WELCOME PATIENT INFORMATION

Transcription

1 WELCOME PATIENT INFORMATION Date SS# Patient Name Last Name First Name Middle Initial Address City State Zip Code Sex M F Age Birth date Married Widowed Single Minor Separated Divorced Partnered for years Occupation Patient Employer/School Employer/School Address Spouse s Name Birth date Spouses s Employer Whom may we thank for referring you? Do you have Insurance? Yes No If Yes, Who: PHONE NUMBERS Home Phone ( ) Cell Phone ( ) Best time to reach you IN CASE OF EMERGENCY, CONTACT: Name Relationship Home Phone ( ) Reason for Visit When did symptoms occur? Is this condition getting progressively worse? Yes No Have you had this problem before? Yes No If Yes, when? Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain): Sleep Habits: Difficulty Falling Asleep Yes No Difficulty Staying Asleep Yes No Urine: How Often: Frequent Scanty Color: Clear Yellow Dark Yellow Bowel Movements: How Often: Constipation Yes No Diarrhea Yes No Odor Yes No Loose Yes No Color Black Brown Mucous Flatulence Yes No Chills/Fever Yes No Perspiration Yes No Spontaneous Diet Cravings: Sweet Salt Spicy Sour Pepper Menses: (Women Only) Clotting Yes No Pain Yes No Length Abnormal Normal Duration Abnormal Normal Color Abnormal Normal Quality Abnormal Normal Flow Scanty Heavy Normal Onset/Age NATURAL CARE WELLNESS CENTER 6 SEELEY LANE, ELIOT, ME PATIENT CONDITION Birth Controls Yes No Age Hormone Replacement Therapy: Yes No If yes, When Discharge Yes No What treatment have you already received for your condition? Medications Surgery Physical Therapy Chiropractic Services None Other Name and address of other doctor(s) who have treated you for your condition: Date of your last Physical Exam Date of your last X-Ray: Work Phone ( )

2 PATIENT INFORMATION 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 Disease Yes No Tumors, Growths Yes No Breast Lump Yes No Heart 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 Dependency Yes No High Cholesterol Yes No Psychiatric Care Yes No Other Chicken Pox Yes No Kidney Disease Yes No Rheumatoid Arthritis Yes No Liver Disease 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 Other Medications: Allergies: Vitamins/Herbs/Minerals: FOR DOCTOR USE ONLY: DO NOT WRITE BELOW Spirit: Complexion: Pale Yellow Red Blue Green Odor: Sweet Scorched Rotten Putrid Voice: Fast Slow SingSong Hollow Deep Angry: Yes Meek: Yes No Fast: Yes No Body Color: White Yellow Other Tongue: Red Pale Purple Spots White Yellow Dry Yellow Scalloped Toothmarked Size & Shape: Large Swollen Stiff Flaccid Long Short Cracked Quivering Deviated Toothmarked Pulse: Rapid Slow Full Empty Wiry Slippery Big Minute Superficial Deep Frail Tight Long Short Knotted Soggy Intermittent Hidden Hollow Leather Hurried Flooding Confined Scattered Other Information:

3 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.

4 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:

5 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: