Schoonman Chiropractic & Rehabilitation Center Paul M. Schoonman, D.C. 11 Chestnut Street Suite 7 Andover, MA 01810

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1 Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number: (Home) (Work) Social Security Number: Date of Birth: Occupation: Male ( ) Female ( ) Emergency Contact Information: Name: Phone Number: Acceptance as Patient: I understand and agree that the doctor(s) of Schoonman Chiropractic have the right to refuse to accept me as a patient at any time before treatment begins. The taking of history and conducting a physical evaluation are not considered treatment, as this is part of the process of information gathering, for the doctor to determine if you are a the right candidate for care in this office. Insurance Policy: Schoonman Chiropractic & Rehabilitation will process your insurance forms upon request. We will do our utmost to provide sufficient information to your carrier to obtain payment for your treatment. We have found, in some instances, insurance companies will deny or reduce payment despite our best efforts to demonstrate necessity of care. In the event that full payment is not made for any reason, you are responsible the full balance on your account. Date: Signature:

2 Patient Consent Form I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: 1 Conduct, plan and direct my treatment and follow-up among multiple healthcare providers who may be involved in that treatment directly and indirectly. 2 Obtain payment from third-party payers. 3 Conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address listed above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are legally bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name: Signature: Relationship to Patient: Date:

3 I authorize and direct that payment be made to: Assignment of Benefits Paul M Schoonman, DC. Schoonman Chiropractic and Rehabilitation For any and all insurance benefits or reimbursement for services rendered by him which amounts would otherwise be payable to me under any insurance or pre-paid health care plan. Date: Signature: Release of Information. I authorize the release of information concerning my health and health care services to my insurance companies, pre-paid health care, Medicare of Medicaid. Date: Signature: Payment Agreement. I understand that there is no guarantee that my insurance companies or pre-paid health care plan will cover or pay for all of my charges. Notwithstanding denial, reduction of benefits or failure to pay for any reason, I understand that I am responsible for all remaining charges. Date: Signature:

4 Health Information Major Complaint: Other Complaints: How long have you had this condition? Have you had similar conditions in the past? Is this condition interfering with your Work Sleep Daily Routine How long has it been since you felt good? What aggravates this condition? Is your pain worse at Night Morning Daytime What helps this condition? Please list any other healthcare providers you have seen for this condition: Do you have a pacemaker? Yes No If yes, please inform the doctor. Do you have a history of fainting? Yes No If yes, please inform the doctor. Have you had any surgeries, falls, or accidents? If yes, please explain:

5 Medical History Date: Patient Name: Please check yes or no to the conditions listed below: Do you have chest pain? Do you have any change in bowel or bladder habits? Do you have a sore that does not heal? Do you have unusual bleeding or discharge? Do you have any thickening in your breasts or elsewhere? Do you have indigestion or difficulty swallowing? Do you have any change in warts or moles? Do you have a nagging cough or hoarseness? Do you have headaches for hours or days? Do you have blurred vision? Do you have night sweats? Do you have pain in the neck, jaw or face? Do you have a drooping eyelid or changes in your pupils? Do you have vertigo (dizziness)? Do you have double vision? Do you have any visual disturbances? Do you have any nausea or vomiting? Do you have any slurred speech? Do you have any ringing in your ears? Do you take birth control pills? Have you ever had cancer? Does pain ever wake you up from a sound sleep? Are you losing weight without trying? Are you coughing up blood or noticing it in your stools or urine? Have you had any loss of bowel or bladder control? Have you lost consciousness or had double vision recently? Please list any prescription medications you are taking, if any: Please list any over-the-counter medications or supplements you are taking:

6 Family History In chart below, please indicate if your mother, father, or both have any of the following: Condition Mother Father Both High Blood Pressure Heart Attack Emphysema Seizures-Convulsion HIV Positive Asthma Diabetes Kidney Disease Pacemaker Ulcer or Stomach Problems Stroke Arthritis-Rheumatism Mental Illness Thyroid Disease Circulation Problems Cancer Osteoporosis Comments:

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