Docstoc

Sarro Family Chiropractic

Document Sample
Sarro Family Chiropractic Powered By Docstoc
					                                         Dr. Tim Hignite, Chiropractic Physician
                                      931 E. Arlington, Suite 2 • Ada, Oklahoma 74820
                         Telephone (580) 436-9079 • Toll Free (877) 44-CHIRO • Fax (580) 436-8204



                                             PATIENT INFORMATION


Last Name __________________________________ First Name _______________________ Middle Initial ________
Name you prefer to be called? (Nickname)_____________________________________________________________
Address _________________________________________ City _________________ State _________ Zip _________
Email ___________________________________________________________________________________________
Home Phone (______) ___________________________ Cell Phone (______) _______________________________
Work Phone (______) ____________________________ Do you prefer to receive calls at:  Home  Work  Cell
Date of Birth____________________________________ Social Security ____________________________________
Sex  Female       Male             Occupation________________________________________________________
Employer_____________________________________ Employer Address ___________________________________
Marital Status  S    M       D     W       Spouse’s Name_____________________________________________
                                               Spouse’s Phone (______) ____________________________________
Primary care doctor _______________________________________________________________________________
How did you hear about our office?___________________________________________________________________
Person to contact in an emergency:_______________________________________ Phone______________________


New Federal guidelines have been issued to insure that your protected health information (PHI) is indeed protected. In
order for our office to comply we must offer you a chance to view or receive a copy of our HIPAA Notice of Privacy
Practices. This allows you to know how your information is used. If you are ever unsure on how your information is
used please talk to Dr. Tim Hignite. Please print and sign your name below to indicate you have been made aware of the
HIPAA policy.

______________________________________________                           ___________________________
Patient (or Guardian) Signature                                          Date


I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my
account for any professional services rendered. I certify that, to the best of my knowledge, I have completed this form
with complete and accurate information. If this information changes I will notify this office in a timely manner.

______________________________________________                           ___________________________
Patient (or Guardian) Signature                                          Date
                            AUTHORIZE BENEFITS TO CHIROPRACTIC PHYSICIAN
         I hereby authorize insurance payments to be paid directly to you as my chiropractic physician. I also understand
that I am responsible for any portion of my bill that is not covered by my insurance company. This includes all
designated co-pays or co-insurance assigned to me as an enrollee. This includes paying all usual charges in full until I
meet my assigned deductible. Usual charges are defined as the Chiropractic Physician’s normal charges that are
required by contract to be filed to each of his or her contracting carriers.

        If any of my benefit is denied as not a covered benefit, I understand that I am to reimburse my chiropractic
physician his or her full usual charges. This agreement applied even if the insurance company attempts to discount non-
covered services either verbally or in writing, i.e., an EOB notice.

        If I choose not to have my insurance filed, I agree to pay full billed charges for these services. Billed charges are
defined as a Chiropractic Physician’s normal charges if a patient does not have or does not choose to utilize their
insurance benefits.

        I understand all of the above and my signature indicated that I have read the above and grant the requests of
authorizations.



        ________________________________________________
        Patient Signature (or parent if minor)


        ________________________________________________
        Date
                                                 HEALTH HISTORY
Name _____________________________________________                                         Date __________________

                                                             Patient Comment                         Chiropractor’s
                                                              If answer is Yes                         Comments
Current Health Habits:
       Did/do you smoke? If so, how much?        Y   N  _____________________________            _____________________
       Did/do you use smokeless tobacco?         Y   N  _____________________________            _____________________
       Did/do you drink alcohol? How much?       Y   N  _____________________________            _____________________
       How much water do you drink?                     _____________________________            _____________________
       How much caffeine do you have a day?             _____________________________            _____________________
       Diet - do you eat healthy foods?          Y N _____________________________               _____________________
       Are you sexually active? Protected?       Y N _____________________________               _____________________
       Physical or emotional stress?             Y N _____________________________               _____________________
       Exercise regularly?                       Y N _____________________________               _____________________
       Do you sleep well? Hours per night?       Y N _____________________________               _____________________
       Sleeping posture?  side  stomach         back _____________________________            _____________________

Family History
                     Heart Disease       Arthritis      Cancer        Diabetes        Other
Father’s side                                                                        __________________
Mother’s side                                                                        __________________
Associated health problems of relatives:___________________________________________________________________
Cause of parents or siblings death:____________________________________ Age at Death:________________________
____________________________________________________________________________________________________

Accidents/Falls/Trauma
                       Date                                          Please Explain
Car/Motorcycle   ________________      ________________________________________________________________________
School           ________________      ________________________________________________________________________
Work             ________________      ________________________________________________________________________
Broken Bones     ________________      ________________________________________________________________________
Dislocations     ________________      ________________________________________________________________________
Other            ________________      ________________________________________________________________________

