APPLICATION FOR CARE AT Elevation Chiropractic, LLC
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- Myra Laureen Cummings
- 8 years ago
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1 Whom may we thank for referring you to this office? Today s Date: PATIENT DEMOGRAPHICS APPLICATION FOR CARE AT Elevation Chiropractic, LLC HRN: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: Address: Home Phone: Mobile Phone: Marital Status: Single Married Do you have Insurance: Yes No Work Phone: Social Security #: Driver s License #: Employer: Occupation: Spouse s Name Spouse s Employer Number of children and Ages: Name & Number of Emergency Contact: Relationship: HISTORY of COMPLAINT Please identify the condition(s) that brought you to this office: Primarily: Secondarily: Third: Fourth: On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling the number: Primary or chief complaint is : Second complaints is : Third complaint: : Fourth complaint: : When did the problem(s) begin? When is the problem at its worst? AM PM mid-day late PM How long does it last? It is constant OR I experience it on and off during the day OR It comes and goes throughout the week How did the injury happen? Condition(s) ever been treated by anyone in the past? No Yes If yes, when: by whom? How long were you under care: Name of Previous Chiropractor: What were the results? N/A *PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling What relieves your symptoms? What makes them feel worse? LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL : : :
2 Is your problem the result of ANY type of accident? Yes, No Identify any other injury(s) to your spine, minor or major, that the doctor should know about: PAST HISTORY Have you suffered with any of this or a similar problem in the past? No Yes If yes how many times? When was the last episode? How did the injury happen? Other forms of treatment tried: No Yes If yes, please state what type of treatment:, and who provided it: How long ago? What were the results. Favorable Unfavorable please explain. Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body: If you have ever been diagnosed with any of the following conditions, please indicate with a P for in the Past, C for Currently have and N for Never have had: Broken Bone Dislocations Tumors Rheumatoid Arthritis Fracture Disability Cancer Heart Attack Osteo Arthritis Diabetes Cerebral Vascular Other serious conditions: PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem: HOW LONG AGO TYPE OF CARE RECEIVED BY WHOM INJURIES SURGERIES CHILDHOOD DISEASES ADULT DISEASES SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes How often? Daily Weekends Occasionally Never 2. Alcoholic Beverage: consumption occurs Daily Weekends Occasionally Never 3. Recreational Drug use: Daily Weekends Occasionally Never 4. Hobbies -Recreational Activities- Exercise Regime: How does your present problem affect the following, See pg 2- Activities of Life FAMILY HISTORY: 1. Does anyone in your family suffer with the same condition(s)? No Yes If yes whom: grandmother grandfather mother father sister s brother s son(s) daughter(s) Have they ever been treated for their condition? No Yes I don t know 2. Any other hereditary conditions the doctor should be aware of. No Yes: I hereby authorize payment to be made directly to Elevation Chiropractic, LLC., for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Elevation Chiropractic for any and all services I receive at this office. Patient or Authorized Person s Signature Doctor s Signature - - Date Completed - - Date Form Reviewed
3 ACTIVITIES OF LIFE Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life: ACTIVITIES: EFFECT: Carrying Groceries No Effect Painful (can do) Painful (limits) Unable to Sit to Stand No Effect Painful (can do) Painful (limits) Unable to Climbing Stairs No Effect Painful (can do) Painful (limits) Unable to Pet Care No Effect Painful (can do) Painful (limits) Unable to Driving No Effect Painful (can do) Painful (limits) Unable to Extended Computer Use No Effect Painful (can do) Painful (limits) Unable to Household Chores No Effect Painful (can do) Painful (limits) Unable to Lifting Children No Effect Painful (can do) Painful (limits) Unable to Reading/Concentration No Effect Painful (can do) Painful (limits) Unable to Bathing No Effect Painful (can do) Painful (limits) Unable to Dressing No Effect Painful (can do) Painful (limits) Unable to Shaving No Effect Painful (can do) Painful (limits) Unable to Sexual Activities No Effect Painful (can do) Painful (limits) Unable to Sleep No Effect Painful (can do) Painful (limits) Unable to Static Sitting No Effect Painful (can do) Painful (limits) Unable to Static Standing No Effect Painful (can do) Painful (limits) Unable to Yard work No Effect Painful (can do) Painful (limits) Unable to Walking No Effect Painful (can do) Painful (limits) Unable to Washing/Bathing No Effect Painful (can do) Painful (limits) Unable to Sweeping/Vacuuming No Effect Painful (can do) Painful (limits) Unable to Dishes No Effect Painful (can do) Painful (limits) Unable to Laundry No Effect Painful (can do) Painful (limits) Unable to Garbage No Effect Painful (can do) Painful (limits) Unable to Lifting Groceries No Effect Painful (can do) Painful (limits) Unable to Dressing No Effect Painful (can do) Painful (limits) Unable to Driving No Effect Painful (can do) Painful (limits) Unable to Other: No Effect Painful (can do) Painful (limits) Unable to Patient signature: Today s Date: / /
