PATIENT INFORMATION Today's Date_______________
Last Name_______________________________ First Name___________________________ MI __
Date of Birth___/___/____ AGE_______ Social Security #_________/_____/_________ Sex M F
Marital Status S M D W Occupation _____________________Employer_____________________
Spouse Name_________________________Children? Yes No How many?________Ages_______
Name of Policy Holder______________________________________Date of Birth_____/_____/____
Relationship to Patient: self ( ) spouse ( ) child ( ) SS # of Policy Holder_______/_____/_______
Company Name_______________________ID # ______________________Group_________________
1. Most patients are referred to our office by a caring family member or friend. What made you decide to visit our office?
Friend / Family / Doctor Name:__________________________ Yellow pages __ Sign __ Website __ Presentation __
2. Research shows that your spine should be checked regularly. How many times have you visited a chiropractor in your lifetime?____________________ Never___________
3. When was your last complete spinal examination including x-rays?_______________________________never____
4. Have you ever been told that you have a spinal curvature, spinal arthritis, or inherited spinal problem? Yes or No
5. Spinal misalignment cause decay and degeneration which results in grinding or cracking. Do you ever hear noises when you move your head or neck? Yes or No
6. Spinal misalignments can make you feel like you need to twist, stretch or crack you neck or back. Do you ever feel the need to crack or pop your neck or lower spine? Yes or No
7. Poor posture leads to poor health and often indicates a spinal problem. How would you rate your posture?
Poor - 1 2 3 4 5 6 7 8 9 10 - Excellent
8. Stress can cause or accelerate spinal damage. Rate your stress level over the last 90 days.
Low - 1 2 3 4 5 6 7 8 9 10 - High
9. Prescription medications may cause various side effects, hide the severity of health problems, and hinder the body's ability to heal. What medications are you currently taking?
Reason for Visit or Signs of Loss of Wellness
The reason for this visit is a result of (please circle): work, sports, auto, trauma, chronic, unknown, repetitive mvmt
EXPLAIN WHAT HAPPENED___________________________________________________________________________
Pain or Problem started : __________________________________________________________________________
Pain / Symptoms are: Sharp____ Dull_____ Constant_____ Achy_____ Intermittent______
What Activities aggravate your condition or pain? __________________________________________________________
What Activities lessen you condition or pain? _____________________________________________________________
Is condition worse suring certain times of the day?__________________________________________________________
Is condition interfering with: Work? ____ Sleep? ____ Home? ____ Other? ____________________________________
Is condition progressively getting worse? _________________________________________________________________
Have you seen other doctors for this condition?_____________________________________________________________
CHECK ALL THAT APPLY:
__Low back problems __ Pain between shoulders __ neck problems __ arm problems __ leg problems
__Swollen Joints __ painful joints __ Stiff joints __ sore muscles __ weak muscles __ walking problems
__ vision changes __ loss of feeling __ paralysis __ dizziness __ fainting __headaches __ muscle jerking
__ convulsions __ forgetfulness __ numbness/tingling __ sinus problems __ persistent cough
__ sore throats __ nausea __ broken bones __ bladder problems __ constipation __diarrhea
Previous Surgeries Yes or No ___________________________________________________________
Accidents Yes or No ___________________________________________________________________
Other Problems _______________________________________________________________________
Smoke Yes or NO Drink Yes or NO Eat Healthy Yes or NO Sleep Well Yes or No Exercise Yes or NO
Matthew J. Joseph
Joseph Chiropractic Clinic
40 S. Walnut St
Sharpsville, PA 16150
SIGNATURE ON FILE
___ I authorize use of this form on all my insurance submissions and release of information to all my Insurance Companies.
___ I understand that I am ultimately responsible for my bill including what is not covered by my insurance company.
___ I authorize my doctor and his staff to contact my insurance company relating to any and all claims.
___ I authorize payment direct to my doctor.
___ I permit a copy of this authorization to be used in place of the original.
Print Name _________________________________________________________________
Signature ______________________________________ Date ______________________
Name of Primary Care Physician: _______________________________________
Location/Phone # of Primary Care Physician: _____________________________________
Consent for Use or Disclosure of Health Information
Our Privacy Pledge
We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and will always will, respect the privacy of your health information.
There are several circumstances in which we may have to use or disclose your health information.
1. We may have to disclose your name and health information to another health care provide or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
2. We may have to disclose your name, health information, and billing records to another party if they are potentially responsible for the payment of your services.
3. We will need to use your name and health information within our practice to provide treatment to you, for quality control or other operational purposes.
We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form (164.520) We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy notices.
Your right to limit uses or disclosure
You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding to us.
Your right to revoke your authorization
You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have the right to your health information if they decide to contest any of your claims.
I have read your consent policy and agree to its terms. I am also acknowledging that I have received a copy of this notice.
Appointment Reminders and Personal Acknowledgments and Health Care Information Authorization
Dr. Joseph and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. If this contact is made by phone and you are not at home, a message may be left on your answering machine. By signing this form, you are giving us authorization to contact you with these reminders and information. Additionally, you are giving permission to acknowledge your birthday, accomplishments and referrals of patients to Joseph Chiropractic either displayed in the office, by email, by US mail or by personal delivery of a referral gift.
You may restrict the individuals or organizations to which your healthcare information is released or you may revoke your authorization to us at any time; however, your revocation must be in writing and mailed to our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have the right to your health information if they decide to contest any of your claims.
Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by federal privacy rules.
You have the right to refuse to give us this authorization. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
You may inspect or copy the information that we use to contact you to provide appointment reminders, birthday, accomplishments or referrals or information about treatment alternatives, or other health related information at any time (164.524).
This notices is effective as of _____________.
This authorization will expire seven years after the date on which you last received services from us.
I authorize you to use or disclose my health information in the manner described above. I am also acknowledging that I have received a copy of his authorization.
Patient Name Printed ____________________________________________________________
Patient Signature ________________________________________________________________
Personal Representative Printed ____________________________________________________
Personal Representative Signature __________________________________________________
Relationship to Patient ___________________________________________________________
Copyright @2002 Pennsylvania Chiropractic Association. All rights reserved