In & Out Chiropractic • 5099 W. Dobbins Rd • P.O. Box 91 • Laveen, AZ 85339 • 602-237-2555
Patient Health History Form
Please fill out completely. Today’s Date: _______________ Last Name: ___________________________ Gender: M / F First Name: _______________________ Middle Initial: ________
How were you referred to our office? _____________________________________________________
Address ____________________________________________ City _________________ State _____ Zip ___________ Home Phone ___________________ Work Phone ___________________ Mobile ___________________ Social Security # _________________ Date of Birth _________________ Age ____ Date of Injury/Onset _________ Marital Status: S M W D Spouse’s Name ______________________________ Number of Children _____
Email Address: ____________________________________________________ (This is how we will correspond with you) Employer: ___________________________________ Occupation ___________________________________________ Primary Care Physician: _______________________________________ Phone: ________________________________ Emergency contact: ___________________________________________ Phone: ________________________________ Patient health Questionnaire Please check all that apply. Knowledge of these conditions may influence the type of treatment you receive. □Angina □Anorexia □Aortic Aneurysm □Arthritis □Asthma □Bladder Infection □Blood Disorder □Breast Lump □Cancer (breast, prostate, etc.) □Chest Pain □Chronic Cough □Chronic Sinusitis □Colitis □Convulsions □Diabetes □Depression □Digestive Disorders □Dizziness □Emphysema Height: _____feet _____ inches □Epilepsy □Fainting □Headache □Heart Disease □Heartburn/Indigestion □Hepatitis □Herniated Disk □High Blood Pressure □Jaw Pain □Liver/Gallbladder Problems □Kidney Disorder □Loss of Bladder Control □Nervousness □Pacemaker □Pain - Neck □Pain – Mid Back □Pain – Low Back □Pain – Arm/Elbow □Pain – Hand Weight: ________ pounds □Pain - Wrist □Pain - Shoulder □Pain – Ankle or Foot □Pain – Leg □Pain - Knee □PMS/PMDD □Prostate Problems □Rapid Heartbeat □Rheumatic Fever □Pregnancies □Scoliosis □Stroke □Swelling, Stiffness of Joints □Tinnitus (Ear Noises) □Tuberculosis □Ulcer □Vision Disturbances □Venereal Disease □Other __________________________ Dominant Hand: □Right □Left
Family Health History: If a family member has had any of the following, please circle: Cancer Diabetes Heart Problems High Blood Pressure Chronic Headaches Epilepsy Thyroid Lupus Lung Problems Chronic Back Problems Rheumatoid Arthritis Alcoholism Other __________________________________________ I certify that all the above personal health information, on pages one and two, is complete and accurate to the best of my knowledge. I agree to notify this doctor immediately whenever I have changes in my health condition in the future. Patient or Guardian Signature ______________________________________________ Date ______________________
In & Out Chiropractic • 5099 W. Dobbins Rd • P.O. Box 91 • Laveen, AZ 85339 • 602-237-2555 Patient Health Questionnaire Please mark the areas of complaint Patient Name ____________________________ Date _______ Please describe your current problem _______________________ _____________________________________________________ Is your current problem the result of: □Auto Accident □Work Accident □Slip & Fall □Other How did your problem begin ______________________________ ______________________________________________________ Date problem began ____________ Other doctors seen for this condition ________________________ ______________________________________________________ List other treatments or tests you’ve had for this condition ___________________________________________________ ___________________________________________________ Have you been treated for any other health condition by a physician in the last year? □Yes □No If yes, please explain: __________________________________________________________________________________________________ On a scale of 1-10, 10 being severe pain, what is the severity of your problem (at its worst) ________________________ How often are your symptoms present? □Constantly Describe your current pain/symptoms: □Dull □Numbness Since it began, is your problem: □Sharp/Stabbing □Soreness □Frequently □Burning □Aches □Occasionally □Throbbing □No Change □Standing □Standing □Walking □Walking □Sitting □Sitting □Other ___________________ □Other ___________________ □Weakness □Intermittently □Shooting □Tingling
□Other ____________________
□Improving □Movement
□Getting Worse □Lying Down □Exercise □Exercise □Lying Down
What makes the problem better?: □Nothing What makes the problem worse? □Nothing
□Inactivity/Rest □Inactivity/Rest □Not at all
□Movement Can you perform your daily home activities: Do you exercise? □Yes, often Describe your job requirements:
□Yes
□Only with help □Light Labor □High
□Not at all □Heavy Labor □Other________________
□Yes, occasionally □Mainly Sitting
Can you perform your daily work activities: Describe your stress level: □None to mild
□Yes, all activities □Moderate
□Only some
□Not at all
