DENISON CHIROPRACTIC – Patient/EHR Information
Patient Name: ______Date: ______
Do you have a Pacemaker: Yes No Have you had Chiropractic Care before: Yes No
Name/Nickname you wish to be called: ______Age: ____ Date of Birth: ____ - ____ - ____
Gender: Male Female Social Security: ____ - ____ - _____ Occupation: ______
Address: ______City: ______State: _____ Zip: ______
E-Mail Address: ______@______
Prime #: (____)-____-______Cell Home Work Second #: (____)-____-______Cell Home Work
Marital Status: Married Single Divorced Widowed Other ______# of Children: _____
Emergency Contact: ______Relationship: ______Phone #: (___) - ____ - ______
If Female - Date of Last Menses: ____-____-______Is there a chance you may be Pregnant? Yes No
Employment Status: Employed Self Employed Student Retired Other ______
Primary Physician: ______
Previous Surgeries: ______
CMS requires providers to report both race and ethnicity
Race: American Indian or Alaska Native Black or African American White or Caucasian
Asian Native Hawaiian or Pacific Islander Other I Decline to Answer
Ethnicity: Hispanic or Latino Not Hispanic or Latino I Decline to Answer
Smoking Status: Every Day Smoker Occasional Smoker Former Smoker Never Smoked
Verification Question: What is your mother’s 1st and maiden name: ______
Family History:
Relative / Illnesses/Medical ConditionsFather
Mother
Brother (s)
Sister (s)
Are you currently taking any medications?
(Please include regularly used over the counter medications)
Medication Name & Dosage / Medication Name & DosageI choose to decline receipt of my clinical summary after every visit: Yes No
(These summaries are often blank as a result of the nature and frequency of chiropractic care.)
Patient or Guardian Signature: ______Date: ______
DC (Patient/EHR Information)
DENISON CHIROPRACTIC - Authorization & Notice of Privacy
Patient Name: ______Date: ______
Authorization Of Treatment, and Permission Of Personal Information
I authorize Denison Chiropractic to examine me and provide appropriate care and testing as determined by the doctor. I also give Denison Chiropractic permission to contact me about scheduled appointments or other care related issues.
I give my permissions to Denison Chiropractic to share my information with the following family members or listed persons:
______
Authorization, Release, and Agreement to Pay for Service Rendered
I authorize Denison Chiropractic to release any information including the diagnosis and the records of treatment or examinations rendered to me during the period of such Chiropractic care to third party payers and / or other health practitioners.
I authorize and hereby request my insurance company to pay insurance benefits to the chiropractor, otherwise payable to me.
I understand Denison Chiropractic files my insurance for my convenience. Verification of benefits or pre-certification does not guarantee the payment of a claim. I understand that my insurance carrier may pay less than the actual bill of service. I agree to be responsible for payment of all services rendered on myself or my spouse.
Notice of Privacy Practices Acknowledgement
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
· Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who
may be involved in that treatment directly and indirectly.
· Obtain payment from third-party payers.
· Conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Patient or Guardian Signature: ______Date: ______
DC Intake 5 of 5 (HIPPA)
DENISON CHIROPRACTIC - Review Of Systems
Patient Name: ______Date: ______
Please use the scale below (0 to 4) to rate each of the symptoms on this page according to your health status over the past 30 days: 0 = Never have this symptom
1 = Occasionally have this symptom, effect not severe
2 = Occasionally have this symptom, effect is severe
3 = Frequently have this symptom, effect not severe
4 = Frequently have this symptom, effect is severe
Head / Energy/Activity / Lungs______Headaches
______Faintness
______Dizziness
______Insomnia / ______Fatigue/Sluggishness
______Apathy/Lethargy
______Hyperactivity
______Restlessness / ______Chest Congestion
______Asthma, Bronchitis
______Shortness Of Breath
______Difficulty Breathing
Eyes / Weight / Heart
______Watery or Itchy Eyes
______Swollen, Red or Sticky Eyelids
______Bags or Dark Circles Under Eyes
______Blurred or Tunnel Vision (not
including near or far sightedness) / ______Binge Eating/Drinking
______Craving Certain Foods
______Excessive Weight
______Compulsive Eating
______Water Retention
______Underweight / ______Irregular or Skipped Heartbeat
______Rapid or Pounding Heartbeat
______Chest Pain
Ears / Emotions / Digestive Tract
______Itchy Ears
______Earaches, Ear Infections
______Drainage From Ear
______Ringing In Ears, Hearing Loss / ______Mood Swings
______Anxiety/Fear/Nervousness
______Anger/Irritability/Aggressiveness
______Depression / ______Nausea, Vomiting
______Diarrhea
______Constipation
______Bloated Feeling
______Belching, Passing Gas
Nose / Mind / ______Heartburn
______Intestinal/Stomach Pain
______Stuffy Nose
______Sinus Problems
______Hay Fever
______Sneezing Attacks
______Excessive Mucus Formation / ______Poor Memory
______Confusion, Poor Comprehension
______Poor Concentration
______Poor Physical Condition
______Difficulty Making Decisions
______Stuttering or Stammering
Mouth Throat / ______Slurred speech / Other
______Chronic Coughing
______Frequent Need to Clear Throat
______Sore Throat, Hoarseness
______Swollen or Discolored Tongue
______Canker Sores / ______Frequent Illness
______Frequent or Urgent Urination
______Genital Itch or Discharge
Skin / Joints/Muscles / Grand Total:
______Acne
______Hives, Rashes, Dry Skin
______Hair Loss
______Flushing, Hot Flashes
______Excessive Sweating / ______Pain or Aches in Joints
______Arthritis
______Stiffness or Limited Movement
______Pain or Aches in Muscles
______Weakness or Fatigued Muscles
DC Intake 3 of 5 (MSQ)
DENISON CHIROPRACTIC – Functional Rating Index
Patient Name: ______Date: ______
In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities.
