patient health record patient file no. - spokane...

Patient File No._________________

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I agree that I am responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider for services rendered. Patient’s Signature Date Guardian Signature Authorizing Care Date

Who should receive bills for payment on your account?

Patient Spouse Parent Personal Health Insurance

Worker’s Comp Auto Insurance Medicare Medicaid

Ownership of X-ray films. It is understood and agreed that the payments to the Doctor for x-rays is for examination of x-rays only. The x-ray negatives will remain the property of this office. They are kept on file where they may be seen

at any time while I am a patient in this office.

First Name: __________________________________

MI: ________ Last Name_______________________

Address

City_____________State_______Zip

Home Phone_______________ Cell

Age Gender M F #Child

Date of Birth ____________ Language______________

Race________________ Ethnicity___________________

Employer

Work Phone

Type of Work

Marital Status: Married Single Divorced

Separated Widowed

Social Security #

Driver’s License #

Email Address:

PATIENT HEALTH RECORD

ABOUT THE SPOUSE OR PARENT

Name Employer Work # Home #___________________ YES NO Please contact in the event of an emergency. If no, who may we contact if emergency arises? _________________________________

AUTHORIZATION FOR CARE

Credit/Debit Information

Name_______________________

CC# _______________________

Exp: ____ Zip__________

Security Code(CVS)____________

Patient Name:___________________________________ Date:____________________________

Salina Family Chiropractic Tel 509-467-2888

Primary condition that I am concerned with: Location of Pain: When it began: How did it occur:

The pain is: Sharp Dull Burning

Pressure Itching Pins & Needles

Other: % of time with pain: 0---10--20--30--40---50---60--70--80--90--100 or constant pain Intensity of pain: 0 or no pain—2——4——6——8——10— or unbearable pain

Does the discomfort radiate or extend from one point to another? Yes No If yes, please describe:

Condition is aggravated by: Relieved by: Affect on daily activity: Affect on sleep:

Progress: Getting worse Staying the same No change

Related to fall or accident: Yes No

Has this ever happened before: Yes No Other Doctors seen for this condition: What other things have you done to try to relieve this problem:

Over the counter medication Heat Stretching

Prescription medication Ice Exercise

Other:

Second condition that I am concerned with: Location of Pain: When it began: How did it occur:

The pain is: Sharp Dull Burning

Pressure Itching Pins & Needles

Other:

% of time with pain: 0---10--20--30--40---50---60--70--80--90--100 or constant pain Intensity of pain: 0 or no pain—2——4——6——8——10— or unbearable pain

Does the discomfort radiate or extend from one point to another? Yes No If yes, please describe:

Condition is aggravated by: Relieved by: Affect on daily activity: Affect on sleep:

Progress: Getting worse Staying the same No change

Related to fall or accident: Yes No

Has this ever happened before: Yes No Other Doctors seen for this condition: What other things have you done to try to relieve this problem:

Over the counter medication Heat Stretching

Prescription medication Ice Exercise

Other:



Patient History

Are you seeing anyone else for other problems or health conditions? □ Yes □ No Please list the problem/s, date problem/s began, and Provider/s treating you for the condition/s: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Past health history Have you been diagnosed with Diabetes Yes No

□ □

Type I____or Type II_____ If yes, include date & provider seen_________________

Past injuries or surgeries: Date Description Falls Automobile accidents Head injuries Broken bones Dislocations Surgeries Please list any other pertinent past health problems such as broken bones, auto accidents, hospitalizations, etc. Family history: Please list any pertinent family health history problems such as heart disease, cancer, rheumatoid arthritis, etc. Age Pertinent health problem Father Mother Brother Sister

Medications What medications are you currently taking? Include vitamins, herbs, minerals… List Date Started, Brand Name, Generic Name, Strength, Dosage, Frequency, Duration, Quantity, Refills Available, Prescribed by Please be as specific as possible

HEALTH HABITS

Do you smoke? No Yes ______ packs/day

Do you drink alcohol? No Yes ______ drinks/day

Do you drink coffee? No Yes ______ cups/day

Do you exercise regularly? No Moderate Daily

Do you wear Heel lifts Sole lifts

Inner soles Arch supports



Do you have allergies? □Food □Environmental □Medication List Type of Allergy and Reaction _________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ Psychiatric:

Have you ever been diagnosed with a mental disorder? Yes No If yes, please explain:

Who may we thank for referring you to our office?

