Lineberry Chiropractic, PA
Dr. Keith Lineberry, D.C.
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INSURANCE INFORMATION:
Check all types of insurance that may be applicable in this case for which you are providing a valid insurance card:
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ACCIDENT: Is your visit today accident related? Yes / No If NO, skip to next page
Is your visit today accident related?
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The accident occurred:
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Lineberry Chiropractic, PA
Mark the areas on the diagram showing the location of your pain, numbness, tingling, aching:
List, if anything, what you have tried that does provide relief, even if temporary (heat, ice, rest, stretching, exercises, change of position, compression, medications, supplements, etc.):
List, if anything, what aggravates or makes it worse:
Check all areas of pain that you experience:
Head(ache)
Neck
Mid-back
Low-back
Shoulder
Other (explain)
What hurts the worst?
How often are your symptoms present? Intermittent / 25% / 26-50% / 51-75% / 76-99% / Constant
Intermittent
25%
26-50%
51-75%
76-99%
Constant
On the scale below, indicate how often your pain has interfered with your daily activities in the past week: Not at all Constantly
0
1
2
3
4
5
6
7
8
9
10
Have you been treated by another medical professional for these symptoms? Yes / No
Yes
No
If 'yes', name of professional + date of treatment:
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Lineberry Chiropractic, PA
Dr. Keith Lineberry, D.C.
Check all that apply to YOU:
More about your health history:
Corticosteroid use (Cortisone, prednisone, etc.)
Other health issues & surgeries
Dizziness
Fainting
Epilepsy
Seizures
Visual issues (blurred vision, floaters, etc.)
Diabetes
High blood pressure
Pacemaker
Abnormal weight loss
Abnormal weight gain
Arthritis
Osteoporosis
Numbness
Fever within the past week
Have had an event(s) of the following nature:
cardiovascular
kidney/bladder
respiratory
Cancer / Tumor - Type + location
Stroke - Date occurred
Other health issues or surgeries
Have had previous falls, injuries, trauma - dates + what body part involved
Currently pregnant or may be pregnant - # of weeks
Current medications + vitamins/supplements:
FAMILY HISTORY: Check if family problems with:
Rows
Stroke
Heart problems
Rheumatoid arthritis
Autoimmune
Stroke
Cancer
Diabetes
Blood Pressure
Back Trouble
AUTHORIZATION + RELEASE: We want you to know how your Patient health Information will be used in this office and your rights concerning those records. If you would like to have a 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.
I authorize payment of insurance benefits directly to the chiropractor/practice. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers/payors, and to secure the payment of benefits. I understand that I am responsible for all costs of 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. I understand and agree to allow this office to use my Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care.
The following person(s) have my permission to receive my Patient Health Information:
Patient's signature
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Guardian's signature authorizing care
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