WELCOME PATIENT CONDITION

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1 NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME WELCOME PATIENT CONDITION PATIENT INFORMATION Date Reason for Visit SS# Patient Name Last Name First Name Middle Initial Address Do you suffer from symptoms or problems with any of the following?: Arthritis Asthma Allergies Colitis Constipation Diabetes City Diarrhea Diverticulitis Hemorrhoids State Zip Code Headaches Heart Problems Candidiasis Fatigue Bad Breath Indigestion Backache Kidney Prostate Uterus Skin Disorders Eye Sex M F Age Birth date Married Widowed Single Minor Separated Divorced Partnered for years Foot aches Cancer Do you use? Genitals Gastritis Bleeding w/stools IBS Aspirin Antacids Occupation Patient Employer/School Employer/School Address Bowel Movements? Number per day Color Odor Shape Spouse s Name Birth date Spouses s Employer Do you receive chiropractic care? Yes No Whom may we thank for referring you? Do you have Insurance? Yes No If Yes, Who: If Yes, how often? Do you know your blood pressure? Do you know your pulse rate? PHONE NUMBERS Home Phone ( ) Cell Phone ( ) Best time to reach you IN CASE OF EMERGENCY, CONTACT Name Relationship Home Phone ( ) Work Phone ( )

2 PATIENT INFORMATION What treatment have you already received for your condition: Medications Surgery Other None Date of your last Physical Exam: Date of your last Colonoscopy: Is there any thing else you would like the doctor to know about your condition? Place a mark on Yes or No to indicate if you have had any of the following: AIDS/HIV Yes No Diabetes Yes No Migraine Headaches Yes No Rheumatic Fever Yes No Alcoholism Yes No Emphysema Yes No Miscarriage Yes No Scarlet Fever Yes No Allergy Shots Yes No Epilepsy Yes No Mononucleosis Yes No Stroke Yes No Anemia Yes No Fractures Yes No Multiple Sclerosis Yes No Suicide Attempt Yes No Anorexia Yes No Glaucoma Yes No Mumps Yes No Thyroid Problems Yes No Appendicitis Yes No Goiter Yes No Osteoporosis Yes No Tonsillitis Yes No Asthma Yes No Gonorrhea Yes No Pacemaker Yes No Tuberculosis Yes No Bleeding Disorders Yes No Gout Yes No Parkinson s Diseases Yes No Tumors, Growths Yes No Breast Lump Yes No Hear Disease Yes No Pinched Nerve Yes No Typhoid Fever Yes No Bronchitis Yes No Hepatitis Yes No Pneumonia Yes No Ulcers Yes No Bulimia Yes No Hernia Yes No Polio Yes No Vaginal Infection Yes No Cancer Yes No Herniated Disk Yes No Prostate Problem Yes No Venereal Disease Yes No Cataracts Yes No Herpes Yes No Prosthesis Yes No Whooping Cough Yes No Chemical High Cholesterol Yes No Psychiatric Care Yes No Other Dependency Yes No Kidney Disease Yes No Rheumatoid Chicken Pox Yes No Liver Disease Yes No Arthritis Yes No Measles Yes No Exercise: None Moderate Daily Heavy Work Activity: Sitting Standing Light Labor Heavy Labor Habits: Smoking Alcohol Coffee/Caffeine Drinks High Stress Level Packs/Day Drinks/Week Cups/Day Reason Are you Pregnant? Yes No If Yes, Due Date Injuries/Surgeries you have had: Such as: Falls Head Injuries Broken Bones Dislocations Medications: Allergies: Vitamins/Herbs/Minerals:

3 NAME D.O.B. ADDRESS PHONE OCCUPATION SEX HEIGHT WEIGHT CHILDREN Please list any prescription medications, herbs, vitamins, and/or supplements: Please list any surgeries you ve had and the dates of surgeries: Do you suffer from symptoms or problems with any of the following: arthritis asthma allergies colitis constipation diabetes diarrhea diverticulitis hemorrhoids heart problems headaches candidiasis fatigue bad breath indigestion backache kidney prostate uterus skin disorders eye footaches genitals gastritis cancer Do you use? aspirin antacids cigarettes alcohol coffee Bowel movements: Number per day color odor shape Do you receive chiropractic care? Yes No How often? Exercise: How often? What type? Do you know your blood pressure? Pulse rate Is there anything you would like the doctor to know about you? I, the undersigned, hereby acknowledge that Jody Ferreira, DC has not, is not, and will not prescribe (order for use as medicine) for me at any time, and I, the undersigned, will not hold them accountable for such. The therapist is helping me with natural hygiene at my request, and is not diagnosing for treating disease, nor practicing any form of medicine. Signature Date

4 NATURAL CARE WELLNESS CENTER DR. SCOTT AND DR. JODY FERREIRA 6 SEELEY LANE (RT. 236) ELIOT, ME INDIVIDUAL PATIENTS AUTHORIZATION This authorization is to confirm or deny the use or disclosure of protected health information. Patient s Name: Date: Please initial on all that apply. If you do not agree with any statements, please mark an X on the blank to confirm that you have read and understood the statement. I authorize the release of my medical records to my family practitioner or other physician. List Names I authorize the release of my medical records to my health insurance company for payment of services rendered. I authorize the release of my medical records to any third party payer including insurance, workman compensation, attorney, auto insurance, etc. I authorize NATURAL CARE WELLNESS CENTER to send information to my house concerning birthdays or newsletters, etc. I authorize NATURAL CARE WELLNESS CENTER to leave any message on my home or work answering machine such as appointment time.

5 NATURAL CARE WELLNESS CENTER DR. SCOTT AND DR. JODY FERREIRA 6 SEELEY LANE (RT. 236) ELIOT, ME AUTHORIZATION, ASSIGNMENT AND CONSET TO TREAT Our office policy requires payment in full for all services rendered a the time of visit, unless other arrangements have been made with the business manager. If the account is not paid within 90 days of the date of service, and no financial arrangement has been made, you will be responsible for any expenses incurred in collecting your account., I hereby authorize NATURAL CARE WELLNESS CENTER to bill the insurance company for services rendered on my behalf. The bulling of such services are a privilege and not a guarantee of coverage. I further authorize the physician and/or supplier to release any information required to process insurance claims., I authorize the direct payment to you any sum I now or hereafter owe, by my attorney out of the proceeds of any settlement of my case, and/or by any insurance company obligated to make payment to me or you based in whole or part upon the charges made for the services., I understand that whatever amounts you do not collect from the insurance company and/or attorney, whether it be all or part of what is due, I personally owe and agree to pay you. I hereby authorize the doctor s of NATURAL CARE WELLNESS CENTER and whomever they designate as their assistant or authorized representative to administer chiropractic care, acupuncture or colon hydrotherapy as they deem necessary. We invite you to discuss openly treatment, services, and charges rendered at this office, so that there is mutual agreement and clarity. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my medical status. Signature: Date: Signature of Guardian if Patient is under 18 years of age: Date:

6 PRIVATE PRACTICES ACKNOWLEDGEMENT I HAVE RECEIVED THE NOTICE OF THE HIPPA PRIVACY PRACTICES AND I HAVE BEEN PROVIDED AN OPPORTUNITY TO REVIEW IT. NAME: BIRTHDAY SIGNATURE: DATE:

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