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Affordable Health Center D.B.A Palm Coast Chiropractic and Rehab

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					                              Affordable Health Center D.B.A
                         Palm Coast Chiropractic and Rehab Center
                                   3 Boulder Rock Drive
                                   Palm Coast, FL 32137

                                       Patient Information

Patient Name: ………………………………………………………………………Date:……………………….

Address: ………………………………………………………………………………………...........................

……………………………………………………………………………………………………………………………...

Social Security#: ………………………………………….Birth Date: ………….............................

Phone (Home): ……………………………(work):…………………………(Cell): ………………..........

Male            Female            Married           Single        Child         Other…………

Student: full time          Part time           N/A             Email: …………………………….



                         Emergency Contact
Name: ……………………………………………………………………………………………………………………
Address: …………………………………………………………………………………………………………….....
City ………………………………………………… State……………………………………. Zip: ……………...
Relationship……………………………………………………………………………………………………………
Work Phone: …………………………………………….. Home Phone: …………………………………
                       Employment Information
Employer Name: ……………………………………… Phone NO: ……………………………………
Address: ………………………………………………………………………………………………………………..
City: ……………………………………………State………………………..………… Zip …….………………..


                                 Referring Physician
Physician / Practice Name: ………………………………………………………………………………....
Address:
………………………………………………………..........................................................................
City: ………………………………………………… State …………………. Zip Code ……………………….
Physician / Practice Phone No.: ………………………………………………. Fax: …………………...
Medical Information Form

THE FOLLOWING INFORMATION IS VERY IMPORTANT
TO USE IN EVALUATING YOUR HELTH PLEASE
COMPLETELY FILLOUT THIS FORM AND LET US KNOW
IF YOU HAVE ANY QUESTIONS

Name: ……………………………………………………………………………….
DOB: …………………………………………………………….
Chief Complaint: (what is the reason for your visit):
…………………………………………………………………………………
………………………………………………………………………………..
………………………………………………………………………………..
………………………………………………………………………………
With regard to the above, have you had any of the
Following tests or x-rays:

CT SCANE     YES        NO
Body part scanned ………………………………………………………

Where ……………………………….. When …………………………….MEDICATION ALLERGIES

                                                    Allergies              What Happened?

MRI SCANES: YES           NO            ---------------------------        ----------------------------
                                        --------------------------         ----------------------------
Body Part Scanned ……………………………………………………. ----------------------------       ----------------------------
                                        ----------------------------       ----------------------------
Where ……………………………….. When …………………………….----------------------------         ----------------------------
                                        ----------------------------       ----------------------------
EMG: YES        NO

Where ……………………………….. When …………………………….
Other: ………………………………… When …………………………….
OTHER: ………………………………………………………………………….. OF WORK
                                       TYPE

                                                    Heavy Medium         Light Sedentary
MEDICATION
What             Dosage            How often        Are you pregnant? : YES                  NO
………………………        ……………………..        …………………………       Do you smoke? : YES                 NO
………………………        ……………………..        …………………………       Drink alcohol? : YES              NO
………………………        ……………………..        …………………………
                                                    How many drinks per week?
………………………        ……………………..        …………………………
                                                    Allergic to x-ray dye? : YES             NO
………………………        ……………………..        …………………………
PLEASE LIST ANY PRIOR HOSPETAL ADMISIONS, SUYRGICAL PRO CEDURES OR PAST PROBLEMS:

Problem / procedure …………………………………………………………………………………………..

Where ………………………………………………………………………………… When …………………….

Problem / procedure …………………………………………………………………………………………….

Where ………………………………………………………………………………… When …………………….

Problem / procedure …………………………………………………………………………………………….

Where ………………………………………………………………………………… When …………………….

Problem / procedure …………………………………………………………………………………………….

Where ………………………………………………………………………………… When …………………….

Problem / procedure …………………………………………………………………………………………….

