Chiropractic Wellness Center, Dr. Marc Terebelo

Chiropractic Wellness Center, Dr. Marc Terebelo

30555 Southfield Rd., Suite 155, Southfield, MI 48076

Phone: (248) 593-8282 Fax: (248) 593-8284

Patient Information

Name: ______Age: ____ Preferred Name: ______

Date of Birth: ______Gender: ____ Social Security #:______

Address: ______

City: ______State: _____Zip: ______

Phone (home):______(cell):______(work):______

Occupation: ______Employer: ______

Referred By: ______

Marital Status: ______Spouse’s/Partner’s Name: ______

Number of Children: ____

Email Address: ______

Guarantor’s info if different: name/date of birth/address/phone/Social Security #

______

1. What is your chief complaint: ______

2. Indicate on the drawings below where you have pain/discomfort

4. How would you describe the type of pain?

□ Sharp□ Numb

□ Dull□ Tingly

□ Diffuse □ Sharp with motion

□ Achy□ Shooting with motion

□ Burning□ Stabbing with motion

□ Shooting□ Electric-like with motion

□ Stiff□ Other:______

5. Who else have you seen for your problem?

□ Chiropractor□ Neurologist□ Primary Care Physician

□ ER physician□ Orthopedist□ Other:______

□ Massage Therapist□ Physical Therapist□ No one

6. How long have you had this problem? ______

7. What is your: Height______Weight ______

8. What type of exercise do you do?

□ Strenuous □ Moderate □ Light □ None

9. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column.

Past / Present / Condition / Past / Present / Condition
Headaches / Kidney Disorders/Stones
Neck Pain / High Blood Pressure
Upper Back Pain / Heart Attack
Mid-Back Pain / Chest Pains
Low Back Pain / Stroke
Shoulder Pain / Angina
Elbow Pain / Diabetes
Wrist/Hand Pain / Epilepsy
Leg Pain / Prostrate Problems
Knee Pain / Bladder Infection
Past / Present / Hip Pain / Bladder Control
Epilepsy / Systemic Lupus
Condition / Condition
Gall Bladder Issues / Depression
Visual Disturbances / Anxiety
Condition / Past / Present / Condition
HIV/AIDS / Arthritis
Drug/Alcohol Use / Cancer
Smoking / Tumor
Allergies / Asthma
Jaw Pain / Hepatitis
Birth Control / Pregnancy
Ulcers / Gastric Reflux
Dizziness / Memory Loss

10. List all nutritional supplements you are currently taking:

______

11. List all surgical procedures you have had:

______

12. Have you ever been hospitalized?□ No□ Yes

Describe: ______

13. Anything else pertinent to your visit today?

______

______

Treatment Authorization

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Any amount authorized to be paid directly to the doctor’s office will be credited to my account on receipt or will be returned to the insurance company and re-issued to the patient, if applicable. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment any fees for professional services rendered to me will be immediately due and payable.

I hereby authorize the doctor’s office to examine and treat my condition as he/she deems appropriate through the use of Chiropractic Health Care and I give authority for these procedures to be performed. The patient also agrees that he/she is responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medical diagnosed conditions nor for any medical diagnosis.

Patient/Guardian Signature______Date:______

Acknowledgment OF RECEIPT OF HIPAA PRIVACY NOTICE

I, , have received a copy of this office’s Notice of
Privacy Practices. I understand that 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 health care providers who may be directly and indirectly involved in providing my treatment.

Obtain payment from third-party payers.

Conduct normal health care operations such as quality assessments and accreditation.

Patient
Signature
Date
For Office Use Only
We attempted to obtain written Acknowledgment of receipt of our Notice of Privacy Practices, but Acknowledgment could not be obtained because:
Individual refused to sign
Communications barriers prohibited obtaining the Acknowledgment
An emergency situation prevented us from obtaining Acknowledgment
Other (Please Specify) ______
______
Staff signature / Date

Preferred Name: ______Preferred Language: English Other
Date: ______Race: American Indian or Alaska Native,

Cell:______Asian, Black or African-American, White

Other:______Hispanic or Latino, Multi-Racial, Other

Ethnicity: Hispanic Not Hispanic

Preferred method of telephone contact: ______

Email address:______

Please list any/all medically prescribed medications you are taking at this time and precise dosage per day in mg.

1. ______Strength______Frequency______

2. ______”______”______

3. ______”______”______

4. ______”______”______

5. ______”______”______

6.______”______”______

7.______”______”______

8.______”______”______

9.______”______”______

10.______”______”______

Do you have any Allergies? Yes_____ No______

Medicine Severity: Mild/Mod/Severe Describe Reaction

______
______
______

Do you use any form of tobacco? (age 13 and over) Yes______NO______Whattype?______

If Cigarettes or cigars, how many do you smoke per day?______

Height______Weight______Doctor Use Only: BP:

______

Patient Name

PATIENT SUPPLEMENT LOG

Date StartProductDate Start Product

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