Welcome to Active Care Atlanta

Transcription

1 Welcome to Active Care Atlanta Name Birth Date Age Male Female Cell # Home # Work # Address City, State & Zip Occupation Employer Social Security # - - Marital Status Single Married Divorce Other Emergency Contact Relation Phone # How did you hear about us? o Friend/Family Online Insurance Website Attorney o Event Sign Physician s Referral Other 1. Reason for today s visit 2. What s your current pain level now? No pain Worst 3. Indicate the area(s) showing the type of discomfort you have using the provided markings. Aching Dull Pain //// Stabbing r Tingling * Numbness Pins & Needles Burning 4. Is this visit related to an auto accident or work related injury? No Yes Incident Date 5. How long have you had the symptom? 6. If you ve had the issue before, When 7. What caused the symptom/injury to occur? Don t know 8. What makes it better? 9. What makes it worse? 10. List any other doctors and type of treatment received for above conditions When 11. Have you had Xray, MRI, CT, etc. for the condition? When & Where 12. List all medications you are currently taking (OTC, Prescriptions, Vitamins, Herbs...) 13. Have you had previous chiropractic care? More than 30 times 10 to 30 times Less than 10 times Never 14. Can you perform daily home activities? All Some None 15. Rate your stress level over the last 30 days? Low High 16. FEMALE ONLY» Is there any chance that you are pregnant? No Yes / Maybe

2 Review of Systems: Do you have any of the following? (Check all that apply)) ENDOCRINE SKIN CONDITIONS HEMATOLOGIC CARDIOVASCULAR n None of below past current n None of below past current n None of below past current n None of below past current Thyroid Rash or Itching Hepatitis Poor Circulation Diabetes Change in skin color Blood Clots High Blood Pressure Hair Loss Lumps / Masses Cancer High Cholesterol Menopause Varicose Veins Easily Bruising Heart Disease Appetite Change Bleeding Heart Attack CONSTITUTIONAL NEUROLOGIC GASTROINTESTINAL Aortic Aneurism n None of below past current n None of below past current n None of below past current Pace Maker Weight Loss/Gain Stroke Gall Bladder Jaw Pain Low Energy Seizures Bowel Problems Irregular Heartbeat Chills/Fever Head Injury Diarrhea Swelling of Legs Night Sweats Brain Aneurysm Constipation Chest Pain PSYCHIATRIC Pinched Nerves Liver Problems EYES n None of below past current Parkinson s Ulcers n None of below past current Depression/Anxiety Carpal Tunnel Nausea/Vomiting Glaucoma Stress Vertigo Bloody Stool Double Vision Memory Loss Blurred Vision MUSCULOSKELETAL EAR/NOSE/THROAT GENITOURINARY RESPIRATORY n None of below past current n None of below past current n None of below past current n None of below past current Gout Difficulty Swallowing Kidney Disease Asthma Arthritis Dizziness Kidney Stones Tuberculosis Muscle Weakness Hearing Loss Frequent Urination Short of Breath Osteoporosis Nosebleeds Burning Urination Pneumonia Broken Bones Bleeding Gums Blood in Urine Frequent Cough Joint Replacement Please list other conditons not listed above 1. List all surgeries you have had in the past 2. Have you had a car accident before Never Yes When 3. Family History: Tell us about any conditions your immediate family members are being treated for Social History 4. Do you consume alcohol? No if yes, Beer Liquor Wine How much & often? 5. Do you consume caffeine? No if yes, Coffee Soda Tea How much & often? 6. How s your diet? Healthy/Controlled Gluten Free/Paleo Vegetarian High Fat High Protein High Carbohydrate High Fiber High Sugar High Salt Low Fat Low Protein Low Carbohydrate Low Fiber Low Sugar Low Salt Other 7. Do you smoke? No if yes, How much, often & long have you been smoking? 8. Do you exercise? None days /week Stopped recently What type 9. Does your condition limit your exercise level? A lot Some No The above information is true and accurate to the best of my knowledge. Patient / Guardian s Name Signature Date ACTIVE CARE ATLANTA, T: F:

3 Auto Accident Report 1. Date of the accident: 13. Did you get an estimate for car repair? Yes Amount $ Not yet Totaled 2. Were you the? Driver Rear Passenger Front Passenger Pedestrian 3. Was the vehicle struck from the? Behind Front Left Side Right Side Other 4. Who is at fault? Myself Opponent Both 5. Were there other people in the car? Yes How many? No 6. Were you wearing a seat belt? Yes No 7. Did your air bag deploy? Yes No 14. What Model and Year is your car? Model Year 15. Did you go to the hospital? Yes No If Yes, When Where What X-ray CT Scan MRI Scan Medication Splint Dressing None/Other 16. Have you seen any other medical providers since your accident? Yes No If Yes, Doctor s name 8. Did you lose consciousness upon impact? Yes for how long? No 17. Do you have an attorney for this accident? Yes No If Yes, Name & contact info 9. Did you suffer any cuts or contusions? Yes where? No 10. Did you have any dislocations or fractures? Yes where? No 11. Did the police come to the accident scene? Yes - Please provide us a police report 12. Did the accident happen in GA? Yes Other state No If No, Interested in consulting with an attorney? Yes Possibly No 18. Have you opened a claim yet? Yes Not yet If Yes, under My ins. Opponent ins. Both Insurance name Claim # Adjuster name Adjuster phone # The above information is true and accurate to the best of my knowledge. Patient / Guardian s Name Signature Date

4 Payment Policies & Procedures (Please initial below) Auto Accident, Worker s Comp. or Slip and Fall: If Active Care Atlanta agrees to wait for my settlement, I am responsible to make sure that Active Care Atlanta receives payment for services rendered at the time my case is settled. Our cancellation fee is $25.00 for a missed appointment without letting us know 4 hrs before appointment time. There will be a $25.00 service charge on all returned checks. Acknowledgement of Receipt of Notice of Privacy Practices: I acknowledge that I received the Active Care Atlanta Notice of Privacy Practices. Guardian of under 18 yr: I give permission for my child to be treated when I am not present. Yes No Assignment of Benefit I direct and authorize my insurance company or attorney to make payments DIRECTLY to ACTIVE CARE ATLANTA for any and all benefits due as a result of my treatment. In the event that payment is mailed directly to me from an insurance company, I will bring in the check within 2 weeks of receipt. I become fully financially responsible for any and all charges incurred in the course of my treatment, including services not covered or paid by my insurance. I hereby authorize ACTIVE CARE ATLANTA to: (1) release any information necessary to my insurance carriers and attorney to secure payment of benefits; (2) process insurance claims generated in the course of treatment; (3) issue a complaint to my insurance carriers or the Insurance Commissioner on my behalf if necessary. A photocopy of this assignment is to be considered as valid as an original. Patient / Guardian s Name Signature Date

5 Notice of Chiropractic Provider Lien I authorize ACTIVE CARE ATLANTA to furnish you, my attorney, with a full report of their treatment of myself regarding the accident in which I was recently involved. I authorize and direct you, my attorney, to pay directly to ACTIVE CARE ATLANTA sums due for medical services rendered to me both by reason of this accident and by reason of any other bills that are due to ACTIVE CARE ATLANTA. You, my attorney, are to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate ACTIVE CARE ATLANTA. Furthermore, I give a lien on my case to ACTIVE CARE ATLANTA against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or myself, as a result of the injuries for which I have been treated. I agree never to rescind this document and that a rescission will not be honored by you, my attorney. I instruct that in the event another attorney is substituted in this matter, the new attorney will inherit and honor this lien as if it were executed by him/her. I understand that I am directly and fully responsible to ACTIVE CARE ATLANTA for all medical bills submitted by ACTIVE CARE ATLANTA for services rendered to me and that this agreement is made solely for ACTIVE CARE ATLANTA S additional protection and in consideration of their awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. Please acknowledge this letter by signing below and returning to ACTIVE CARE ATLANTA. I have been advised that if my attorney does not wish to cooperate in protecting ACTIVE CARE ATLANTA S interest, ACTIVE CARE ATLANTA will not await payment but may declare the entire balance due and payable. Patient / Guardian s Name Signature Date The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect and fully compensate ACTIVE CARE ATLANTA. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney s fees and costs. Attorney Name Signature Date