TB Yes No Cancer Yes No Diabetes Yes No Asthma Heart Disease Kidney Disease Lung Disease Colon Disease Gaul Bladder Disease

Transcription

1 DATE CHIROPRACTIC CASE HISTORY DA FORM Last Name First Name Middle Name Address City State Zip Mailing Address City State Zip Home phone Work phone Cell phone Social Security # Date of Birth / / Age Sex F M Married Single Widow/Widower Divorced In Case of Emergency call: Name Phone # Occupation or type of work you do Employer Spouse name Occupation Employer How did you learn about our office? Who referred you? FAMILY HISTORY Parents: Father (age) Mother (age) Brothers Sisters Has anyone in your family ever had? Family History TB Yes No Cancer Yes No Diabetes Yes No Asthma Heart Disease Kidney Disease Lung Disease Colon Disease Gaul Bladder Disease Liver Disease Female Disease/condition Personal History Mark the childhood diseases you had or vaccines you had: Measles or Vaccines Yes No Mumps or Vaccine Yes No Chicken Pox or Vaccine Yes No Polio or Vaccine Yes No Any other Childhood dis. Date of you last medical physical examination Has any physician treated you for any health condition in the last year? YES NO If, yes tell what you were treated for. Circle on or Fill in the blank: Language spoken at home Do you speak more than one Language? YES NO If yes, what languages do you speak? Ethnicity: Are you Hispanic? YES NO What race are you? I understand and agree that the health and accident policies are an agreement between my insurance company and myself not between my insurance company and this office. I authorize this chiropractic clinic to release any medical information and to complete any usual and customary reports and forms at no charge to assist in collecting from my insurance company. If mine is a regular health insurance case, I agree to pay a percentage of services as they are rendered. However, I understand that I am ultimately responsible for payment in full at this office, Redus Chiropractic Care, Inc. I also understand that if I suspend or terminate my schedule of care, as determined by my treating doctor, any fees for professional services will be immediately due and payable. I agree that the above mentioned Office be given power of Attorney to endorse/sign my name on any and all check for payment of my doctor bill. HEALTH INSURANCE: YES NO INSURANCE COMPAY NAME

2 With my signature, I hereby state that all of the above information is truthful and accurate. I have read and fully understand the above information Signature of Patient Date Guardian Signature Authorizing Care Date Page 1 B 07/06/2012

3 PATIENT INTAKE FORM #1A PLEASE FILL OUT PAGE #la AND #lb FOR EACH PROBLEM THAT YOU ARE SEEING DR. REDUS FOR TODAY Patient Name: Date. File# DOB Phone#(H) (C) 1. Is today's problem caused by: o Auto Accident o Workman's Compensation -Other 2. Indicate on the drawings below one problem where you have pain/symptoms use another intake form for each problem 3.For each of the conditions listed below: Place a check in the "PAST" column if you have had the condition in the "PAST" If you PRESENTLY have a condition listed below, place a check in the "PRESENT" column. Past Present Past Present Past Present 0 o Headaches 0 o High Blood Pressure 0 o Diabetes 0 o Neck Pain 0 o Heart Attack 0 o Excessive Thirst 0 o Upper Back Pain 0 o Chest Pains 0 o Frequent Urination 0 o Mid Back Pain D o Strol<e D _ Eat Extra during Stress 0 o Low Back Pain 0 oangina 0 o Drug/Alcohol Dependence 0 o Shoulder Pain 0 o Kidney Stones D o Allergies 0 o Eibow/Upper Arm Pain 0 o Kidney Disorders 0 o Depression D o Wrist Pain 0 o Bladder Infection 0 o Systemic lupus 0 o Hand Pain 0 o Painful Urination o Epilepsy 0 o Hip Pain 0 o Loss of Bladder Control o o Dermatitis/Eczema/Rash 0 o Leg Pain 0 o Prostate Problems 0 o HIV/AIDS 0 o Knee Pain 0 o Abnormal Weight Gain/Loss 0 o Ankle/Foot Pain 0 o Loss of Appetite For Females Only 0 ojaw Pain 0 o Abdominal Pain 0 o Birth Control Pills 0 o Joint Pain/Stiffness 0 o Ulcer 0 o Hormonal Replacement 0 o Arthritis 0 o Hepatitis 0 o Pregnancy 0 o Rheumatoid Arthritis 0 o Liver/Gall Bladder Disorder 0 o Cancer 0 o General Fatigue Other 0 o Tumor 0 o Muscular In coordination 0 oasthma 0 o Visual Disturbances 0 o Chronic Sinusitis 0 o Dizziness ANSWER QUESTION ON BACK OF THIS PAGE

