Page 1 of 10
PATIENT NAME DATE
Patient Information
Name:
Last First MI
Mailing Address:
Phone: (H) (W) (Other)
Email address:
Preferred method of contact (please circle one): cell phone home phone email work phone
Date of Birth: Sex: Male Female SSN:
Marital Status: Single Married Divorced Widowed Separated Minor
Occupation: Employer:
Employer Address: Phone:
How did you hear about our practice?
Emergency contact: Name: Relation:
Phone: (H) (W) (Other)
Incident Information
Is this visit due to an accident? Yes No If yes, what type? Auto Work Other
Has the incident been reported? Yes No If yes, to whom?
Financial Information
Would you like us to bill health insurance on your behalf? No Yes Name of Carrier:
Do you have secondary insurance? No Yes Name of Carrier:
Name of person responsible for insurance: DOB:
Relationship to patient (if other than self): Phone:
PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)
Assignment and Release
I certify that I (or my dependent) have insurance coverage with and I AUTHORIZE,
REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL
PRACTICE, Siena Physical Medicine, INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I understand that I
am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release
all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order
to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic
submissions.
SIGNATURE (X) DATE
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 2 of 10
PATIENT NAME DATE
By using the key below, indicate on the body diagram where you are experiencing the following symptoms:
N = Numbness X = Burning / = Stabbing 0 = Pins & Needles + = Dull Ache
Does your pain radiate (move)?_______________________________________________________________________
When did your symptoms start? Month_____________________ Day_________________ Year________________
(Specific date or month and year; if recurrence of “old” problem provide date of recent flare up)
Please list anything specific or different you had done in the days before experiencing these symptoms:
________________________________________________________________________________________________________
___________________________________________________________________________________________________
How often do you experience your symptoms?
Constantly Frequently Occasionally Intermittently
(76-100% of the day) (51-75% of the day) (26-50% of the day) (0-25% of the day)
What describes the nature of your symptoms?
Sharp Dull Ache Numb Shooting Burning Tingling Stabbing
How are your symptoms changing?
Getting better Not changing Getting worse
During the past 4 weeks, indicate the average intensity of your symptoms: (0 = None to 10 = Unbearable)
1 2 3 4 5 6 7 8 9 10
Who have you seen for your symptoms?
No one Chiropractor Medical Doctor Physical Therapists Other________________________
What treatment did you receive for your symptoms?
Adjustments Physical Therapy Medication Surgery Other____________________
When did you receive this treatment?
In the last month 2 – 3 months ago 3 – 6 months ago 6 months to 1 year ago
1 – 2 years ago 2 – 5 years ago 5 – 10 years ago
What tests have you had for your symptoms?
X-rays MRI CT Scan Other ____________________
When were these tests done?
In the last month 2 – 3 months ago 3 – 6 months ago 6 months to 1 year ago
1 - 2 years ago 2 – 5 years ago 5 – 10 years ago
Have you had similar symptoms in the past? Yes No
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 3 of 10
PATIENT NAME DATE
Neurological/MRI/Vascular
For any YES answer, please explain under Comment section and notify the Doctor:
1. Do you experience neck pain with pain in your shoulder(s), arm(s) or hand(s)? NO YES
Comment:
2. Do you have weakness, numbness, or burning in your shoulders, arms or hands? NO YES
Comment:
3. Do your hands or arms fall asleep regularly? NO YES
Comment:
4. Do you have reduced feeling (sensation) or swelling in your hands or arms? NO YES
Comment:
5. Do you experience a loss of handgrip strength? NO YES
Comment:
6. Do you experience back pain with pain in your buttocks, legs or feet? NO YES
Comment:
7. Do you have weakness, numbness, or burning in your buttocks, legs or feet? NO YES
Comment:
8. Do your legs or feet fall asleep regularly? NO YES
Comment:
9. Do you have reduced feeling (sensation) or swelling in your legs, feet? NO YES
Comment:
10. Do you experience cold hands or feet? NO YES
Comment:
11. Have you tried any medications such as an anti-inflammatory? NO YES
If yes, what kind of medication? ______________________________________________________
________________________________________________________________________________
12. Have you tried any Physical Therapy or Chiropractic treatments before? NO YES
If yes: When? For how long? What kind? _______________________________________________
________________________________________________________________________________
13. Have you had an MRI? NO YES
If yes: When? Who ordered it? What was it ordered for? ___________________________________
________________________________________________________________________________
14. Have you used any splint or braces or other treatment prescribed by an MD? NO YES
If yes: When? What kind? Who ordered it? ______________________________________________
________________________________________________________________________________
15. If you have tried any treatment or medications, did this make your problem better? NO YES
Comment: _______________________________________________________________________
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 4 of 10
PATIENT NAME DATE
Activities of Daily Living Assessment
Please check the appropriate answer and fill in the blanks as needed.