Where ………………………………………………………………………………… When …………………….

Problem / procedure …………………………………………………………………………………………….

Where ………………………………………………………………………………… When …………………….
                                ADDITIONAL INFORMATION FORM

  Last name: ………………………………………………………. First name ………………………………

  Date of Birth: ……………………………

Is there a family history of back or neck trouble         YES          NO
Have u retained an attorney’s services due to your back   YES          NO
or neck problems?
Do you have a Worker’s Compensation claim pending?        YES          NO
Do you have a personal injury claim pending?              YES          NO
DO you have an automobile claim pending?                  YES          NO


  PREVIOUS TREATMENT:

  Put a check next to each type of treatment you have for your back/neck in the past.
  Then check the column that best describes that effect of the treatment. If you have had
  treatment not on this list, write them in the bottom and indicate below how they
  affected you.

  Treatment             Check if you                       Effect of treatment
                        have had this
                                                HELPED          MADE THINGS      NO CHANGE
                                                                  WORSE

  Hot Packs/Ice
  Ultra sound
  Massage Therapy
  TENCES/Electrical
  Stimulation
  Physical Therapy
  Traction
  Bed rest
  Chiropractic
  services
  Injection (Facet
  Epidural)
  Brace
  Pain Clinic
  Other
How long have you had the current Problem with your back or neck? (Check one of the
following)

     0-4 weeks (very acute               4-12 weeks (acute)           Greater than 12
weeks (sub – chronic)

       Greater than a year (Chronic) if greater than a year, How long? ................

Where do you currently have pain? (Check all that apply)

Back Pain Arm Pain Leg Pain Neck Pain I do not have any pain today
Is the problem …………………….. Constant …………………… Intermittent

Is the problem .…….…………….. Getting Worse ……………….. Getting Better ……………

Staying the Same

DO you have: (Check all that apply) …………………… Radiating pain in the arm or leg

…………………….. Weakness, numbness, tingling, cramps in arm or legs ………. Falls,
imbalances, or difficulty walking

What was the cause of your problem? (Check one of the following )

………………….. Working …………… Sports ………….. Motor Vehicle Accident ………. No
Injury ………… other Indicated which of the following activities increases your pain :
(Check all that apply)

………Exercise ………… Coughing ………… Sitting ………. Lifting ………… Standing ……….

Walking …………. Sneezing …….. Sleeping ……. Walking up stairs ……… Walking up stairs
…….. Twisting …………. Bending Forward …………. Bending backwards …… Other



PLAEASE PLACE A CHECK ON THE LINE BELOW INDICATING THE PAIN IN THE LAST WEEK

NONE…………………………………………………………………………………………… SEVERE

        1      2      3     4     5      6    7     8     9      10
                                Medical History form II
NAME: ………………………………………………………………………………………………………………

DO YOU HAVE PERSISTENT PROBLEMS IN ANY OF THE FOLLOWING AREAS?
GENERAL         YES        NO     CARDIC                                  YES     NO
FEVER                             CHEST PAIN
WEIGHT LOSS                       PALPITATIONS
WEIGHT GAIN                       CONGEDTIVE HEART FAILURE OR ANKLE
                                  SWELLING
FATIGUE                           HEART ATTACK
NIGHT SWEATS                      HIGH BLOD PRESSURE


MUSCULOSKELETAL                 YES   NO     RESPIRATORY                  YES     NO
JOINT PAIN                                   CHRONIC COUGH
JOINT SWELLING                               SHORTNESS OF BREATH
MUSCLE PAIN/CRAMP                            ASTHAMA
                                             PNEUMONIA
                                             EMPHYSEMA
                                             TUBERCULOSIS
                                             SLEEP APNEA


NEUROLOGIC                             YES   NO    EAR,NOSE,THROAT          YES    NO
HEADACHES                                          HEARING DIFFICULTY
NUMBNESS /PARALYSIS                                RINGING OR DIZZINESS
STROKE/TIA                                         HOARNESS
WEAKNESS PARALYSIS                                 SWALLOWING DIFICULTY
BLADER OR BOWEL, INCONTINENCE


