PATIENT INFORMATION Name: Date: Age: Date of Birth: S.S#: Email: Address: Street Name & Number City State Zip Home Phone #: Cellular #: Wk #: Marital Status: S M W D EMPLOYMENT INFORMATION Employer Name: Occupation: Address: Street Name & Number City State Zip INSURANCE INFORMATION Private Ins. (group): Auto Accident Have you engaged an attorney in connection with the present illness/accident? No Yes, If yes Attorney Name: Phone #: INSURANCE COMPANY Name: Phone #: Policy#: Group #: Patient s relationship to Policy Holder: Spouse Parent Sibling Other Relative Policy Holder: Name: DOB: S.S#: Employer Name: Phone #: SECONDARY INSURANCE COMPANY INFORMATION Name: Phone #: Policy#: Group #: Patient s relationship to Policy Holder: Spouse Parent Sibling Other Relative Policy Holder: Name: DOB: S.S#: Employer Name: Phone #: AUTO ACCIDENT INSURANCE COMPANY INFORMATION / Date of Accident: Name: Phone #: Policy#: Claim #: Patient s relationship to Policy Holder: Spouse Parent Sibling Other Relative Policy Holder: Name: DOB: S.S#: IN CASE OF AN EMERGENCY Name: Phone#: Address: Street Name & Number City State Zip Patient s relationship to Policy Holder: Spouse Parent Sibling Other Relative Z:#1 FORM/New PT Packets:PIP-PI Updated: 8/10/12
MEDICAL HISTORY What treatment have you already received for your condition? Surgery: Was your surgery Successful Unsuccessful/who preformed this surgery? Physical Therapy: Was your therapy Successful Unsuccessful/ where was it? Chiropractic Services: Was your treatment Successful Unsuccessful/ where was it Other None Name and address of the other Doctor(s) who treated you for your condition: Date of Last: Physical Exam Spinal X-Ray Blood Test Spinal Exam Chest X-Ray Urine Test Dental X-Ray MRI, CT-Scan, Bone Scan Place a mark on Yes or No to indicate if you have had any of the following: AIDS/HIV Yes No Chicken Pox Yes No Liver Disease Yes No Rheumatoid Arthritis Yes No Alcoholism Yes No Diabetes Yes No Measles Yes No Rheumatic Fever Yes No Allergy Shots Yes No Emphysema Yes No Migraine Headaches Yes No Scarlet Fever Yes No Anemia Yes No Epilepsy Yes No Miscarriage Yes No Stroke Yes No Anorexia Yes No Fractures Yes No Mononucleosis Yes No Suicide Attempt Yes No Appendicitis Yes No Glaucoma Yes No Multiple Sclerosis Yes No Thyroid Problems Yes No Arthritis Yes No Goiter Yes No Mumps Yes No Tonsillitis Yes No Asthma Yes No Gonorrhea Yes No Osteoporosis Yes No Tuberculosis Yes No Bleeding Disorders Yes No Gout Yes No Pacemaker Yes No Tumors, Growths Yes No Breast Lump Yes No Heart Disease Yes No Parkinson s Disease Yes No Typhoid Fever Yes No Bronchitis Yes No Hepatitis Yes No Pinched Nerve Yes No Ulcers Yes No Bulimia Yes No Hernia Yes No Pneumonia Yes No Vaginal Infections Yes No Cancer Yes No Herniated Disk Yes No Polio Yes No Venereal Disease Yes No Cataracts Yes No Herpes Yes No Prostate Problem Yes No Whooping Cough Yes No Chemical Dependency Yes No High Cholesterol Yes No Prosthesis Yes No Other: Kidney Disease Yes No Have you ever had any nervous or mental illnesses? Yes No Have you had psychiatric care? Yes No Have you received a medical discharge from the Armed Forces Yes No EXERCISE WORK ACTIVITY HABITS None Sitting Smoking Packs/day Moderate Standing Alcohol Drinks/week Daily Light Labor Caffeine Drinks Cups/Daily Heavy Heavy Labor High Stress Level Reason Women Only: Are you pregnant? Yes No If yes Due Date: # of Pregnancies: Method of delivery: C-Section # Vaginal # Miscarriages # Other Female Surgeries: Injuries/Surgeries you have had Descriptions Date Falls Head Injuries Broken bones Dislocations Surgeries MEDICATIONS ALLERGIES VITAMINS/HERBS/MINERALS Pharmacy Name: Phone #:
FOR WOMEN ONLY X-RAY Release Form I have been advised by the doctor or staff member of this office that x-rays can be HAZARDOUS to an unborn child. At this time, and to the best of my knowledge, I am not pregnant. I consent to having life size, digital x-ray pictures taken. Patient Signature: Date: Witness: Date: FOR WOMEN ONLY
CONSENT TO TREATMENT Date: Patient Name: (Print Name) Omit any statement, which you do not wish to authorize by marking a line through the statement with your initial and date. Consent to Treatment: I, as the patient or on behalf of the patient, do hereby consent to and authorize all medical, chiropractic and therapeutic treatment considered necessary or advised in the judgment of the doctor on duty. I understand that no guarantees and/or assurances have been made as to the results which may be obtained. Financial Agreement: I hereby guarantee payment for services at Texas Medical Institute located at 6789 Camp Bowie; Fort Worth TX and/or 3304 S.W. Loop 820 Fort Worth TX. I understand that I will be held responsible for