Standing Sitting
_____able to stand as long as desired without pain _____able to sit as long as desired without pain
_____able to stand ____ (minutes) without pain _____able to sit ____ (minutes) without pain
_____unable to stand at all due to pain _____unable to sit at all due to pain
Lying Driving
_____able to lay as long as desired without pain _____able to drive wherever necessary without pain
_____able to lay ____ (minutes) without pain _____able to drive ____ (minutes) without pain
_____unable to lie at all due to pain _____not able to drive at all due to pain
Exercise Walking
_____able to exercise as long as desired without pain _____able to walk as long as desired without pain
_____able to exercise ____ (minutes) without pain _____able to walk ____ (minutes) without pain
_____not able to exercise at all due to pain _____not able to walk at all due to pain
Pushing Pulling
_____able to push as much as desired without pain _____able to pull as much as desired without pain
_____able to push ____ (lbs) without pain _____able to pull ____ (lbs) without pain
_____not able to push at all due to pain _____not able to pull at all due to pain
Bending Sleeping
_____able to bend as far as desired without pain _____able to sleep as long as desired without pain
_____able to bend ____ (degrees) without pain _____able to sleep ____ (minutes) without pain
_____not able to bend at all due to pain _____not able to sleep at all due to pain
Reaching
_____able to reach as far as desired without pain
_____able to reach ____ (degrees above shoulder level) without pain
_____not able to reach at all due to pain
Other:
Please list any other activities that you are having difficulty with and the level of difficulty below. Examples
include: shopping, throwing, writing, reading, opening jars, personal care, housework, etc.
Social History
How often do you exercise? Frequently Moderately Occasionally Never
Your work activities mostly involve: Sitting Standing Light Labor Heavy Labor
Your main sleeping position: Back Side Stomach
Do you use a cervical pillow? Yes No
What is your daily/weekly intake of the following?
Caffeine ____ cups/day/week Alcohol drinks/week Cigarettes packs/day/week
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 5 of 10
PATIENT NAME DATE
Health History
Please list the name of your primary care physician (Doctor and/or practice)
Please list any specialists currently treating you (please list specialties)
Review of Systems:
Please indicate whether you are experiencing/have experienced the following:
Cardiovascular None ___ Respiratory None ___ Allergic/Im m unologic None ___
Present Past Present Past Present Past
High blood pressure Asthma Immune disorder
Aortic aneurism Tuberculosis AIDS/HIV
Heart disease Shortness of breath Cortisone/Steroid use
Heart attack Emphysema Rheumatoid arthritis
Irregular heart beat Chronic bronchitis Allergy shots
Chest pain
High cholesterol Hem atologic/Lym phatic None ___ Gastrointestinal None ___
Pace maker Present Past Present Past
Sw elling of legs Hepatitis Bow el problems
Blood clots Constipation
Neurological None ___ Cancer Stomach problems
Present Past Anemia Ulcer
Stroke Liver disease
Seizures/Epilepsy Musculoskeletal None ___ Hernia
Head injury Present Past Bloody stools
Brain aneurysm Gout
Numbness Arthritis Endocrine None ___
Severe headaches Joint stiffness Present Past
Pinched nerves Muscle w eakness Thyroid problem
Parkinson's disease Osteoporosis Diabetes
Carpal tunnel Jaw pain Goiter
Multiple Sclerosis Broken bones
Balance/spinning Herniated disc Constitutional None ___
Joint replacement Present Past
Eyes None ___ Weight loss/gain
Present Past Integum entary None ___ Energy level problem
Double vision Present Past Prosthesis
Blurred vision Skin ulcers Difficulty sleeping
Cataracts Skin disease
Glaucoma Eczema Psychiatric None ___
Psoriasis Present Past
Ear/Nose/Throat None ___ Rashes Anxiety disorder
Present Past Depression
Dizziness GenitoUrinary None ___ Nervousness
Hearling loss Present Past Chemical dependency
Difficulty sw allow ing Menstrual problems Eating disorder
