the physician and/or his or her representatives to release any and all information contained in my complete medical and billing record to:
- My insurance company or its representatives.
- Other persons or entities financially responsible for my care or treatment.
- The Medicare program and its fiscal intermediaries, if applicable or otherwise required/permitted/regulated by law.
- Federal and state agencies, as required or permitted by laws and regulations.
Responsible Party/Guardian Signature

Clear
Date:

MonthDayYear
Date
Informed Consent

We encourage and support a shared decision-making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent. Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. In addition, there are reported cases of stroke associated with visits to Medical Doctors, Osteopaths, Chiropractors, Physical Therapists, and Occupational Therapists.
Would you like a copy of our Informed Consent Form?

Yes (Patient needs to sign Consent form)No – I decline a copy of the (ICF) form
Signature

Clear
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Masula Chiropractic Neurology and Family Wellness Center is required by law to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Would you like a copy of our Notice of Privacy Act Form?

Yes (Patient needs to sign NPP form)No – I decline a copy of the (ICF) form
I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAS BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE MASULA FAMILY CHIROPRACTIC TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.
Patient Signature

Clear
Date

MonthDayYear
Date
Parental Consent for Minor Patient:

In addition, by signing below, I give permission for the above-named minor patient to be managed by the doctor even when I am not present to observe such care.
Patient Name:
Patient Age:
DOB:

MonthDayYear
Date
Printed name of person legally authorized to sign for.
Name:
Relationship to Patient:
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

New Patient Form

Demographics

Employment Information

Health Insurance

Emergency Contact Information

Patient Condition Please

Family History

Review of Symptoms

ALLERGIES/SENSITIVITIES

Surgical History

Social History

Female Medical History:

FINANCIAL POLICY