the court cost, legal fees, or agency fees which may be incurred in the collection of the account. Assignment of Benefits: I hereby authorize all insurance companies to pay directly to Texas Medical Institute and any ancillary providers, any providers, any benefits and fees under my insurance policy or policies. I understand that this order does not relieve any of my obligations to pay the account or any balance that is not covered or paid by the insurance company carrier which may be my responsibility. Release of Medical Information: I hereby consent and authorize Texas Medical Institute located and any ancillary providers, any providers to release any medical information in connection with the services rendered for determination of benefits and/or collection of said benefit from my health insurance carrier. Teaching Facility: I understand that Texas Medical Institute is affiliated with medical schools, nursing schools, and other academic programs and therefore resident physicians, interns, and students may be involved with my care. Nurse Practitioners/Physician Assistant: I understand that Texas Medical Institute provides care by Physicians, Nurse Practitioners, and Physician Assistants. Nurse Practitioners and Physician Assistants are not physicians, but function under the supervision of a physician either directly or via protocols established by the physician. I HAVE READ THE AUTHORIZATION, CONSENT, AND AGREEMENT AND I ACCEPT THE TERMS DESCRIBED ABOVE. Patient Name: Date: Signature of Patient or Responsible Party Relationship Witness Signature Date
Patient Record of Disclosures HIPPA Privacy rule: III. Other Uses and Disclosures of Health Information We will not use or disclose your health information for any purpose other than those identified in this written Authorization. We cannot take back any uses or disclosures already made with your permission. I wish to be contacted in the following manner (check all that applies): Home telephone #: O.K to leave messages with detailed information Leave message with call-back number only Fax to this number#: Work telephone #: O.K to leave messages with detailed information Leave message with call-back number only Fax to this number#: Written Communication Mail to my home address Mail to my work/office Other Patient Signature Date Print Name Healthcare entities must keep records of PHI disclosures; information provided below, if completed properly, will constitute an adequate record. NOTE: Uses and disclosure for PHI may be permitted without prior consent in an emergency. Record of Disclosures of Protected Health Information Date Disclosed to 1 Purpose By Whom 2 3 1. Check this box if the disclosure is authorized 2. Print: T = Treatment Record; P = Payment Information; O = Other Healthcare provider 3. How was disclose made: F = Fax; P = Phone; E = E-mail; O = Other
Standard Authorization Form To Use or Disclose Protected Health Information (PHI) Patient Name: Date: Address: SS#:xxx-xx- D.O.B: Receive Records From: Release Records To: Texas Medical Institute 6789 Camp Bowie Blvd Fort Worth TX 76116 P: 817-731-2102 Fax: 817-731-2157 Please send a copy of my records as indicated for date(s) of Treatment: Specifically: History & Physical Nursing Notes EEG/EKG/CAT Scan Discharge Summary Social Serv. Notes MD Orders Operative Report Laboratory other please specify: MD Progress Notes Radiology Purpose for releasing medical information Signature of Patient, Parent or Legal Guardian Witness Date I understand that my express consent is required to release any health information relating to testing, diagnosis and/or treatment of alcohol or drug related medical problems and this special consent also will apply to HIV/AIDS related diagnoses, sexually transmitted diseases and psychiatric disorders/mental health. This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 C.F.R. Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. This authorization can be revoked but not retroactive to the release of information made in good faith. Signature of Patient, Parent or Legal Guardian Witness Permission to FAX records for medical emergency? Yes No Date
Patient Name: (Print Name) ACCIDENT DETAILS Date: Date of Accident: / / Time of Day AM PM Location of the accident: City or Town: State: What was your position in the vehicle? Driver Front Passenger Rear passenger Pedestrian What type of vehicle were you driving? What speed were you traveling at the of the accident? Who hit who? Struck by another vehicle Struck another vehicle Struck a stationary object What was your vehicles point of impact? What type of vehicle was the Other vehicle? What was the Other vehicles point of impact? What speed was the Other vehicle traveling? Where you wearing seat restraints? YES NO What position were your vehicle head rests in? Where your vehicles air bags deployed? YES NO Where you prepared for impact? YES NO What position was your body in just before impact? What happened to your body at the moment of impact? Please describe in detail how the accident occurred:
ACCIDENT DETAILS CONTINUED Were you rendered unconscious as a result of the collision? YES NO Did you receive medical attention at the scene of the accident? YES NO Where did you go immediately after the accident? Has another doctor treated you for these injuries? YES NO If YES Name and address of the other Doctor(s) who treated you: Have you been x-rayed since the accident? YES NO Have you lost any days of work as a result of the accident? YES How many? NO Please list each of your body parts that struck the following vehicle parts during the accident (if any): Dashboard: Windshield: Steering Wheel: Right Door: Left Door: Seat: Other: Have you ever been in a previous auto accident? Please give all instances with dates and injuries sustained: INFORMATION ABOUT THE PARTIES TO THE ACCIDENT Did a police officer write up a report on the accident? YES (Provide a copy for this office) NO Was a ticket or citation issued? YES to Me The Driver of the car I was in the other person NO ------------------------(check all that apply)-------------------------------- Are you licensed to drive? YES NO Where you in your own vehicle at the time of the accident? YES NO If NO: Owners Name: Relation: Address:
PATIENT COMFORT ASSESSMENT GUIDE Name: Where is your pain: Circle the words that describe your pain; aching sharp penetrating throbbing tender nagging shooting burning numb stabbing exhausting miserable gnawing tiring unbearable Circle ONE occasional continuous What time of day is your pain the worst? morning afternoon evening nighttime Rate your pain by circling the number that best describes your pain at its worst in the last month. 1 2 3 4 5 6 7 8 9 10 (1 being the least 10 being the worst/extreme pain) Rate your pain by circling the number that best describes your pain at its least in the last month. 1 2 3 4 5 6 7 8 9 10 (1 being the least 10 being the worst/extreme pain) Rate your pain by circling the number that best describes your pain on average in the last month. 1 2 3 4 5 6 7 8 9 10 (1 being the least 10 being the worst/extreme pain) Rate your pain by circling the number that best describes your pain right now. What makes you pain better? What makes you pain worse? 1 2 3 4 5 6 7 8 9 10 (1 being the least 10 being the worst/extreme pain) What treatments or medicines are you receiving for your pain? Circle the number to describe the amount of relief the treatment or medicine provide(s) you. a) No 1 2 3 4 5 6 7 8 9 10 Complete Treatment or Medicine (include dose) relief relief b) No 1 2 3 4 5 6 7 8 9 10 Complete Treatment or Medicine (include dose) relief relief d) No 1 2 3 4 5 6 7 8 9 10 Complete Treatment or Medicine (include dose) relief relief e) No 1 2 3 4 5 6 7 8 9 10 Complete Treatment or Medicine (include dose) relief relief
PATIENT COMFORT ASSESSMENT GUIDE CONTINUED What side effect or symptoms are you having? Circle the number that best describes your experience during the past week. a. Nausea Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever b. Vomiting Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever c. Constipation Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever d. Lack of Appetite Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever e. Tired Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever f. Itching Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever g. Nightmares Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever h. Sweating Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever i. Difficulty Thinking Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever j. Insomnia Barely Noticeable 1 2 3 4 5 6 7 8 9 10 Sever Circle the one number that describes how during the past week pain has interfered with your: a. General Activity Does not 1 2 3 4 5 6 7 8 9 10 Completely b. Mood Does not 1 2 3 4 5 6 7 8 9 10 Completely c. Normal Work Does not 1 2 3 4 5 6 7 8 9 10 Completely d. Sleep Does not 1 2 3 4 5 6 7 8 9 10 Completely e. Enjoyment of Life Does not 1 2 3 4 5 6 7 8 9 10 Completely f. Ability to Concentrate Does not 1 2 3 4 5 6 7 8 9 10 Completely g. Relations with Does not 1 2 3 4 5 6 7 8 9 10 Completely Other People