Are you presently taking any medications (over the counter or prescribed), vitamins or supplements? If so, please list.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Have you had x-rays taken in the past year? If so, why? ______________________________________________________________

Are you now or have you ever been disabled from work? ____________________________________________________________

Operations and Procedures
Vaccinations     __________             Tubes in Ears  __________           Sinus   __________
Tonsillectomy    __________             Appendectomy __________             Hernia __________
Gall Bladder     __________             Female Organs __________            Thyroid __________
Back Operations __________              Rectal Surgery __________           Stomach __________
Other (type and date) ________________________________________________________________________

Have you had any of the following?
___ Appendicitis               ___ Anemia                ___ Heart Disease       ___ Mental Disability
___ Pneumonia                  ___ Measles               ___ Influenza           ___ AIDS/HIV
___ Rheumatic Fever            ___ Mumps                 ___ Alcoholism          ___ Depression
___ Polio                      ___ Chicken Pox           ___ STDs                ___ Diagnosed Osteoporosis
___ Tuberculosis               ___ Diabetes              ___ Arthritis           ___ Loss of Consciousness
___ Whooping Cough             ___ Cancer                ___ Allergies           ___ Spinal injections
Past Chiropractic Care? Y N Dr’s. Name ____________________________ Results ___________________________________

Please mark any of the following that you have now or have experienced:
General                                 ___ Bloody stool                        ___ Dental Problems
___ Headache                            ___ Recent change in bowel habits       ___ Gum Disease
___ Fever                               ___ Recent constipation or diarrhea     ___ Sore Tongue
___ Chills                              ___ Hiatal Hernia                       ___ Taste Changes
___ Night Sweats                                                                ___ Pain in jaw (opening or chewing)
___ Fainting                            Muscle & Joints                         ___ Difficulty Swallowing
___ Dizziness                           ___ Weakness                            ___ Asthma
___ Convulsions                         ___ Twitching                           ___ Frequent Colds
___ Loss of Sleep                       ___ Stiff Neck                          ___ Enlarged Thyroid
___ Fatigue                             ___ Backache                            ___ Tonsillitis
___ Nervousness                         ___ Arthritis                           ___ Sinus Trouble
___ Loss of Weight                      ___ Swollen Joints
___ Numbness or Pain in                 ___ Tremors                             Neurologic
    arms/hands/legs/feet                ___ Foot Trouble                        ___ Brain Tumor
___ Loss of Balance                     ___ Painful Tail Bone                   ___ Spinal Cord Tumor
___ Loss of Memory                      ___ Spinal Curvature                    ___ Cerebral Palsy
                                                                                ___ Dyslexia
Respiratory                             Skin                                    ___ Epilepsy
___ Chronic Cough                       ___ Skin Eruptions                      ___ Multiple Sclerosis
___ Spitting Blood                      ___ Itching                             ___ Muscular Dystrophy
___ Spitting Phlegm                     ___ Bruising Easily                     ___ Myasthenia Gravis
___ Chest Pain                          ___ Dryness                             ___ Parkinson’s Disease
___ Difficulty Breathing                ___ Boils                               ___ Alzheimers/Dementia
___ History of Lung Disease             ___ Sensitive Skin
___Wheezing                             ___ Hives or Allergies                  Women Only
                                        ___ Eczema or Rash                      ___ Currently on Birth Control
Genito-urinary                          ___ Unusual Spots/Moles                 ___ Currently Pregnant
___ Bed Wetting                                                                 ___ Painful Periods
___ Frequent Urination                  Cardio-Vascular                         ___ Excessive Flow
___ Painful or Burning Urination        ___ Rapid Heart Beat                    ___ Irregular Cycles
___ Blood in Urine                      ___ Slow Heart Beat                     ___ Peri or Post-Menopausal
___ Lack of Bladder Control             ___ High Blood Pressure                 ___ Hot flashes
___ Kidney Infection                    ___ Low Blood Pressure                  ___ History of ovarian
___ Chronic Bladder Infections          ___ High Cholesterol                        cyst/endometriosis
___ Kidney Stones                       ___ Chest Pain                          ___ Lumps in breast/discharge
___ Yeast Infections                    ___ Pacemaker
                                        ___ Shortness of Breath with Activity   Last menstrual period_____________
Gastro-Intestinal                       ___ Previous Heart Trouble              Last PAP test___________________
___ Poor Appetite                       ___ Swelling of Hands/Feet                        Results_________________
___ Poor Digestion                      ___ Poor Circulation                    Last mammogram________________
___ Excessive Hunger                    ___ Varicose Veins/Leg Cramps                     Results_________________
___ Gas or Bloating                     ___ Strokes                             Last monthly breast exam__________
___ Nausea                                                                      Number of pregnancies____________
___ Vomiting                            Eye, Ear, Nose, Mouth, Throat           Number of Live Births_____________
___ Vomiting Blood                      ___ Abnormal Vision                     Abortions_______________________
___ Acid Reflux                         ___ Pain in Eyes                        Miscarriages/Still Births____________
___ Chronic Constipation                ___ Itchy/Dry Eyes
___ Diarrhea                            ___ Glaucoma or Cataracts               Men Only
___ Colon Trouble                       ___ Deafness                            ___ Prostate Trouble
___ Hemorrhoids                         ___ Earache                             ___ Sexual Dysfunction
___ Liver Trouble                       ___ Ringing in Ears                     ___ Hernia
___ Jaundice                            ___ Nasal Obstruction                   ___ Pain in Testicle
___ Gall Bladder Trouble                ___ Nose Bleeds
___ Ulcers                              ___ Sore Throat                         Last prostate exam_______________
___ Eating Disorder                     ___ Hoarseness                                   Results_________________
Symptoms and Present State of Health
In the space below, please describe the present complaint(s) which brought you to this clinic for care.

