Patient information
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- Bu səhifədəki naviqasiya:
- . I understand that I am financially responsible for all charges whether or not paid by insurance.
- ACCIDENT INFORMATION
- REASON FOR THIS VISIT
- Mark an X on the picture where your symptoms are
- HEALTH HISTORY Please circle any symptom/condition which you have now, or have had in the past
- Signature of patient (or guardian if minor) ___________________________________________ Date _________
- BIRTH HISTORY
- EXERCISE HISTORY (Please circle one)
- WORK ACTIVITY (Please circle one)
- HABITS
- Injuries/surgeries/medications Description Date
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Name:________________________________________Date of Birth____________ S.S #_____________________ Today's Date:_________ Address:___________________________________City:_____________________State:_______Zip:__________E-Mail________________
Phone: (H)_____________________(W)_____________________ Referred to our office by:_______________________________________ Name of Spouse:______________________Parent/Legal Guardian_______________________Children _________________________________
Occupation_______________________________Employer Name and Address__________________________________________________ Height:________Weight:_________Any recent gains or loss?_____ Name of nearest relative/ phone number___________________________
Who is responsible for this account? __________________________Insured’s Name and Birth date _________________________________
Relationship to patient ___________________Insurance Co. Name and Address__________________________________________________ Group Number__________________________________________ Policy Number (ID #) ______________________________________________
I, the undersigned certify that I (or my dependent) have insurance coverage with___________________ and assign directly to Dr. Marko all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to re- lease all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature ___________________________________________ Relationship ______________________________Date________________ ACCIDENT INFORMATION Is this condition due to an accident? Yes No Date of accident____________ Type of Accident (circle one) Auto Work Home Other
Was this reported? Yes No Attorney Name and Phone Number (if applicable ) ___________________________________________________
REASON FOR THIS VISIT Reason for visit:_________________________________________ When was the first time you were aware of it?______________________
How did this condition develop (what caused it)?__________________________________________________
Have you ever had the same or similar problem before? Y N Is this condition getting worse? Y N Rate the severity of your symptoms, on a scale of 1-10 (1 being the least, 10 being most severe) ____________
How often do you have this symptom?____________________ constant or intermittent?_________________ If you have pain, what type of pain is it? (circle one) Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Stiffness Swelling Other______________
Does it interfere with your (circle one) Work Sleep Daily Routine Recreation Sitting Standing Walking Bending Lying Down Have you ever had treatment for this condition before? Y N If yes, by whom / when?____________________________________________
Have you ever been to a Chiropractor before? Y N If yes, whom / when?_____________________________________________________ Please turn over WELCOME TO DRS. MARKO FAMILY CHIROPRACTORS Please answer the following questions to the best of your ability, and return it to the front desk.
HEALTH HISTORY Please circle any symptom/condition which you have now, or have had in the past:
If you have a family history of any of the above, please list them here ____________________________________________ _______________________________________________________________________________________________
Are you pregnant? Y N Due date__________ Pregnancy related symptoms? ___________________________________
Depression Diabetes Digestive problems Dizziness Ear fluid/infections Ears ring/buzzing Eating disorders Emphysema Epilepsy Face seems flushed Fainting Fatigue Fractures Glaucoma Goiter
Gonorrhea Gout
Growing pains Head seems heavy Headaches Hearing problems Heart condition Heartburn Hepatitis Hernia
Herniated disc Herpes
High blood pressure High cholesterol Hyperactivity Infertility Irritability Kidney disease Light hurts eyes Liver disease Loss of balance Measles
Memory loss Miscarriage Mononucleosis Multiple Sclerosis Mumps Neck pain/stiffness Nervousness/tension Numbness Osteoporosis Pacemaker Parkinson’s Disease Pinched Nerve Pins and needles Pneumonia Polio Poor posture PMS Prostate problems Prosthesis Psychiatric disorder Reflux Rheumatoid Arthritis Rheumatic Fever Ringing in the ears Scarlet Fever Scoliosis Shortness of breath Skin disorder Sleeping problems Stomach problems Stroke Suicide attempt Thyroid problems Tonsillitis Tuberculosis Tumors/growths Typhoid fever Ulcers
Vaginal infections Visual problems Whooping Cough A.D.H.D
Aids/HIV Alcoholism Allergies Anemia
Appendicitis Arthritis Asthma Back pain Bed-wetting Bleeding disorders Breast conditions Breathing problems/Sinus Bronchitis Cancer
Cataracts Chemical dependency Chest pain Chicken Pox Cold hands/feet Cold sweats/fever Colic Colon problems Concussion Constipation/diarrhea Depressed immune system
Length of labor and delivery? __________________________
Were any of the following used for delivery? (Please circle) Forceps Vacuum C-section Breech Delivery
APGAR Score__________ Breast feeding bottle feeding EXERCISE HISTORY (Please circle one) None
Moderate
Daily
Heavy
What type of exercise?
__________ _________ ____
WORK ACTIVITY (Please circle one) Sitting
Standing
Light Labor Heavy Labor
Hours per day____________ Days per week____________ HABITS Smoking ( Packs /day)____
Alcohol (drinks /wk.)_____ Coffee/caffeine/day______
High stress level_________ Nutrition?_______________
How many glasses of water do you drink per day?______ Injuries/surgeries/medications Description Date Falls /Accidents (auto or personal) ___________________________________________________________ ___________________
Head injuries______________________________________________________________________________ ___________________ Broken bones/dislocations___________________________________________________________________ ___________________
Surgeries_________________________________________________________________________________ ___________________ Medications _____________________________________________________________________________________________________ Yüklə 117,5 Kb. Dostları ilə paylaş:
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