For each item below, please circle the number which most closely describes your condition right now.
Pain Intensity / Recreation0 1 2 3 4
No Mild Moderate Severe Worst
pain pain pain pain possible
pain / 0 1 2 3 4
Can do Can do Can do Can do Cannot do
all most some a few any
activities activities activities activities activities
Sleeping / Frequency of Pain
0 1 2 3 4
Perfect Mildly Moderately Greatly Totally
sleep disturbed disturbed disturbed disturbed
sleep sleep sleep sleep / 0 1 2 3 4
No Occasional Intermittent Frequent Constant
pain pain, 25% pain; 50% pain; 75% pain; 100%
of the day of the day of the day of the day
Personal Care (washing, dressing, etc.) / Lifting
0 1 2 3 4
No pain Mild pain Moderate pain Moderate pain Severe Pain
no no need to need some need 100%
restrictions restrictions go slowly assistance assistance / 0 1 2 3 4
No Increased Increased Increased Increased
pain with pain with pain with pain with pain with
heavy heavy moderate light any
weight weight weight weight weight
Traveling (driving, etc.) / Walking
0 1 2 3 4
No pain Mild pain Moderate pain Moderate pain Severe pain
on long on long on long on short on short
trips trips trips trips trips / 0 1 2 3 4
No Increased Increased Increased Increased
pain pain pain pain pain
any after 1 after ½ after ¼ with all
distance mile mile mile walking
Work / Standing
0 1 2 3 4
Can do Can do Can do Can do Cannot
usual work usual work 50% of 25% of work
plus no usual work usual work
unlimited extra work
extra work / 0 1 2 3 4
No Increased Increased Increased Increased
pain pain pain pain pain
after after after after with several several 1 hour ½ hour any
hours hours standing
For Office Use Only: Clinical Diagnosis Codes:
Practitioner ID#: ______Patient ID#: ______
Total Score ______/40
DC Intake 4 of 5 (Functional Rating Index)
Welcome to Denison Chiropractic
At Denison Chiropractic it is our mission to help you achieve all of your health goals and needs. Whether your main reason for seeing us is to get out of pain, increase your energy, lose weight or simply take your health to that next level we are here to provide you with the tools and knowledge to help you on your journey to optimal health.
The first step is to establish your current state of health and overall function of your body. In order for us to assess this and to understand the root cause of your symptoms, we will be taking you through a series of non-invasive examinations on your initial visit. This will include a full case history, nerve and muscle tests, postural analysis, functional movement assessment, bioimpedence analysis, heart rate variability and blood pressure.
On the day of your visit we ask that you wear clothing that you are comfortable moving in for the physical portion of the examination. We will be taking a postural photo of you so please don't wear bulky clothing or multiple layers. Ladies, if you have full tights or pantyhose on, we'll ask that you remove those. In addition to this, if you have any previous X-ray or MRI reports please bring these along on this visit for out records if we need to refer to these during the case history.
Simple steps to follow before your examination:
· No alcohol within 24 hours
· No exercise for 4 hours
· Avoid caffeine and food for 4 hours
· Consume 2-4- glasses of water within 2 hours
The initial assessment will take between 45-60 minutes so we ask that you allow sufficient time and if you have any concerns please speak to our reception before your visit if time is a constraint.
1721 S. Austin Ave. * Denison, TX 75020 * 903-463-5151 * DenisonChiropractic.Com
DC (Instructions Day 1)
8WW Patient Information
· Carefully read and follow the instructions enclosed regarding Pre-test Preparation, specifically for body fat measurements.
· The necessary information for you to get your blood work done is enclosed.
· Remember to bring your insurance card with you on your initial exam so that we may obtain a copy for our files.
· Please fill out paperwork and bring with you to initial exam.
· Please include your email address on your paperwork. This is a main source of communication during your program. If you do not have one, please let us know.
· Bring your appointment book/planner on your initial visit so that we can schedule your visits for the program.
· Please remember that there is a 12 hour fasting requirement for your blood work!
1721 S. Austin Ave. * Denison, TX 75020 * 903-463-5151 * DenisonChiropractic.Com
DC(8WW Patient Information)