Electronic Health Records Intake Form



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Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Last Name: Email address: @ Preferred method of communication for patient reminders (Circle one): Email / Phone / Mail DOB: / / Gender (Circle one): Male / Female Preferred Language: Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked CMS requires providers to report both race and ethnicity Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) Native Hawaiian or Pacific Islander / Other / I Decline to Answer Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer Are you currently taking any medications? (Please include regularly used over the counter medications) Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.) Do you have any medication allergies? Medication Name Reaction Onset Date Additional Comments I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.) Patient Signature: Date: For office use only Height: Weight: Blood Pressure: / Heart Rate:

Whom may we thank for referring you to this office? APPLICATION FOR CARE AT SOLDANO FAMILY CHIROPRACTIC CENTER Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: o Male o Female Address: City: State: Zip: E-mail 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: Primary: Secondary: 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: 0 1 2 3 4 5 6 7 8 9 10 Second complaint is: 0 1 2 3 4 5 6 7 8 9 10 Third complaint is: 0 1 2 3 4 5 6 7 8 9 10 Fourth complaint is: 0 1 2 3 4 5 6 7 8 9 10 When did the problem(s) begin? When is the problem at its worst? o AM o PM o mid-day o late PM How long does it last? oit is constant OR oi experience it on and off during the day OR oit comes and goes throughout the week How did the injury happen? Condition(s) ever been treated by anyone in the past? ono How long were you under care: Name of Previous Chiropractor: o Yes If yes, when: by whom? 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 your symptoms feel worse? LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL : : : : Is your problem the result of ANY type of accident? o Yes, o 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: o No o Yes If yes, please state what type of treatment:, and who provided it: How long ago? What were the results. o Favorable o 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 or 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? (See ADL form) 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 Soldano Family Chiropractic Center, 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 Soldano Family Chiropractic Center for any and all services I receive at this office. Patient or Authorized Person s Signature Doctor s Signature - - Date Completed - - Date Form Reviewed PATIENT S NAME: HR#: DATE:

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: Carry Children/Groceries o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Sit to Stand o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Climb Stairs o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Pet Care o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Extended Computer Use o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Lift Children/Groceries o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Read/Concentrate o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Getting Dressed o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Shaving o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Sexual Activities o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Sleep o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Static Sitting o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Static Standing o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Yard work o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Walking o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Washing/Bathing o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Sweeping/Vacuuming o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Dishes o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Laundry o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Garbage o No Effect o Painful (can do) o Painful (limits o Unable to Perform Driving o No Effect o Painful (can do) o Painful (limits) o Unable to Perform Other: o No Effect o Painful (can do) o Painful (limits) o Unable to Perform List Prescription & Non-Prescription drugs you take: Patient signature: Today s Date: / / Continued on next page

Please mark P for in the Past, C for Currently have, or 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 Low Blood Pressure 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)

QUADRUPLE VISUAL ANALOGUE SCALE Patient Name Date Please read carefully: Instructions: Please circle the number that best describes the question being asked. Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: Headache Neck Low Back 1 What is your pain RIGHT NOW? 2 What is your TYPICAL or AVERAGE pain? 3 What is your pain level AT ITS BEST (How close to 0 does your pain get at its best)? 4 What is your pain level AT ITS WORST (How close to 10 does your pain get at its worst)? OTHER COMMENTS: Examiner Reprinted from Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, 855-862, 1993, with permission from Elsevier Science

Informed Consent REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures: I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments. Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at (Insert Practice Name) have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. / / 0 Witness Initials Patient or Authorized Person s Signature Date REGARDING: X-rays/Imaging Studies FEMALES ONLY please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation. o The first day of my last menstrual cycle was on - - (Date) o I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant. By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case. / / 0 Witness Initials Patient or Authorized Person s Signature Date

Patient initials: -retaining page 1 of 2 SOLDANO FAMILY CHIROPRACTIC CENTER NOTICE REGARDING YOUR RIGHT TO PRIVACY continued I have received a copy of Soldano Family Chiropractic Center Patient Privacy Notice. I understand my rights as well as the practice s duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this Notice of Privacy Practice at a time in the future and will make the new provisions effective for all information that it maintains past and present. I am aware that a more comprehensive version of this Notice is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received. Patient s Name DOB HR# Patient s Signature Date Witness Date

Medical Information Release Form (HIPAA Release Form) Name: Date of Birth: Release of Information: [ ] I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: [ ] Spouse [ ] Child(ren) [ ] Other [ ] Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing. Messages: Please call [ ] my home [ ] my work [ ] my mobile number: If unable to reach me: [ ] you may leave a detailed message [ ] please leave a message asking me to return your call [ ] The best time to reach me is (day) between (time) Signed: Date: Witness: Date:

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