4 PAGE #18 PATiENT INTAKE FORM ' 4. How often do you experience your symptoms? o Constantly ( % of the time) o Occasionally (26-50% of the time) o Frequently (51-75% of the time) o Not Often (1-25% ofthe time} 5. How would you describe your pain? o Sharp o Numb o Dull o Tingly o Spreads out o Sharp with motion o Achy o Shooting with motion o Burning o Stabbing with motion o Shooting o Stiff o Electric like with motion o Other: 6. How are your symptoms changing with time? o Getting Worse o Staying the Same o Getting Better 7. Using a scale from 0-10 {10 being the worst), how would you rate your problem? (Please circle) 8. How much has the problem interfered with your work? Not at ail A little bit Moderately Quite a bit Extremely 9. How much has the problem interfered with your social activities? Not at all A little bit Moderately Quite a bit Extremely 10. Who else have you seen for your problem please fill in name below? Chiropractor (Chiropractor other than Dr. Redus), Neurologist Primary Care Physician ER physician.~ Orthopedist other Massage Therapist Physical Therapist No one_ 11. How long have you had this problem? years _months _days _weeks _too long ago 12. How do you think your problem began? Poor posture auto accident work injury from a fall playing golf Exercising sports injury unknown cause other 13. Do you consider this problem to be severe? Yes Yes, at times No 14. What makes your problem worse? Sitting Standing Bending Lifting Walking Throwing Any kind of movement Lying down Other 15. What gives you relief? Stretching Sitting Lying down Exercise Walking Ice Heat Medication Nothing Other 16. What concerns you the most about your problem? Interferes with work daily activities exercising social activities driving vehicle 17. What does it prevent you from doing?

5 PAGE#2A PATIENT INTAKE FORM 18. What is your Height. _ Weight Date of.birth Occupation/ What type of work do you do? How would you rate your overall Health? Excellent Very Good Good Fair Poor 21. What type of exercise do you do? Strenuous Moderate Light None 22. Indicate if you have any immediate family members with any of the following: Rheumatoid Arthritis Diabetes Lupus Heart Problems Cancer ALS 23. List ail prescription medications you are currently taking: List all prescription medications to which you are allergic 24 List au of the over-the-counter medications you are currently taking: List a! I of the over the counter medications to which you are allergic. 25. Have you ever used any form of tobacco? NO YES If yes circie all of the statements that apply to you: Former Smoker Former Dipper Former Chewer Presently Smoke Presently Dip Presently Chew Use Every day Use it some days 26. List a~l surgical procedures you have had: 27. What activities do you do at work? Sit: o Most of the day o Half the day Stand: o Most of the day o Half the day Computer work: o Most of the day o Half the day On the phone: o Most of the day o Half of the day o A little ofthe day o A little of the day o A little of the day o A little of the day 28. What activities do you do outside of work? ANSWER QUESTIONS ON BACK OF THIS PAGE

6 PAGE # 28 PATIENT INTAKE FORM 29. Have you ever been hospitalized? NO YES If yes, circle the reason why? Surgeries Illness Childbirth 30. Have you had significant past trauma? NO YES List trauma Is there anyl:hing else pertinent to your visit that you want to discuss with the doctor today? Patient Signature Date

