Our Commitment: To be the best at delivering wellness care by measuring where a persons current level of health is and designing specific programs to help them gain the level of health they desire.
Patient Information In Case of Emergency Contact
Date______Name______
Patient Name ______Relationship______
Last Name
Home # (____) ______Work # (____) ______
______
First Name Middle Name Employment/School Information
Address ______Occupation ______
City ______State ______Patient Employer/School ______
Zip______Email ______Employer/School Address ______
Sex □ M □ F Date of Birth ______Employer/School Phone ______
□ Married □ Divorced □ Widowed □ Single □ Minor Spouse/Guardian Information
Phone Numbers Name______
Home # (____) ______Cell # (____) ______Date of Birth ______
Cell Carrier______(for text messages) Employer ______
In case of a medical emergency, if the patient is a
Best time/Way to reach you______minor,it is ok to treat in my absence.
______
We WILL be calling after your first appt. to see how your visit went Parent/GuardianSignature
Insurance Information Accident Information
Who is responsible for account? ______Is condition due to an accident? □ Yes □ No Date ______
Relationship to Patient ______Type of Accident □ Auto □ Work □ Home □ Other
Insurance Co. ______To whom have you reported your accident?
ID # ______Group # ______□ Auto Insurance □ Employer □ Work Comp □ Other
Subscribers Name ______Attorney Name (if applicable) ______
Date of Birth______SS# ______Attorney Address ______
Relationship to Patient ______
Assignment and Release
I certify that I, and/or my dependent(s), have insurance coverage with ______and assign directly to OptimaHealth & VitalityCenter all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named clinic may use my health care information and may disclose such information to the above-named insurance company and ______their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
______
Signature of Patient, Parent or GuardianPrint Name of Patient, Parent or Guardian
______Date Signed Relationship to Patient
OFFICE POLICY
We believe that REGAINING AND MAINTAINING YOUR HEALTHis our main priority and a clear definition
of our office policies will allow both you the patient, and us the doctor, to concentrate on just that.
M:\Forms - Masters\New Patient Forms\New patient intake forms over 2 years old\Patient Intake Form - complete for printing.doc
M:\Forms - Masters\New Patient Forms\New patient intake forms over 2 years old\Patient Intake Form including 3 problem areas.doc12/18/181 [Type here]
What is your main health concern:______
______
1a. Where is your PRIMARYproblem area located: _______
Cervical (neck): ____left side ___right side ___upper neck ___lower neck
Thoracic (mid back): ____left side ___right side ___between shoulders
Lumbar (lower back): ____left side ___ right side ___tailbone area
Upper Extremity Problem: ____shoulder- left / right ___elbow- left / right
____wrist- left / right ____hand- left / right ___hip- left / right
____ knee-left / right ____ankle- left / right ___ foot- left / right
b.When did the PRIMARYproblem start:______
Describe onset of problem: ___ acute (new) ___chronic (always there) ____gradual
What is the cause of the problem: ___unknown ___accident ___other
Have you had prior problem here: ___ none ____on & off for yrs ___yes, but not for yrs
c.Description ofPRIMARY problem: ______
Describe your problem: ____improving ____getting worse ____no change
If the problem has changed, how: ____gradually ____slowly ____slightly
Quality of pain: ___achy ____burning ____dull ____sharp ____stiff ___throbbing Description of problem: ____mild ____moderate ____severe
On scale from 1-10, with 1 being mild and 10 being severe, what is your pain? ______
Is problem: ___constant ____frequent ____intermittent ____occasional
How often do you have the problem:____daily ___weekly ___comes & goes___always
Does the pain radiate? If yes, where: ___head __neck ___shoulder/arm- left / right
When is problem the worse: ___morning ____afternoon ____evening ____night
When is problem better: ___morning ____afternoon ____evening ____night
What makes the problem worse: ______
What makes the problem better: ______
Do you have any: __numbness __spasms __weakness If yes, where: ______
2a. Where is your SECOND problem area located: ______
Cervical (neck): ____left side ___ right side ___upper neck ___lower neck
Thoracic (mid back): ____left side ___ right side ___between shoulders
Lumbar (lower back): ____left side ___ right side ___tailbone area
Upper Extremity Problem: ____shoulder- left / right ___ elbow- left / right
____wrist- left / right ____ hand- left / right ___ hip- left / right
____ knee- left / right ____ ankle- left / right ___ foot- left / right
b.When did theSECOND problem start:______
Describe onset of problem: ___ acute (new) ___chronic (always there) ____gradual
What is the cause of the problem: ___unknown ___accident ___other