Prostate problems
Kidney disease
Please list all surgeries and/or hospitalizations (type of procedure or reason for hospitalization & dates):
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 6 of 10
PATIENT NAME DATE
Please list any medications you are currently taking (include nasal sprays, inhalers, patches, ointments,
and/or drops)
Please list any supplements you are currently taking (vitamins/herbs/minerals):
Please list any allergies to medications, foods, or other substances:
Is there a family history of any of the following conditions? (Indicate family member, including parents,
grandparents & siblings)
Heart Disease Diabetes
Cancer Arthritis Other
Please provide any other information that we may need to know prior to treating you:
I certify that all of the above questions were answered accurately. I understand that providing
incorrect information may be dangerous to my health.
SIGNATURE DATE
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 7 of 10
PATIENT NAME DATE
Consent to Care
A patient gives the doctor permission and authority to care for him/her in accordance with appropriate
tests, diagnoses, and analyses. The clinical procedures performed in our clinic are usually beneficial;
however, unexpected issues may arise. In rare cases, underlying physical defects, deformities or
pathologies, may render the patient susceptible to injury. The doctor, of course, will not provide specific
healthcare if he/she is aware that such care may be contraindicated.
Patients are responsible for knowing about their health conditions and advising their doctors about those
conditions, whether they are from latent pathological defects, illnesses, or deformities.
Patients agree to settle any claim or dispute against or with our clinic or our personnel, whether related to
the prescribed care or otherwise, by binding arbitration under the current malpractice terms which can be
obtained by written request.
I have read and understand the above.
__________________________________
Patient Name
__________________________________ _____________________
Patient’s Signature (legal guardian if patient is a minor) Date
__________________________________ _____________________
Minor’s name Relationship to minor
X-ray Questionnaire (for women only)
Our consultation and examination may indicate that x-rays are necessary to
accurately diagnose and analyze your condition. Should x-rays be recommended
we need to understand your status as of today.
Name: __________________________________
There is a possibility that I may be pregnant at this time
Yes, I am definitely pregnant
No, I am definitely not pregnant at this time
I request that x-ray films not be taken because:
_____________________________
__________________________________________________________________
__________________________________________________________________
______
Date of last menstrual period: __________________
_____________________________ _____________________
Patient’s Signature Siena Physical Medicine • Cornerstone Wellness Center
Date
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 8 of 10
PATIENT NAME DATE
Missed Appointment Policy
We want you, our patient, to receive the very best care and service possible. Your
Care Program consists of a specific series of treatment given over a pre-planned
time span. If you do not follow this plan, then you will not achieve the desired results.
We care about you and the success of your program here. Therefore, please follow
these guidelines:
1. Keep all of your appointments. Arrange the other activities in your life so that this
can occur.
2. If you become ill, please consider coming in anyway, because treatments may
help you recover.
3. If you are unable to keep an appointment due to an emergency, please call us
and let us know so we can reschedule your appointment.
4. With the exception of unexpected emergencies, please notify us of any
appointment changes (rescheduling or cancelations) at least 24 hours in
advance.
5. All canceled or missed appointments must be rescheduled and made up within
one week.
