new patient registration form

Joseph Chiropractic Clinic Registration

PATIENT INFORMATION                                                                            Today's Date_______________

Last Name_______________________________ First Name___________________________ MI __

Street Address_______________________________________________________________________

City___________________________________________State_____________ZIP__________________

Email_______________________________________________________________________________

Home #_________________________Work#_______________________Cell#____________________

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_______

INSURANCE INFORMATION

Name of Policy Holder______________________________________Date of Birth_____/_____/____

Relationship to Patient:  self ( ) spouse ( ) child ( )    SS #  of Policy Holder_______/_____/_______

Company Name_______________________ID # ______________________Group_________________ 

Questionnaire

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?_____________________________________________________________

Home Remedies?___________________________________________________________________________________

 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: _____________________________________

 

                                                                     _____________________________________

 

                                                                     _____________________________________

 

                                                                   ______________________________________

                                                                                                                           

 

  

        

 

 

 

 

Joseph Chiropractic

 

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.

Printed Name__________________________________________ 

 

Signature_______________________________________________                          

Date________________

                                 

Provider Representative_________________________________

Date________________

 

   

Joseph Chiropractic

 

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.

 

Date ______________

Patient Name Printed ____________________________________________________________

 

Patient Signature ________________________________________________________________

 

Personal Representative Printed ____________________________________________________

 

Personal Representative Signature __________________________________________________

 

Relationship to Patient ___________________________________________________________

Copyright @2002 Pennsylvania Chiropractic Association. All rights reserved