Have you had prior problem here: ___ none ____on & off for yrs ___ yes, but not for yrs
Doctor's Use
______
______
c. Description of SECOND problem: ______
Describe your problem: ____improving ____getting worse ____no change
If the problem has changed, how: ____gradually ____slowly ____slightly
Quality of pain: ___achy ____burning ____dull ____sharp ____stiff ___throbbing Description of problem: ____mild ____moderate ____severe
On scale from 1-10, with 1 being mild and 10 being severe, what is your pain? ______
Is problem: ___constant ____frequent ____intermittent ____occasional
How often do you have the problem: ____daily ___weekly ___comes & goes ___always
Does the pain radiate? If yes, where: ___head __neck ___shoulder/arm- left / right
When is problem the worse: ___morning ____afternoon ____evening ____night
When is problem better: ___morning ____afternoon ____evening ____night
What makes the problem worse: ______
What makes the problem better: ______
Do you have any: __numbness __spasms __weakness If yes, where: ______
3a. Where is your THIRD problem area located: ______
Cervical (neck): ____left side ___ right side ___upper neck ___lower neck
Thoracic (mid back): ____left side ___ right side ___between shoulders
Lumbar (lower back): ____left side ___ right side ___tailbone area
Upper Extremity Problem: ____shoulder- left / right ___ elbow- left / right
____wrist- left / right ____ hand- left / right ___ hip- left / right
____ knee- left / right ____ ankle- left / right ___ foot- left / right
b.When did the THIRDproblem start:______
Describe onset of problem: ___ acute (new) ___chronic (always there) ____gradual
What is the cause of the problem: ___unknown ___accident ___other
Have you had prior problem here: ___ none ____on & off for yrs ___ yes, but not for yrs
c. Description ofTHIRD problem: ______
Describe your problem: ____improving ____getting worse ____no change
If the problem has changed, how: ____gradually ____slowly ____slightly
Quality of pain: ___achy ____burning ____dull ____sharp ____stiff ___throbbing Description of problem: ____mild ____moderate ____severe
On scale from 1-10, with 1 being mild and 10 being severe, what is your pain? ______
Is problem: ___constant ____frequent ____intermittent ____occasional
How often do you have the problem: ____daily ___weekly ___comes & goes ___always
Does the pain radiate? If yes, where: ___head __neck ___shoulder/arm- left / right
When is problem the worse: ___morning ____afternoon ____evening ____night
When is problem better: ___morning ____afternoon ____evening ____night
What makes the problem worse: ______
What makes the problem better: ______
Doctor's Use
______
______
IF YOU HAVE MORE THAN THREE PROBLEM AREAS
ASK THE FRONT DESK FOR AN ADDITIONAL SHEET
Allergies/Lifestyle/Additional Information
Please list any medications: ______
Please list any medications you are allergic to: ______
Please list any foods or chemicals you are allergic to: ______
Do you currently smoke?____ If yes, how many per day:_____ Type: cigarettes / cigarsAlcohol use: (Circle One) Never Rarely Moderate DailyRecreational Drug use: Type: ______Never or Frequency______
Have you had chiropractic care in the past? ______If female- Are you currently pregnant?____ If yes, due date______
Systems Review:List any issues you are experiencing with the followingsystems:
Ears: ______Eyes: ______Nose: ______Mouth: ______Throat: ______Lungs/Breathing: ______
Heart Health: ______Bowels: ______Bladder/Kidneys: ______
Number of times you urinate during the day: ___ During the night:___ How often do you have a bowel movement: _____
Health History-Please circle "Y" for a condition that you currently have,
and "P" for a condition that you have had in the past.
AIDS/HIVY P Diabetes Y P Multiple SclerosisY P
AlcoholismY P Emphysema Y P OsteoporosisY P
AllergiesY P Epilepsy Y P PacemakerY P
AnemiaY P Fibromyalgia Y P Parkinson’s DiseaseY P
AppendicitisY P Glaucoma Y P Pneumonia Y P
ArthritisY P Gout Y P Prostate Problems Y P
AsthmaY P Heart Disease Y P Prosthesis Y P
Blood ClotsY P Hepatitis Y P Rheumatoid Y P
Breast LumpY P Hernia Y P Scarlet Fever Y P
BronchitisY P Liver Disease Y P StrokeY P
CancerY P Lupus Y P Thyroid Problems Y P
CataractsY P Lyme Y P UlcersY P
Chicken PoxY P Migraines Y P Whooping CoughY P
DepressionY P Mononucleosis Y P Yeast Infection Y P
Other Illness: ______
List any injuries or surgeries:______List any broken bones:______
Family History- Please list specific blood relatives who have had the following conditions: indicate either: mother, father, sister, brother, aunt, uncle and which side the grandparent is on maternal (M) or paternal (P)
Arthritis: ______Blood Clots: ______Cancer: ______Memory Loss: ______Diabetes: ______Stroke: ______
Heart Disease: ______High Blood Pressure: ______
Other Significant Family Illness: ______
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