Have you been adjusted by a Chiropractor before? Yes No Reason for those visits? Doctor’s Name Approximate date of last visit

Has any adult in your family seen a Chiropractor? Yes No

Has any child in your family seen a Chiropractor? Yes No

EXPERIENCE WITH CHIROPRACTIC

Were you aware that:

…Doctors of Chiropractic work with the nervous system? Yes No

…the nervous system controls all bodily functions and systems? Yes No

…Chiropractic is the largest natural healing profession in the world? Yes No …if Chiropractic care starts at birth, one may achieve a

higher level of health throughout life? Yes No Thank you for referrals!

EXPERIENCE WITH CHIROPRACTIC PRINCIPLES

GOALS FOR MY CARE

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program. Please check the type of care desired to that we may be guided by your wishes whenever possible.

Relief Care – Symptomatic relief of pain or discomfort.

Corrective Care – Correcting and relieving the cause of the problem as well as the symptoms.

Comprehensive Care – Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care.

I want the Doctor to select the type of care appropriate for my condition. Patient’s Signature Date



PROFESSIONAL FEE STATEMENT FOR SERVICES Consultation and Comprehensive Orthopedic/Neurological Exam $60 - $150

Routine X-Ray Series (Cervical and Lumbar) $120 X-Ray per Area $40-110 Basic Office Visit (Adjustment) $40 - $90 Neuromuscular Re-education $40 Manual Traction $22 House Calls, After Hours or Emergency $50 - $100 Our experience has shown that it is wise to have an understanding with our patients as to our office policies and fees. Therefore, this form has been prepared for your convenience and information. We offer several methods of payment for your Chiropractic care at our office and you may choose the plan that you prefer. This information will enable use to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well-being and we will do our best to help you. Agreement: At Salina Family Chiropractic we do our best to estimated correct payments by third parties. At times a client will have a balance. For your and our convenience we require authorization to bill your credit or debit card for services rendered. I have read and agree to the above fee statement and credit authorization. (Patient's Signature) (Date)

Authorization: In addition, if applicable, this authorizes my provider of medical services, including but not limited to: physicians, hospitals, therapists, chiropractors to disclose and furnish all types of medical information pertaining to my condition and to their care and treatment of me, including charges for the purpose of this authorization. I authorize the medical personnel to release and provide copies of the requested information for the financial settlement, referral of, treatment, processing claims, evaluation of, settling or litigation of my case/condition. This authorization shall remain valid unless I choose to revoke it earlier in writing. My signature below specifically allows the release of medical records (if signing as parent/guardian, please indicate) for purposes of account collection/patient referral. (Patient's Signature) (Print Name) (Date)

I understand and agree that health and accident insurance policies are an arrangement between me and my insurance carrier. I also understand that Salina Family Chiropractic will prepare the necessary reports and forms to assist me in collecting from the insurance company for visits considered to be medically necessary. Any amount authorized to be paid directly to Salina Family Chiropractic will be credited to my account on receipt. Insurance Co Name Group/Policy No. Claim Address Phone

About the Insured Person on the Policy Name Insured’s Social Sec # Relation Insured’s Date of Birth

Employer

ABOUT MY INSURANCE



Acknowledgement of Notice of Privacy Practices

My signature below acknowledges that I have had an opportunity to view and/or receive a copy of the Provider’s Notice of Privacy Practice. I acknowledge that I have the right to request a restriction of my protected health information. Signature Date To restrict your health information in our office, please check mark those that apply: _______ I do NOT want to receive clinic mailings (newsletters, birthday cards, etc) _______I would like the following entities to have access to my information:

Signature Date

Informed Consent For Chiropractic Care

Chiropractic care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral artery injury that could lead to stroke. Prior to receiving chiropractic care at Salina Family Chiropractic, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spine health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care. I understand and accept that there are risks associated with chiropractic care and give my consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment. __________________________ _______________________ Patient Name (printed) Relationship to patient __________________________ _______________________ Patient or legal Guardian Signature Date __________________________ _______________________ Witness Signature (office staff) Date

patient health record patient file no. - spokane...

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