GASTROINTESTIONAL                      YES    NO   ENDOCRANE                YES    NO
GERD/HIATAL HERNIA                                 DIABETES
GASTROINTESTINAL BLEED                             THYROID DISEASE
PEPTIC ULCER DISEASE
BOVEL DISORDER
HEPATITIS/JAUNDICE


OTHER          YES    NO        OTHER                                       YES    NO
CANCER                          PERIPHERAL VASCULAR DISEASE
ANEMIA                          DEEP VENOUS THROMBOSIS
KIDNEY                          DEPRESSION/ANXIETY
DISEASE
                             Affordable Health Center D.B.A
                        Palm Coast Chiropractic and Rehab Center
                   INFORMED CONSENT FOR TREATMENT-CHIROPRACTIC,
                      PHYSICAL THERAPHY AND PAIN MANAGEMENT

I, here by request and consent to the performance of chiropractic adjustments or any other
chiropractic procedures to include but not be limited to various modes of physical therapy, X-rays, or
any other diagnostic tests on me, on the patient named below for whom I am legally responsible by
Louis P. Salvagio D.C. employed by Affordable Health Center D.B.A Palm Coast Chiropractic and Rehab
Center, Palm Coast, including those who are working with, associated with or servicing as back up for
Louis P. Salvagio D.C. / Affordable Health Center D.B.A Palm Coast Chiropractic and Rehab Center,
Palm Coast including those who are working the clinic office listed below I also request and consent to
the performance of pain management procedures to include but not limited to prescription drug
therapy, trigger point injections and various other procedure by Laura J. Yard M.D. employed by
Affordable Health Center D.B.A Palm Coast Chiropractic and Rehab Center, Palm Coast.

Affordable Health Center D.B.A Palm Coast Chiropractic and Rehab Center, Palm Coast, I understand
and am informed that as the practice of medicine and the practice of chiropractic, physical therapy,
and pain management that there are risks associated with treatment. This includes but is not limited
to fracture, disc injuries, strokes, dislocation, sprains, muscular strains, drug dependency, seizures’,
and withdrawal. I do expect the doctors to anticipate and explain all risks and complications
associated with my condition. I wish to rely on my doctor’s judgment during any of treatment.
Alternative Treatments may include referral for medication, surgeries, and acupuncture. If no
treatment is sought, your condition could worsen, remain the same or improve. I consent and give
permission for Louis P. Salvagio D.C. and Laura Yard M.D. to examine and treat my condition.
I have read, or have had read to me, the above consent. I have also had the opportunity to ask
question about the consent. By signing below I have agreed to the above named procedures and
treatment. This consent form will cover the entire course of treatment through my current or future
conditions.
If a minor is seeking treatment is legal guardian will sign to authorize as the above mentioned
indicates.

……………………………………………………………..               …………………………………………………
PATIENT SIGNATURE                        PATIENT NAME PRINTED
……………………………………………………………..               …………………………………………………
MINOR NAME PRINTED                   AUTHOIZED SIGNATURE FOR MINOR
……………………………………………………………..               …………………………………………………
PATIENT ADDRESS SOCIAL SECURITY NUMBER   PATIENT DATE OF BIRTH
……………………………………………………………..               …………………………………………………
PATIENT ADDRESS
          Assignment Authorization and Responsibility of Insurance Benefits

I here by authorize and direct my insurance company and/ or my attorney to pay
directly to Affordable Health Center D.B.A Palm Coast Chiropractic and Rehab Center,
Palm Coast. Such sums may be due in owing this office for service rendered. In the
event my insurance company, which is obtained to make payment to Affordable Health
Center D.B.A Palm Coast Chiropractic and Rehab Center, Palm Coast, upon the charges
made by this office for their services, refusal to make such payment upon reasonable
and customary time will advertently revert back to the patient. As a courtesy to our
patients, our billing department will contact to either via certified letter or telephone
within a 90 day period if we are unable to resolve our charges with your insurance
company.