4 Please mark P for in the Past, C for Currently have and N for Never Headache Pregnant (Now) Dizziness Prostate Problems Ulcers Neck Pain Frequent Colds/Flu Loss of Balance Impotence/Sexual Dysfun. Heartburn Jaw Pain, TMJ Convulsions/Epilepsy Fainting Digestive Problems Heart Problem Shoulder Pain Tremors Double Vision Colon Trouble High Blood Pressure Upper Back Pain Chest Pain Blurred Vision Diarrhea/Constipation High Cholesterol Mid Back Pain Pain w/cough/sneeze Ringing in Ears Menopausal Problems Asthma Low Back Pain Foot or Knee Problems Hearing Loss Menstrual Problem Difficulty Breathing Hip Pain Sinus/Drainage Problem Depression PMS Lung Problems Back Curvature Swollen/Painful Joints Irritable Bed Wetting Kidney Trouble Scoliosis Skin Problems Mood Changes Learning Disabilty Gall Bladder Trouble Numb/Tingling arms, hands, fingers ADD/ADHD Eating Disorder Liver Trouble Numb/Tingling legs, feet, toes Allergies Trouble Sleeping Hepatitis (A,B,C) List Prescription & Non-Prescription drugs you take:
5 Patient Name File#/HRN Date INITIAL NERVE SYSTEM PROFILE When was your most recent auto accident? What speed was the collision? Type of impact: Front Impact / Side Impact / Rear Impact Was treatment received? Please describe When was your most recent strain / stress at work? Please describe the manner of the injury Was treatment received? Please describe Does your job require you remain in long term stressful postures? (i.e. all day seating, repeated lifting, long term computer use) Spinal traumas in the past? Collision, quick burst, or repetitive motion sports: football, wrestling, basketball, baseball, soccer, tennis, golf, track and field Trauma as a child! i.e. fall on your head, impact to your head, concussion, fall onto your back or tailbone, biking accident Work around the house lifting, bending, woke up with stiff neck, back went out INITIAL NUTRITIONAL PROFILE Have you tested with high triglycerides or high cholesterol? (Y / N) Values? Have you tested with high blood pressure? (Y / N) Are you diabetic? Have you been diagnosed as pre-diabetic or with metabolic syndrome? (Y / N) Do you eat breakfast daily from Monday to Friday? (Y / N) How many days per week do you skip one meal? (0) (1) (2) (3) (4+) How many fast food, refined foods, or pre-pared meals do you eat per week? (0) (1-3) (4-6) (7+) How many servings of fruit do you have on a given day? (0-1) (2-3) (4+) How many servings of vegetables do you have on a given day? (0-1) (2-3) (4-5) Do you regularly drink (1 or more per day) any of the following? (circle all that apply) Diet Soda Coffee Juice Milk Soda Alcohol Please list any supplements you take regularly: INITIAL FITNESS PROFILE How many times per week do you exercise? Cardiovascular Hours Days/Wk Weight Training Hours Days/Wk Low Impact (Yoga, etc.) Hours Days/Wk What is your target weight? What is your current weight? How willing are you to change any of these things to reach your health goals? (Scale of 1-10)
6 INITIAL TOXICITY PROFILE Are you regularly exposed to cleaning products or industrial chemicals? (Y / N) Have you ever noticed mold growing in your home or your place of work? (Y / N) Does your home, work, school, or car have damp or mildew smell? (Y / N) Have you received a full standard profile of vaccinations? (Y / N) Do you receive yearly flu shots? (Y / N) How many flu shots have you received? (estimate) Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities? (Y / N) Do you have symptoms of hormonal system imbalance (thyroid, reproductive, adrenal)? (Y / N) INITIAL STRESS PROFILE Do you get an average of 8 hours of sleep per night (Y/N) Do you ever take pills to go to sleep or relax (Y/N) Do you often feel short on time and procrastinate on projects? (Y / N) Do you experience feelings of anxiety about completing tasks? (Y / N) Do you feel like you don't give enough time or attention to important areas in your life like family, personal growth, or a hobby? (Y / N) Do you rely more on your memory than a planner and action list to get things done? (Y / N) Do you take time to pray, meditate, or visualize on a regular basis? (Y / N) Doctor Signature Date
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