Major Complaint ___________________________________________________________________________________
When did your Pain/Problem begin? ___________________________________________________________________
Did your problem begin:  Immediately after a specific incident  Multiple incidents  Gradually over time  No specific reason
Please describe how your problem began? ______________________________________________________________
Please describe your pain:  Sharp  Dull/ Ache  Sore  Weakness  Shooting  Burning Tingling
                                Other______________________
How often are the complaints present?  Constant (76-100%)  Frequent (51-75%)  Occasional (26-50%)  Intermittent (<25%)
What makes your condition/pain better? _______________________________________________________________
What makes your condition/pain worse? _______________________________________________________________
Is this condition worse during certain times of the day?____________________________________________________
Is this condition interfering with Work?__________       Sleep?__________Routine?_______Other?________________
Since your problem began, is it:  Getting Worse  Getting Better  Not Changing
Have you received treatment for this present condition?___________________________________________________
          Any home remedies? _________________________________________________________________________
Have you had a similar condition in the past? ____________________________________________________________



                       Pain Scale                                       Circle on the drawing             A= ACHE
 Please circle the number that best describes your pain.                below the areas causing           B= BURNING
                                                                        you pain and write a              S= STABBING
                                                                        letter describing it.             N= NUMBNESS
       0 1 2       3 4 5 6 7 8 9 10
                                                                                                          P= PINS & NEEDLES
        NONE        LITTLE MEDIUM SEVERE




About Your Care
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the Chiropractor
to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child
during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance
company to pay directly to the Chiropractor or chiropractic group insurance benefits otherwise payable to me. I understand that my
chiropractic insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services
rendered on my behalf or my dependents.

Patient Signature______________________________________________________              Date__________________________
                    INFORMED CONSENT TO CHIROPRACTIC TREATMENT
        I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic
procedures, including a comprehensive exam, diagnostic x-rays, physical therapy techniques, on me (or on the
patient named below for which I am legally responsible) by the licensed doctors of chiropractic at this office.

        I understand that, as with any health procedure, there are certain conditions that may arise during a
chiropractic adjustment. Those complications include but are not limited to: fractures, dislocations, muscle strain,
costovertebral strains and separations. Some types of manipulations of the neck have been associated with injuries
to the arteries in the neck leading to or contributing to serious complications including stroke. This is a very rare
occurrence (a one in three million chance). We screen our patients for indications that they are candidates for
chiropractic adjustments to the best of our ability. I do not expect the doctor to be able to anticipate all risk and
complications during the course of the procedure(s) that the doctor feels at the time, based upon the facts then
known, are in the best interest.

       I have had an opportunity to discuss with the doctor the nature, purpose, and risk of chiropractic
adjustments and other recommended procedures and have had my questions answered to my satisfaction. I
understand that the results are not guaranteed.

       I have read or have had read to me the above explanation of the chiropractic adjustment and related
treatment. By signing below, I state that I have weighed the risks involved in undergoing treatment and have
myself decided that it is in my best interest to undergo the chiropractic treatment recommended. Having being
informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire
course of treatment for my present condition and for any future condition (s) for which I seek treatment.


___________________________________________
Printed name of patient


___________________________________________ _______________________
Signature of Patient                         Date


___________________________________________ ________________________
Signature of patient’s parent/guardian (if minor) Date