6. A $10.00 service charge may apply for no call/no show appointments and those
canceled or rescheduled without 24 hours advance notice.
7. There is also a $30.00 charge for missing an appointment with the physician or
nurse practitioner.
I have read, understand, and agree to follow the above policy.
Patient’s Name: ____________________________________
Signature: _________________________________________
Staff Witness: ______________________________________
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 9 of 10
PATIENT NAME DATE
Financial Policy
1. We will attempt to verify your insurance coverage.
2. After coverage and deductible are verified, this office may accept assignment on most policies,
provided the insured/patient signs an appropriate statement of benefits and/or a lien authorizing
payment to be sent to the doctor.
3. Waiting for payment from an insurance company is a courtesy which may be withdrawn under
certain circumstances.
4. Patients are responsible for paying any deductibles, co-payments or co-insurance, and any non-
covered services on a monthly basis. We may allow payment arrangements; please schedule an
appointment with the Clinic Manager to discuss any special financial needs.
5. Insurance policies are an arrangement between the insurance carrier and the patient/insured.
6. Insurance companies are not bound by the information they provide to us on your behalf.
7. Our office does not warrant or guarantee that any insurance company will pay, nor does this
office promise that any insurance company will or should pay the fees charged. Any services not
covered, and any coverage reductions by an insurance carrier, are the patient’s responsibility.
8. As a courtesy, this office may submit insurance claims on behalf of our patients. We will not enter
into any dispute with any insurance company. If coverage problems arise, patients are expected
to work directly with the insurance adjuster or agent. Any denied or disputed claims will be
treated as uncovered.
9. If a patient’s account should go to collections for any reason, the patient is responsible for paying
any and all court costs, attorney’s fees, and/or collection costs incurred in collecting the account
balance.
10. All insurance payments, regardless of which company issues payment, are applied to patient
accounts as long as any balance remains on the account. This means refunds are made only
after balances are satisfied and cleared with this office.
11. If a patient receives checks from an insurance company, patient agrees to bring these into our
clinic within seven (7) days so that we may determine if any action is needed or if the check is on
assignment to this office.
12. Patients who incur a change in their contact information, insurance coverage or employers agree
to provide this office with the current information immediately.
13. If this office offers any discount for treatment and the patient decides to drop out of care, then our
standard fees will apply and any discounts will be forfeited.
14. This office accepts payment via MasterCard, Visa, Discover Card, personal checks and cash.
15. Any questions concerning this or any other matter should be raised to someone on our staff prior
to seeing the doctor.
16. Patients who discontinue care and have a financial agreement with our office are responsible for
any/all charges already incurred.
I have read and fully understand the financial policy and agree to abide by these terms.
_____________________________________ ______/______/______
Patient Signature or Responsible Party Date
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636
Page 10 of 10
PATIENT NAME DATE
Patient Acknowledgement of Receipt of Notice
of Privacy Practices
Patient Name: ________________________________
I acknowledge that I have reviewed the Notice of Privacy Practices of Siena Physical
Medicine. Please initial one of the following options and sign below.
__________ I wish to receive a paper copy of Privacy Notice.
__________ I wish to receive an electronic copy of Privacy Notice.
My email address is:
_________________________________________@_______________
__________ I do not request a copy of the Privacy Notice at this time. I
acknowledge that I can request a copy at any time and the Privacy Notice is
available in the office.
Please initial below:
__________ I acknowledge that it is the policy of Siena Physical Medicine to
leave messages regarding my care on my answering machine, voice mail, or with
another person in my home. I may make a request of an alternative means of
communication (within reason) in writing.
__________ I acknowledge that if I should have a problem or question in regard
to my rights, I may speak with the Clinic Manager about my concerns.
___________________________________ ________________________
Signature of Patient/Guardian Date
___________________________________ ________________________
Witness (Office Staff) Date
Siena Physical Medicine • Cornerstone Wellness Center
7227 E Baseline Rd Ste 106 • Mesa AZ 85209 • phone 480.832.5777 • fax 480.907.2636