PARTIAL CLAIMS AGREEMENT CHECK AGREEMENT Patient (or if a minor), on behalf of hereby IRREVOCABLY ASSIGNS to Texas Medical Institute in consideration of deferred billing and collection to Texas Medical Institute any claims, chose in action, demand and causes of action, or whatsoever kind and nature, that have now or may have in the future for injuries or damages as a result of an accident or incident occurring on or about the day of to the extent of charges for medical services or related goods provided, or medical services or related goods to be provided by Texas Medical Institute. If this agreement is made on behalf of a minor the parent or guardian assigns only the cause of action such parent or guardian has for recovery of the minor s medical expenses incurred as a result of said accident or incident. Texas Medical Institute shall not be liable for any cost and/or expenses associated with any claims or litigation unless Teas Medical Institute files that litigation. Texas Medical Institute shall have no duty whatsoever to prosecute the claim or litigation. Nothing herein shall prevent patient from pursuing any claim or litigation which patient otherwise has right to pursue and which patient has not assigned to Texas Medical Institute. If a lawsuit is filed by either the patient or Texas Medical Institute, arising from the said accident or incident, the non-filling party may intervene and file a second lawsuit arising from the same accident or incident. In the event Texas Medical Institute seeks and receives payment from a Worker s compensation insurance policy for its medical treatment of patient then this Partial Claim Assignment/Joint check Agreement shall not apply. This Partial claim Agreement is applicable to any claims involving work related injuries against employers (including employers who do not subscribe to Workers Compensation Insurance) or third parties. I IRREVOCABLY instruct and direct any third party, whether or not I am represented by an attorney, making payment in damages incurred by patient as a result of said accident or incident, to make such payment by check, draft, or other remittance jointly payable to Texas Medical Institute and patient, parent, guardian (and/or Attorney) and deliver such payment to 6789 Camp Bowie Blvd; Ft Worth TX 76116. Texas Medical Institute will provide physicians who will direct medical care for injuries for which patient is currently seeking treatment. The patient promises to pay usual and customary charges for Texas Medical Institute s medical treatment. Signed this day of, 201 Patient / Parent / Legal Guardian LIMITED POWER OF ATTORNEY I hereby irrevocably grant Texas Medical Institute the power to endorse my name upon nay check, draft, or other negotiable instrument representing payment from any insurance company for the medical service or related goods provided to me by Texas Medical Institute. Signed this day of, 201 Patient / Parent / Legal Guardian I authorize and direct any attorney retained by me at anytime, to pay directly to Texas Medical institute all money for service rendered or goods provided to me, and to withhold such sums from the proceeds of my portion of any settlement, claim, judgment or jury verdicts. THIS INSTRUCTION IS IRREVOCABLE UNLESS ALL PARTIES AGREE TO REVOKE THE INSTRUTIION IN WRITING. Signed this day of, 201 Patient / Parent / Legal Guardian As used in the above BASIC AGREEMENT; PARTIAL CLIAMS ASSIGMENT/JOINT CHECK, AGREEMENT; LIMITED POWER OF ATTORNEY; AND INSTRUCTION TO MY ATTORNEY, the term Texas Medical institute shall mean, Greg Gardner, D.O. and Associates, Joseph Ysbrand DC, Bobbie Thompson DC, Amy Mohr DC, and Atherton Sorrenti, DC. I have read the above and section and I fully understand them. Signed this day of, 201 Accepted: Texas Medical Institute by: Patient / Parent / Legal Guardian
ACKNOWLEDGEMENT STATE OF TEXAS COUNTY OF TARRANT The for going Partial Claim Assignment / Joint Check Agreement, attached hereto and incorporated by reference was acknowledged before me on this day of, 201 Patient / Parent / Legal Guardian SWORN AND SUBSCRIBED TO BEFORE ME, the undersigned Notary Public, on this day of, 201 Notary Public in and for the STATE OF TEXAS My Commission Expires:
LETTER OF PROTECTION Patient Name: Date: / / Attorney Name: We, the undersigned patient and attorney, will protect the interests of Texas Medical Institute out of the proceeds of any settlement, judgment or verdict, and out of any no-fault disbursements, relating to the accident listed above. By interests we mean any outstanding balance owed to the practice for treatment rendered to me, the patient, for injuries sustained on the above date. The letter of protection shall not be modified or revoked without written consent of Texas Medical Institute. Patient s Signature Date: / / Attorney s Signature Date: / / 6789 Camp Bowie Blvd 3304 SE Loop 820 Fort Worth TX 76116 Fort Worth TX 76140 Phone: 817.731.2102 Phone: 817.615.8633 Fax: 817.731.2157 Fax: 817.615.8635