Please list all allergies including allergies to medications: ___________________________________________________ List all medications you are presently taking (including vitamins and Supplements) _______________________________ __________________________________________________________________________________________________ List any surgeries, fractures, serious illness or hospitalizations _______________________________________________ __________________________________________________________________________________________________ □Coffee/Caffeine/Energy Drinks/day_____wk_____ □Alcohol use – drinks/day_____wk_____ □Smoking – packs/day_____ □Drug use __________________
Assignment of Proceeds, Contractual Lien, Release of Medical & Plan Documents and Authorization (Agreement) In and Out Chiropractic 5099 W. Dobbins PO Box 91 Laveen, AZ 85339 602-237-2555 I hereby direct any and all insurance carriers, attorneys, agencies, governmental departments, companies, individuals, and/or other legal entities (“payers”) which may elect or be obligated to pay benefits to me for any medical conditions, accidents, injuries, or illnesses, past or future (“condition”), to pay directly to, and exclusively in the name of, In and Out Chiropractic (“I&OC”) such sums as may be owing to I&OC for charges incurred by me, including but not limited to, charges for treatment, narrative reports, depositions, testimony, and any other charges incurred by me at the Office (“charges”). I further grant a contractual lien to I&OC with respect to my charges, applicable to all payers, however, I understand that nothing in this agreement shall be construed as an election by I&OC to claim protection under any statutory lien law. For the purposes of this Agreement, “benefits” shall include, but shall not be limited to, proceeds from any settlement, judgment, or verdict, as well as any proceeds relating to commercial health or group insurance, disability benefits, worker’s compensation benefits, medical payments benefits, personal injury protection, lost wages benefits, lost services benefits, no-fault coverage, uninsured and underinsured motorist coverage, third-party liability distributions, malpractice proceeds, attorney retainer agreements, and any other benefits or proceeds payable to me for the purposes stated herein, regardless of whether such proceeds are related to my charges or not. I further agree that, in the event a payer refuses to pay I&OC, I hereby assign, insofar as permitted by law, all of my rights, remedies, and benefits to I&OC to extent of my charges, as well as any and all causes of action that I might have against such payer, to prosecute such causes of action either in my name or in the Offices name, and to settle or otherwise resolve such causes of action as the office sees fit. In the event that I retain one or more attorneys to represent me in this matter, I will direct each attorney a letter of protection to this office regarding my charges. Upon issuance, I hereby agree that such letter(s) of protection cannot be revoked or modified without the expressed written consent of this office. I further direct each attorney to provide immediate notice to the Office regarding any funds received by the attorney relating to my accident, to promptly pay such Office, and to provide a full accounting of such funds to the Office upon its request. I hereby direct all payers to release to I&OC any information regarding any coverage or benefits which I may have including, but not limited to, the amount of the coverage, the amount paid thus far, and the amount of any outstanding claims. I authorize this Office to release any information regarding my treatment or pertinent to my case(s) to all payers as defined above to facilitate collection under this Agreement. I hereby direct this Office to file a copy of this Agreement, together with any applicable charges, with any or all payers, regardless of whether a claim has been established with said payers. I hereby authorize I&OC to endorse/sign my name on any and all checks listing me as a payee which are presented to this Office for payment of an account relating to me, my spouse, or any of my dependents. I further authorize I&OC to apply any credit balances on charges incurred by me to any other outstanding charges still owed by me, my spouse, or my dependents, regardless of whether these other charges are related to my condition. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. I understand that I remain personally responsible for the total amounts due I&OC for their services. This Agreement does not constitute any consideration for this Office to await payments and it may demand payments from me immediately upon rendering services at its option. If this Office must take any action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse I&OC for all costs of such collection efforts, including, but not limited to, all court costs and all attorney fees. This Agreement shall not be modified or revoked without the mutual written consent of I&OC and myself. I hereby revoke any previously signed authorizations, whether executed at this office or any other office to the extent that the terms of those authorizations conflict with the terms of