New Patient Forms

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Whom may we thank for referring you to this office? ______________________________________

APPLICATION FOR CARE AT Advanced Chiropractic Solutions

Today’s Date: __________________                                                                                       HRN: ___________________

PATIENT DEMOGRAPHICS

Name: ___________________________________________               Birth Date: _____-_____-_____   Age: _______      o Male   o Female

Address: _________________________________________    City: _________________________________ State: _____ Zip: ___________

E-mail Address: _____________________________   Home Phone: _______________ Mobile Phone: _______________ Work Phone: ___________________

Marital Status: o Single   o Married            Do you have Insurance: o Yes   o No  

Social Security #: ___________________________________               Driver’s License #: _______________________________________________

Employer: ________________________________________    Occupation: ____________________________________________________

Spouse’s Name _________________________________________Spouse’s Employer ___________________________________________

Number of children and ages: ________________________________________________________________________________________

Name & Number of Emergency Contact: ______________________ ___________________Relationship: ___________________________


HISTORY of COMPLAINT

Please identify the condition(s) that brought you to this office:   Primary: _____________________________________________________

Secondary: __________________________   Third: _____________________________   Fourth: __________________________________

 

On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling the number:

Primary or chief complaint is:           0   –   1   –   2   –   3   –    4   –   5   –   6   –   7   –   8   –   9   –   10

Second complaint is:                       0   –   1   –   2   –   3   –    4   –   5   –   6   –   7   –   8   –   9   –   10

Third complaint is:                           0   –   1   –   2   –   3   –    4   –   5   –   6   –   7   –   8   –   9   –   10

Fourth complaint is:                         0   –   1   –   2   –   3   –    4   –   5   –   6   –   7   –   8   –   9   –   10

When did the problem(s) begin? ____________________ When is the problem at its worst? o AM   o PM   o mid-day   o late PM

How long does it last? o It is constant   OR   o I experience it on and off during the day   OR   o It comes and goes throughout the week

How did the injury happen? __________________________________________________________________________________________

Condition(s) ever been treated by anyone in the past? o No   o Yes         If yes, when: ______ by whom? _______________________________

How long were you under care: ____________     What were the results? _____________________________________________________

Name of Previous Chiropractor: _______________________________     o N/A

PLEASE MARK the areas on the 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? _________________________________

 

LIST RESTRICTED ACTIVITY:                                          CURRENT ACTIVITY LEVEL                            USUAL ACTIVITY LEVEL

___________________________________:                             _________________________________                _________________________________

___________________________________:                             _________________________________                _________________________________

___________________________________:                            _________________________________                _________________________________

___________________________________:                             _________________________________                _________________________________

 

Is your problem the result of ANY type of accident? o Yes,   o No

 

Identify any other injury(s) to your spine, minor or major, that the doctor should know about: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

PAST HISTORY

Have you suffered with any of this or a similar problem in the past? o No o Yes   If yes, how many times? _________ When was the last episode? _____________________ How did the injury happen? _____________________________________________________________

 

Other forms of treatment tried: o No  o Yes   If yes, please state what type of treatment: _________________________________, and who provided it: _________________________ How long ago? _______What were the results. o Favorable o Unfavorableà 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:  ______________________________________________________________________________________________________________

If you have ever been diagnosed with any of the following conditions, please indicate with a P for in the Past, C for Currently have or N for Never have had:

___ Broken Bone    ___Dislocations         ___ Tumors      ___Rheumatoid Arthritis    ___ Fracture     ___Disability   ___Cancer

___ Heart Attack     ___Osteo Arthritis    ___ Diabetes    ___Cerebral Vascular          ___ Other serious conditions: _________

 

PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:

                                               HOW LONG AGO                      TYPE OF CARE  RECEIVED                                   BY WHOM

INJURIES                         à

SURGERIES                     à

CHILDHOOD DISEASES à

ADULT DISEASES           à

 

SOCIAL HISTORY

1. Smoking: ¨cigars ¨ pipe  ¨ cigarettes     How often? ¨ Daily     ¨ Weekends     ¨ Occasionally     ¨ Never

2. Alcoholic Beverage: consumption occurs                         ¨ Daily    ¨ Weekends     ¨ Occasionally     ¨ Never

3. Recreational Drug use:                                                         ¨ Daily    ¨ Weekends     ¨ Occasionally     ¨ Never

4. Hobbies -Recreational Activities- Exercise Regime: How does your present problem affect? (See ADL form)

FAMILY HISTORY:

1. Does anyone in your family suffer with the same condition(s)?   ¨ No   ¨ Yes

    If yes whom: ¨ grandmother   ¨ grandfather   ¨ mother  ¨ father   ¨ sister(s)   ¨ brother(s)   ¨ son(s)   ¨ daughter(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: ___________________________________

 

I hereby authorize payment to be made directly to Advanced Chiropractic Solutions, for all benefits 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 Advanced Chiropractic Solutions for any and all services I receive at this office.

 

_____________________________________                                                             _____ - _____ - _____

Patient or Authorized Person’s Signature                                                            Date Completed

 

_____________________________________                                             _____ - _____ - _____

Doctor’s Signature                                                                                                          Date Form Reviewed

 

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