I will also be responsible for any co-pays therapies, and or treatment which were
necessary and discussed by the doctors but may not be deemed “medically necessary”
or a covered service by your insurance company. I further understand that is a balance
remains and I choose not to settle my debt, I will be responsible for any legal feels
rendered by both parties including, but not limited to , court costs and the doctors time
need to resolve the debt.

……………………………………………………………            ……………………………………………….
PATIENT NAME PRINTED                PATIENT SIGNATURE
……………………………………………………………            ……………………………………………….
DATE                               PATIENT ACCOUNT NUMBER
……………………………………………………………            ……………………………………………….
WITNESS               Affordable Health Center D.B.A Palm Coast
                      Chiropractic and Rehab Center, Palm Coast


                  MEDICAL RELEASE AUTHORIZATION
Please release all complete medical reports and or all diagnostic studies pertaining to
the above mentioned patient to Affordable Health Center D.B.A Palm Coast
Chiropractic and Rehab Center, Palm Coast.

……………………………………………………………….                            ……………………………………………
PATIENT NAME                                         PATIENT SIGNATURE

…………………………………………………………….                              …………………………………………
PATIENT SOCIAL SECURITY NUMBER                        DATE OF BIRTH
Dear Patient:
This questionnaire will allow you to describe your accident/injury in detail. Please complete it carefully as
the information provided will assist the doctor in evaluating and documenting your condition. Thank you.
PLEASE USE A NO.2 PENCIL ONLY TO FILL IN APPROPRIATE ANSWERS. FILL IN THE BUBBLES COMPLETELY AS
INDICATED HERE…
ERASE CHANGES CLEANLY. DO NOT FOLD THIS FORM.
PATIENT NAME: _________________________________ DATE: _______________________________

A. DATE AND TIME OF ACCIDENT/INJURY                   4. If there were lacerations (cuts), where were they?
Date __/__/____       Time __________am/pm                 Head                  Shoulders       Buttocks
B. DESCRIPTION OF ACCIDENT/INJURY                          Neck                 Arms              Hips
      Automobile Accident Questionnaire Marked             Upper/Mid Back        Elbows          Thighs
(Skip Section B)                                           Lower Back            Forearms         Knees
     Workmen’s Compensation Questionnaire                  Pelvis               Wrists            Legs
Marked                                                     Chest/Rib Cage       Hands             Ankles
     Slip/Fall/Accident       Pedestrian Accident          Abdomen                                Feet
Other:          Accident      Injury                       Other ___________________________
1. What was the cause of your accident/injury?        5. Describe any other significant injury:
    __________________________________                    _____________________________________
    __________________________________                    _____________________________________
    __________________________________                6. Emergency care at accident/injury site
    __________________________________                    a. Did you receive emergency care?
2. Describe in your own words what happened:                   Yes         No
    ___________________________________                   b. What type of emergency care did you receive?
    __________________________________                           Bandages         Splints        Brace
    __________________________________                            Neck Collar      Other
    __________________________________                7. Destination after accident/injury
    __________________________________                  a. Where did you go? b. By whom were you driven?
    __________________________________                    Hospital     Home         Myself     Ambulance
                                                          School       Work         Friend     Family
                                                          Other                     Other
C. IMMEDIATELY AFTER ACCIDENT/INJURY                  D. HOSPITAL VISIT AFTER ACCIDENT/INJURY
1. Did you lose consciousness?                        1. When did you go to the hospital?
     Yes        No         Don’t Know                     Immediately   Later That Day      Next Day
2. How did you feel?                                      Days after    Date___/___/___
    Confused     Dazed       Dizzy                        Other _________________________
    Nervous      Weak        Other ___________        Hospital Name:        Examined by Doctor
3. Where did you immediately develop pain?            __________________    ___________________
                                                      Admitted:    Yes  No Discharge Date _______
    Head                Shoulders      Buttocks
                                                      2. If x-rays were taken, of what body part(s)?
    Neck                Arms           Hips
                                                           Head                  Shoulders       Buttocks
    Upper/Mid Back      Elbows         Thighs
                                                           Neck                  Arms            Hips
    Lower Back          Forearms       Knees
                                                           Upper/Mid Back        Elbows          Thighs
    Pelvis              Wrists          Legs
                                                           Lower Back            Forearms        Knees
    Chest/Rib Cage      Hands          Ankles
                                                           Pelvis                Wrists          Legs
    Abdomen                             Feet
                                                           Chest/Rib Cage        Hands           Ankles
    Other ___________________________
                                                           Abdomen                               Feet
                                                           Other ___________________________
            Affordable Health Center D.B.A Palm Coast
            Chiropractic and Rehab Center, Palm Coast

                                           LETTER OF PROTECTION

I hereby authorize and direct you, my attorney to pay to directly to a Affordable Health center Inc.any and all
unpaid bills for medical service rendered to me related to my injuries sustained in the accident of
(month/day/year):…………………. I further authorized my attorney to withhold such sums from any settlement,
judgment, or verdict as may be necessary to adequately protect said provider. I hereby further give an lien on
my case to said provider against any and all proceeds of my settlement, judgment, or verdict which may be
paid to you my attorney or my self as a result of the injuries for which I have been treated or injuries in
connection there with.

I agree never to rescind this document and that a rescission will not be honored to my attorney. I hereby
instruct that in the event another autonomy is substituted in this matter, the new attorney honor this lien as
inherent to the settlement and enforceable upon the case as if it were executed by him.

I fully understand that I am directly responsible to said provider for all Medical bills submitted by him for
service rendered me and that this agreement is made solely for said provider’s additional protection and in
consideration of his awaiting payment. I further understand that such payment is not contingent on any
settlement, judgment or verdict by which I may eventually recover said fees or charges. I authorized Affordable
Health Center. INC. or is authorized representatives to sign my name to any check written in both our names,
where such check is in payment for its services regarding my condition.

Please acknowledge this letter by signing below and returning to the provider’s office. I have been advised that
is my attorney does not wish to cooperate in protecting the provider’s interest, the provider will not await
payment buy may declare the entire balance due and payable immediately.

If this account Is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to
reasonable attorney’s fees and costs of collection.

Date: ………………………………….         Patient Signature: …………………………..
Patient’s Name: ………………………………………………………………..

The undersigned being attorney of records for the above patient does here by agree to observe all the terms of
the above agrees to with holder such sums from any settlement, judgment, or verdict, as may be necessary to
adequately protect said provider above named. Attorney further agrees that in the event that the lien is
litigated, the prevailing party will be awarded attorney fees and costs. should no recovery be made, attorney is
not responsible for the patient’s bill.

Date: …………………………                                           ……………………………………………….
                                                                Attorney’s Signature
………………………………………………………………..
Print Attorney’s Name
         Affordable Health Center D.B.A Palm Coast
         Chiropractic and Rehab Center, Palm Coast
                     FAX PRIVACY WAIVER FORM
I understand that my medical records may be transmitted electronically by fax and may
be received in error by a third party. In the event that this should occur, I absolve
Affordable Health Center D.B.A Palm Coast Chiropractic and Rehab Center, Palm Coast
of all liability. I give consent to fax my records for the purposes of treatment, payment
for treatment, administrative purposes, and or other health care operations. I may
withdraw this consent at any time in writing.




…………………………………………………………………………………………
Signature of patient or Personal representative


………………………………………………………………………………                          ………………………………………
Print Name                                                Date

				
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