this Agreement. I agree that each and every provision of this Agreement is reasonably necessary for the protection of the rights and interest of I&OC and myself. However, should any provision of this Agreement be found to be invalid, illegal or unenforceable, or for any reason cease to be binding on any party hereto, all other portions and provisions of this Agreement shall, nevertheless, remain in full force and effect. Patient Name (please print): ____________________________________________________________________ Patient Signature: ______________________________________________________ Date: ____/____/______ Name of Custodial Parent of Legal Guardian (please print): ___________________________________________ Parent/Guardians Signature: _______________________________________________ Date: ____/____/_____
Consent for use or Disclosure of Health Information Our Privacy Pledge We area very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always, will respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information. We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition. We may have to disclose your health information and billing records to another party in they are potentially responsible for the payment of your services. We may need to use your health information within our practice for quality control or other operational purposes.
We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form (§ 164.520). We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment, by mail, or email. Please feel free to call us at nay time for a copy of our privacy notices. Your right to limit use or disclosures You have the right to request that we don not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use of disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. Your right to revoke your authorization You may revoke your consent to us at any time; however, you revocation must be in writing. We will not be able to honor you revocation request if we have already released your health information before we receiver your request to revoke you authorization. If you were required to give your authorization as condition of obtaining insurance, the insurance company may have a right to your health information if they deicide to contest any of your claims. I have read your consent policy and agree to its terms. I am also acknowledging that I have received or reviewed a copy of this notice (available in the treatment room). _________________________________ Patient name printed _________________________________ Patient signature Date
_________________________________ Parent or Guardian signature (if a minor)
Patient Consent to Treatment
Please read prior to signing. Please ask any questions before you sign if there is anything that is unclear. The nature of the chiropractic adjustment. A primary treatment we use as a doctor of Chiropractic is spinal manipulative therapy. We may use our hands or a mechanical instrument upon your body in such a way as to mover your joints. That may cause an audible “pop” or “click” and you may feel a sense of movement. Analysis / Examination / Treatment. As a part of the analysis, examination, and treatment, you are consenting to procedures that we may recommend and/or discuss with you. The material risk inherent in chiropractic adjustment. As with any healthcare procedure, there area certain complications which may arise during chiropractic manipulation therapy. These complications include but are not limited to: fractures, disc injuries, dislocation, muscle strain, cervical myelopathy, costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to neck arteries leading to or contributing to serious complications including stroke. It is not uncommon to feel some stiffness and soreness following the first few days of treatment. We will make a reasonable effort during the examination to screen for contraindications to care. However, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us. The probability of those risks occurring. Fractures from chiropractic treatment are rare and generally result form some underlying weakness of the bone which we screen for during the taking of your history and exam. 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: Self-administered, over the counter analgesics and rest; Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers; Hospitalization and/or 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 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. Please check the appropriate block and sign below. I have read [ ] or have had read to me [ ] the above explanation of the chiropractic adjustment and related treatment. I have discussed it with In & Out Chiropractic and have had, any questions answered to my satisfaction. By signing below, I state that I have weighted 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. _________________________________ Patient name printed _________________________________ Patient signature Date _________________________________ Parent or Guardian signature (if a minor) ____________________________________ Doctor’s Name printed ____________________________________ Doctor’s signature Date