coykendallchiropractic - Low Back Pain Form

Low Back Pain Form
Name*

First NameMiddle NameLast Name
Preferred Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:*

MonthDayYear
Date
Age:*
Gender:*

MaleFemaleUnspecified
Home Phone #:*
Please enter a valid phone number.
Cell Phone #:*
Please enter a valid phone number.
Cell Phone Carrier:*
Email*
example@example.com
Status:*

SingleMarriedDivorcedWidowedSeparated
Children?:*

YesNo
How many:*
Spouse’s Name:
What is your occupation:*
Employer:*
Emergency Contact:
Name*
Relationship*
Phone #*
Please enter a valid phone number.
Primary Physician Name:*
How were you referred to Coykendall Chiropractic Office?*

WebsiteFacebookSignPatient NamePhysicianOther
Name of previous chiropractor (if applicable):
Type of Insurance:*

Private Ins.MedicareOther
Name of Insurance carrier
SOCIAL HISTORY
Height*

Ft.In.
Weight:*
Lbs
Do you exercise?*

YesNo
Times per week?
Intensity?

LightModerateStrenuousType?
Do you currently smoke tobacco of any kind?*

YesFormer smokerNever been a smoker
If “Yes”, how often do you smoke:*

EverydaySometimes
If “Yes”, what is your level of interest in quitting smoking? (0=NO interest, 10=very interested) - Circle Level Below*

012345678910
Do you drink alcohol?*

YesNo
How many drinks per week?*
For how many years?
Do you take pain killers?*

YesNo
How often?*

DailyWeeklyMonthlyRarely
What type?*

AspirinIbuprofenTylenolOther
What do your work duties include?*

SittingStandingLight LaborHeavy LaborOther
Please describe your overall health right now*

ExcellentVery GoodGoodFairPoor
What is your current stress level?*

MildModerateHigh
What are your hobbies? *
Signature of Patient, Parent or Legal Guardian (if minor) *

Clear
Date*

MonthDayYear
Date
HEALTH HISTORY
Please Mark ALL of the health conditions below that apply to you currently or in the past
Osteoarthritis/DegenerativeJoint DiseaseAsthmaAnemiaCancer/TumorRheumatoid ArthritisDepression/AnxietyDisc HerniationHigh Blood Pressure/HypertensionHeart Disease/StrokeHeadachesMigrainesOsteoporosis/OsteopeniaEpilepsy/SeizuresFibromyalgia/Chronic FatigueGenetic DisordersDiabetesN/A
Type IType II
Was your blood/lab work test for hemoglobin A1c > 7.0%?*

YesNoNot Sure
Whiplash Injury*

YesNo
Date of Injury:*

MonthDayYear
Date
Joint Pain:*

YesNo
Tick location of pain*

ShoulderElbowHipKneeAnkleOther
Please list any other medical conditions:
Family History: Mark ALL conditions that run in your family
Cancer*

YesNo
Type
Relationship
Anemia*

YesNo
Relationship
Diabetes*

YesNo
Type IType II
Relationship
Heart Problems/Stroke*

YesNo
Relationship
High Blood Pressure*

YesNo
Relationship
Genetic Disorders*

YesNo
Relationship
Rheumatoid Arthritis*

YesNo
Relationship
Other (List):
WOMEN ONLY:
Currently Pregnant?

YesNo
Painful/Abnormal Menstrual Cycle?

YesNo
Menopause?

YesNo
Do you have children?

YesNo
If “Yes”,type of birth?

VaginalC-Section
FRACTURES (Broken Bones, Sprains, Strains, Major Trauma/Injury (List and Date:)*
SURGERIES and/or HOSPITALIZATIONS (List and Date): *
Have you had an X-ray or CT scan or MRI of your low back spine in the past 2 years?*

YesNo
Current taking any medications ?*

YesNo

Any allergies you have had to prescription medications.*

YesNo
List any know allergies you have had to prescription medications.
Signature of Patient, Parent or Legal Guardian (if minor) *

Clear
Date*

MonthDayYear
Date
REASON FOR VISIT
What is the reason for your visit today?*

HeadacheNeck PainMid-Back PainLow Back PainOther
What caused this complaint(s):*
When did this complaint begin?*

MonthDayYear
Date
Is it getting worse?*

YesNoConstantComes and goes
Have you had this or similar complaint in the past?*

YesNo
If “Yes”, when?*
What does your complaint (s) feel like? Check all that apply:*

SharpDullSoreStiffTightAchingSpasmsThrobbingStabbingShootingBurningCrampingNaggingTinglingNumbnessOther
Please Circle or make an “X” on the body diagram to the left where you have pain or other symptoms.*
On the scale below, please circle the severity of your main complaint right now:(0=No pain, 5=Moderate Pain,10=Worst Possible Pain)*