7 Redus Chiropractic Care Dt. Cleve Redus 302 Main Street Jacksbor o, TN Telephone: Fax: Dear Sir 'or Madam: "" Our patient has asked that we request that be sent to our oft1ce so that we might render a more complete diagnose of this cas<~. Following is the patient's social security number and date of birth: Patient: SS#: DOB: Thanl{ you for your prompt attention to this. Sincerely, Cleve Redus, D.C. TN Lie. #DC Date: Ci1ty & State: KNOW ALL MEN BY THESE PRESENTS: ThM I, have requested the release of which are a part of the ofiicc records of relating to my case, and 1 her cby release and forever discharge the aforesaid Dr. from any and all responsibility of liability of any kind, nature or char acter whatsoever from the beginning of the world to this day. This transaction is consummated at my specific request. PLEASI~ Ji'lLL IN INFORMATION Witness Patient Dr. or Clinic's Address: --- Dr. or Clinic's Phone#: Fax#:

8 REDUS CHIROPRACTIC CARE Dr. Cleve Redus 302 Main St. Jacksboro, TN CONTACT NUMBERS IN CASE OF EMERGENCY: Name: Phone Number: --- Name: Phone Number: --- Name: Phone Number:

9 FINANCIAL ARRANGEMENT POLICY Dear Patient: Our financial policy has been established to ensure that the best services can be provided to you and your family, and any misunderstanding can be avoided....,. Our professional services are rendered to the patient and not to the insurance company. The patient is responsible for payment to the doctor, and the insurance company is responsible to the patient. We will file your insurance claims for you and you will be responsible for the part they do not pay. We will not provide services on the assumption that the charges will be paid by the insurance company or another third party payer. \1\/ITH OR WITHOUT INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR FULL PAYMENT OF YOUR TOTAL BILL. PAYMENT IS DUE AND PAYABLE AS SERVICES ARE RENDERED. Please indicate the manner you wish to handle your account ~~-1 will pay cash/check/debit or credit card the day of treatment. 2.!have insurance and will pay my portion the day of treatment. Name of insurance company: ~1 have no insurance and would like to apply for ChiroHealth USA Discount Program. ChiroHealth USA cannot be used with an insurance policy. 4. This is covered by Worker's Compensation. Name of Insurance Company: ,c This is covered by Personal Injury (auto accident, etc.) Claim. I request this office to file the accident claims with my automotive medical insurance or auto insurance company responsible for payment of my medical bills related to this accident. Name of Auto Insurance: This is a Personal injury (auto accident, etc.) Claim. i request this office to file the claims related to this accident with my attorney. Name of Attorney: Patient Signature: --, Date: ~~~~~-

10 DATE: A ~ J l r; ~ L J REDUS CHUtOPRACtU: CARE Dr. Cleve Redus 302 Main Street Jacksboro, TN Fax docredus.chiroweb.com RE: SSN: DOB: ~ DATE OF ACCIDENT: lnsuranc.e CO.: POLICY/CLAIM# Dr. Cleve Redus [ADIES & GENTLEMEN: License# DC Tax ld # Contact Person: Dana AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNIVIENT OF INSURANCE BENEFITS I hereby authorize Dr. Cleve Redus to release infonnation requested by the insurance cmtier. I assign to Dr. Cleve Redus the insurance benefits herein spec1fied and otherwise payable to me, but not to exceed the customary charges for this treatment, and authorize and direct the insurance carrier to make payment of said benefits directly to Dr. Cleve Redus. I understand I am financially responsible to Dr. Cleve Redus for charges not covered and paid by reason of this agreement. PROMISE OF PAY ACCOUNT For and in consideration of services rendered and to be rendered by Dr. Cleve Redus, Ilwe jointly and severally promise to pay all charges incurred foriihe account of the above nan1ed patient from admission to discharge. Signed: Date: (Patient) I hereby acknowledge receipt of the above assignment ofbenefits on behalf of the above named insurance company, ofwhich I am a duly authorized adjuster. Signed: Hate: (Adjuster)