012345678910
What relieves this complaint? Check all that apply:*

SittingStandingWalkingRestingExerciseMovementStretchingMassageChiropracticHeatIceLaying downMedicationNothingUnknownOther
What aggravates this complaint? Check all that apply:*

SittingStandingWalkingGetting up form seatWalking stairsInactivitySleepingPhysical ActivityExerciseMovementBending backwardTwistingReachingLiftingDesk workSneezingCoughingEverythingUnknownOther
How often do you experience your symptoms?*

25% of the day50% of the day75% of the day100% of the day
Timing of complaint: Check appropriate box:*

MorningAs day progressesAfternoonEveningWhile sleepingDuring activitiesAfter activitiesSymptoms are constant and do not changeOther
With time are your symptoms:*

ImprovingWorseningNot changing
Previous Treatment for this Condition*

YesNo
If “Yes”, please provide the following information:*
Providers’s name:
Date consulted: *

MonthDayYear
Date
Is this condition interfering with your: ( Check all that apply)*

SleepGetting in or out of bed or chairPersonal careTravelWorkRecreationLiftingWalkingStandingDaily RoutineSocial ActivitiesExerciseOther
Signature of Patient, Parent or Legal Guardian (if minor) *

Clear
Date*

MonthDayYear
Date
INFORMED CONSENT

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document.
Please ask questions before you sign if there is anything that is unclear.

The nature of the chiropractic adjustment:

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I will use a mechanical instrument upon your body in such a way as to move your joints. You may feel a sense of movement.

Analysis / Examination / Treatment

As part of the analysis, examination, and treatment, your are consenting to the following procedures:

Spinal manipulative therapy
palpation
vital signs
range of motion testing
basic neurological testing
ultrasound

Orthopedic testing
muscle strength testing
postural analysis
EMS
hot/cold therapy
radiographic studies

Other (please explain)
The material risks inherent in chiropractic adjustment.

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatments. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.

Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The availability and nature of other treatment options.

Other treatment options for your condition may include:
1-Self-administered, over-the-counter analgesics and rest 2-Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and painkillers 3-Hospitalization 4-Surgery

If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

The risks and dangers attendant to remaining untreated.

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

I have read the above explanation of the chiropractic adjustment and related treatment. I have discussed it with the Doctor Coykendall at Coykendall Chiropractic Office and have had my questions answered to my satisfaction. I certify that the information I have provided is correct to the best of my knowledge. I will not hold my doctor or any staff member at Coykendall Chiropractic Office responsible for any errors or omissions that I may have made in the compleIon of this form. By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.
Dated:*

MonthDayYear
Date
Dated:

MonthDayYear
Date
Patient’s Name *
(Please print)
Witness’s Name
(Please print)
Signature of Patient, Parent, or Legal Guardian (if a minor)*

Clear
Witness’s Signature

Clear
(Please print)
HIPPA DISCLOSURE AUTHORIZATION FORM
Coykendall Chiropractic Office
Patient consent for use and/or disclosure of protected health information to carry out treatment, payment, and healthcare operations.
hereby states that by signing this consent, I acknowledge and agree as follows:

1. The practice’s privacy notice has been provided to me prior to my signing this consent. The privacy notice includes a complete description of the uses and/or disclosures of my protected health information (PHI) necessary for the practice to provide treatment to me, and also necessary for the practice to obtain payment for that treatment and to carry out its health care operations. The practice explained to me that the privacy notice will be available to me in the future at my request. The practice has further explained my right to obtain a copy of the privacy notice prior to signing this consent, and has encouraged me to read the privacy notice carefully prior to my signing this consent.

2. The practice reserves the right to change its privacy practices that are described in its privacy notice, in accordance with applicable law.

3.I understand that, and consent to, the following appointment reminders that will be used by the practice: telephoning my home and leaving a message on my answering machine or with the individual answering the phone.

4. The practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the practice to treat me and obtain payment for that treatment, and as necessary for the practice to conduct its specific health care operations.

5.I understand that I have a right to request the practice restrict how my PHI is used and/or disclosed to carry out treatment, payment, and/or healthcare operations. However the practice is not required to agree to any restrictions that I have requested. However, if the practice agrees to a requested restriction, then the restriction is binding on the practice.

6.I understand that this consent is valid for seven (7) years. I further understand that I have the right to revoke this consent, in writing, at any time for all future transactions, with the understanding that any such revocation will not apply to the extent that the practice has already taken action in reliance on this consent.
Signature of Patient, Parent or Legal Guardian (if minor)*

Clear
Date*

MonthDayYear
Date
CANCELLATION POLICY/NO SHOW POLICY
1. Cancellation/No Show Policy

We understand that there are times when you must miss an appointment due to
emergencies or obligations for work of family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.

If an appointment is not cancelled at least 24 hours in advance you will be charged a twenty five dollar ($25) fee; this will not be covered by your insurance company.

2. Scheduled Appointments
We understand that delays can happen, however we must try to keep the other patients and doctor on time. If a patient is 15 minutes past their scheduled time, we may have to reschedule the appointment.
Signature of Patient, Parent or Legal Guardian (if minor)*

Clear
Date*

MonthDayYear
Date
THE REVISED OSWESTRY Back PAIN QUESTIONNAIRE
Please read: This questionnaire is designed to enable us to understand how much your back pain has affected your ability to manage your everyday activities. Please answer each section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE, JUST CIRCLE THE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW
SECTION 1-Pain Intensity*

The pain comes and goes and is very mild.The pain is mild and does not vary much.The pain comes and goes and is moderate.The pain is moderate and does not vary much.The pain comes and goes and is severe.The pain is severe and does not vary much.
SECTION 2-Personal Care*

I do not have to change my way of washing or dressing in order to avoid pain.I do not normally change my way of washing or dressing even though it causes some pain.Washing and dressing increases the pain but I manage not to change my way of doing it.Washing and dressing increases the pain and I find it necessary to change my way of doing it.Because of the pain I am unable to do some washing and dressing without help.Because of the pain I am unable to do any washing and dressing without help.
SECTION 3-Lifting*

I can lift heavy weights without extra pain.I can lift heavy weights but it causes extra pain.Pain prevents me from liking heavy weights off the floor, but I can manage if they are conveniently positioned, e.g., on a table.Pain prevents me from liking heavy weights, but I can manage light to medium weights if they are conveniently positioned.I can lift very light weights.I can only lift very light weights at the most..
SECTION 4-Walking*

I have no pain on walking.I have some pain on walking but it does not increase with distance.I cannot walk more than one mile without increasing pain.I cannot walk more than 1/2 mile without increasing pain.I cannot walk more than 1/4 mile without increasing pain.I cannot walk at all without increasing pain.
SECTION 5-Sitting*

I can sit in any chair as long as I like.I can sit only in my favorite chair as long as I like.Pain prevents me from sitting more than one hour.Pain prevents me from sitting more than 1/2 hour.Pain prevents me from sitting more than 10 minutes.I avoid sitting because it increases pain straight away.
SECTION 6-Standing*

I can stand as long as I want without pain.I have some pain on standing but it does not increase with time.I cannot stand for longer than one hour without increasing pain.I cannot stand for longer than 1/2 hour without increasing pain.I cannot stand for longer than 10 minutes without increasing pain.I avoid standing because it increases the pain immediately.
SECTION 7-Sleeping*

I get no pain in bed.I get pain in bed but it does not prevent me from sleeping well.Because of pain my normal night’s sleep is reduced by less than 1/4.Because of pain my normal night’s sleep is reduced by less than 1/2.Because of pain my normal night’s sleep is reduced by less than 3/4.Pain prevents me from sleeping at all.
SECTION 8-Social Life*

My social life is normal and gives me no pain.My social life is normal but increases the degree of my pain.Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.Pain has restricted my social life, and I do not go out very often.Pain has restricted my social life to my home.I have hardly any social life because of the pain.
SECTION 9-Travel*

I get no pain while traveling.I get some pain while traveling, but none of my usual forms of travel make it any worse.I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.I get extra pain while traveling, which compels me to seek alternative forms of travel.Pain restricts all forms of travel.Pain prevents all forms of travel except that done lying down.
SECTION 10-Changing degree of pain*

My pain is rapidly getting better.My pain fluctuates but overall is definitely getting better.My pain seems to be getting better but improvement is slow at present.My pain is neither getting better nor worse.My pain is gradually worsening.My pain is rapidly worsening.
Oswestry Score
Do not edit
Signature of Patient, Parent or Legal Guardian (if minor)*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Name of prescription medication	Dosage/Start Date
1.
2.
3.
4.
5.

Low Back Pain Form

Emergency Contact:

SOCIAL HISTORY

HEALTH HISTORY

Please Mark ALL of the health conditions below that apply to you currently or in the past

Family History: Mark ALL conditions that run in your family

WOMEN ONLY:

REASON FOR VISIT

INFORMED CONSENT

HIPPA DISCLOSURE AUTHORIZATION FORM

Coykendall Chiropractic Office

CANCELLATION POLICY/NO SHOW POLICY

THE REVISED OSWESTRY Back PAIN QUESTIONNAIRE