11 REDUS CHIROPRACTIC CAR! Dr. Cleve Redus 302 Main Street Jacksboro, TN Fax l do hereby authorize Dr. Cleve Redus to furnish you my attorney, with a full report of his examination, diagnosis, treatment, prognosis, etc., of of myself in regard to the accident in which I was involved.., I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing him for medical service rendered me both by reason of this accident and by reason of any other bills that are due his office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said doctor_ I hereby further give a lien on my case to said doctor against any and all proceeds of my settlement, judgment of verdict which may be paid to you, my attorney, or myself as the result of tl1e injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor's additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by whicll I may eventually recover said fee. Dated: Patient's Signature: 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 said doctor above named. Dated: Attorney's Signature: Please date, sign and return one copy to the doctor's office. Keep one copy for your records.

12 REQUEST FOR ASSIGNMENT OF MEDICAL BENEFITS TO HEALTH CARE PROVIDER Name of Patient: Name of Insured (if different from patient): Insurance Company: ~~~- Health Care Provider: I am entitled to medical benefits under a policy of insurance written by the above msurancc company. I have received treatment for an injury from the above health care provider. As allowed by T.C.A t 20, l hereby assign to the above health care provider, from the medical benefits to which l am entitled, a sum of money sufficient to cover the charges of that health care provider for the services l have received. I hereby request that the above insurance company pay that money directly to the health care provider. l understand that the amount which is paid to the above health care provider may be limited by the amcnmts owed to other health care providers who have provided services to me for the same injury and by the amount of medical benefits to which I am entitled under the policy. lf the above insurance company does not permit the assignment of benefits, I hereby request that the company disburse the medical benefit sums to which l am entitled in the form of a check issued in the names of the insured and the above health care provider as joint payees and sent to the orfice of the provider. I understand that if the medical benefits available to me under the policy are insufficient to cover the charges of the above health care provider, I am responsible for paying that portion of the provider's charges not covered by insurance. Patient Date: Witness

13 ACCIDENT BILLING INFORMATION Redus Chiropractic Care Dr. Cl~ve Redus 302 Main Street -" Jacksboro, TN Phone 423~ Fax: Today's Date ~ Type of Accident: DOA:~ ~-- Patient's Narne: Patient's Phone: (H) ---~---~--(C) Patient's Address: Patient's Mailing Address:..,.. Patient's Home Address: ~ Patient's SS#: Insurance Co. Claim#: Phone#: Ins. Mailing Address: Adiustor: Phone#: ~ Fax#: ~---(C) Date attorney took the case; ~ Attorney's Name: Attomey's Phone: Fax#: Attorney's Mailing Address: P~rueg~=~ Phone:

14 AUTO ACCIDENT PATIENT INTAKE FORM Page# 1A Patient Name DOB DOA Claim# Phone (H) Date ~ ~- ~~- -~ File# What was the date of the accident? ---~ What time did the accident occur? How many vehicles were involved in the accident? What was the estimated damage to the vehicle you were traveling in? Dollar amount I don't know. 5. In which state did the accident occur? In which city did the accident occur? 7. Which street or intersection were you on when the accident occurred? In which direction were you traveling? North Northwest Northeast South Southwest Southeast East West 9. What type of impact was the auto accident? Head On Rear Ended The car was hit on: Front Driver's Side Front Passenger's Side Back Driver's Side Back Passenger's Side 10. Did your vehicle hit anything after the accident? If yes, please describe. 11. Where were you sitting in the vehicle during the accident? Front Driver's Seat Front Passenger Seat Passenger Seat Behind Driver Back Middle Passenger Seat Back Passenger Seat 12.Did you know the accident was coming? ~ In what type of vehicle were you riding? What type of vehicle impacted yours? At the time of impact how fast was your vehicle moving? 16. At the time of impact, how fast was the other vehicle moving? During and after the crash what happened to your vehicle? (Circle all that apply) Kept going straight / Stopped and remained in place Kept going straight hitting a car in front Spun Around Was hit by another vehicle Spun around and hit a stationary object Hit a stationary object Other-~ ANSWER QUESTIONS ON THE BACK OF THiS PAGE

15 PAGE# Did you lose consciousness during the accident? - YES NO 19. Ho~ was your head positioned during the accident? Facing Forward Facing Upward Facing Downward Turned Left "" Turned Right Other How was your body positioned during the accident? Bent Forward Turned Left Turned Right Bent Backward Turned Left Turned Right Sitting Correctly Facing Forward 21. How were your hands positioned during the accident? Both hands on Steering Wheel Left hand on Steering Wheel Right hand on Steering Wheel Both hands on Dashboard Left hand on Dashboard Right hand on Dashboard Hands on seat in front of you Hands resting by your sides Hands on ceiling Other 22. Did your head hit anything during the accident?- NO YES If yes, circle what your head hit. Windshield Steering Wheel Side door Dashboard Ceiling Car Frame Side window A Seat Another passenger other Did your face hit anything during the accident? -NO YES If yes, circle what your face hit. Windshield Dashboard Steering Wheel Side Door Ceiling Car Frame Side Window A Seat Anot~er passenger other 24. Did your shoulders hit anything during the accident? -NO YES If yes, circle what you hit. Windshield Steering Wheel Dashboard Side Door Ceiling Car Frame Side Window A Seat A Passenger Other 25. Did your neck hit anything during the accident? -NO YES If yes, circle what your neck hit. Windshield Steering Wheel Dashboard Side door Ceiling Car Frame Side Window A Seat A Passenger Other Did your chest hit anything during the accident?- NO YES If yes, circle what your chest hit. Windshield Steering Wheel Dashboard Side door Ceiling Car Frame Side Window A Seat Another Passenger Other Did your hips hit anything during the accident? NO YES If yes, circle what your hips hit Windshield Steering Wheel Dashboard Side door Ceiling Car Frame Side Window A Seat Another passenger other Did your knees hit anything during the accident? NO YES IF yes, circle what your knees hit. 29. Did your feet hit anything during the accident? NO YES If yes, circle what your feet hit. Windshield Dashboard Steering Wheel Sicie door Ceiling Car Frame Side Window A Seat Another Passenger other What kind of headrest was in your vehicle? - Movable fixed headrest - Non-movable fixed headrest - No headrest

16 Page #2 AUTO ACCIDENT PATIENT INTAKE FORM 31. Where was the headrest positioned behind your head? At the top back of the head At the middle back of the head At the tower back of the head Back of the Neck At the level between the shoulder blades 32. Did you have your seatbelt on during the accident? NO YES 33. Did you slide out of your seatbelt during the accident? NO YES 34. What was damaged in your vehicle? (Circle all that apply) -Windshield -Rear bumper -Mirror - Steering wheel - Front Bumper - Knee bolster - Dashboard -Trunk - Back right door - Seat frame -Front left door -Completely totalled - Side window - Front right door - Rear window - Back left door 35. Choose the items that dented inward -Floorboards -Side door -Dashboard -Ceiling -Van Back door 36. Choose the doors that would not open as a result of the accident - Front left door - Front right door - Rear left door - Rear right door Van Back door 37. Did you go to the hospital? If no, tell why you did not go to the hospital and then skip questions How were you taken to the hospital and who took you? 39. What was the name of the hospital? Were you hospitalized over night? NO YES 41. Circle what you were prescribed at the hospital ~. - Pain medication - Muscle relaxes - Neck brace - Other brace -Sling 42. At the hospital did you receive any stitches for any cuts? NO YES If yes, which body part received stitches? Were X-rays taken at the hospital? NO YES If yes, which part of the body was X-rayed? 44. Did you have an MRI? NO YES If yes, where (which part of the body) did they do the MRI? 45. Did you receive any special imaging? NO YES (example CAT Scan etc) If yes, describe. Patient name (Print) Patient Signature Date