3004 Lee Hwy. D-111, Arlington, VA22201 Phone: (703)671-6038 Fax: (703)671-6048
PATIENT INFORMATION
DATE:______
NAME:______
LASTFIRST MIDDLE INITIAL
BIRTHDATE:______SEX: □M □F
ADDRESS:______
CITY:______STATE:_____ ZIP:______
CONTACT INFORMATION
HOME PHONE: ( )______
CELL PHONE: ( )______
EMAIL ADDRESS:______
OCCUPATION:______
EMPLOYER/SCHOOL:______
EMPLOYER/SCHOOL ADDRESS:______
CITY:______STATE:_____ ZIP:______
EMPLOYER/SCHOOL PHONE: ( )______
SPOUSE’S NAME:______
BIRTHDATE:______
EMPLOYER:______
IN CASE OF EMERGENCY
NAME:______
RELATIONSHIP:______
PHONE NUMBER: ( )______
Who may we thank for referring you?
______
PATIENT CONDITION
REASON FOR VISIT______
WHEN DID SYMPTOMS APPEAR?______
IS THIS CONDITION PROGRESSIVELY GETTING WORSE?
□YES□NO□ UNKNOWN
MARK AN X ON THE PICTURE BELOW WHERE YOU HAVE PAIN, NUMBNESS, OR TINGLING:
RATE YOUR PAIN 1(least)-10(severe):______
TYPE OF PAIN: □SHARP □DULL □THROBBING
□NUMBNESS □ACHING □SHOOTING □BURNING
□TINGLING □STIFFNESS □SWELLING □OTHER
HOW OFTEN DO YOU HAVE THIS PAIN?______
CONSTANT OR COME AND GO?______
DOES IT INTERFERE WITH YOUR:
□WORK □SLEEP □DAILY ROUTINE □RECREATION
ACTIVITIES OR MOVEMENTS THAT ARE PAINFUL TO PERFORM:
□SITTING□STANDING□WALKING
□BENDING□LYING DOWN
IS THIS CONDITION DUE TO AN ACCIDENT? □YES □NO
DATE:______
TYPE OF ACCIDENT: □AUTO □WORK □HOME □OTHER
TO WHOM HAVE YOU MADE A REPORT OF THIS ACCIDENT? □AUTO INSURANCE □EMPLOYER □OTHER
ATTORNEY NAME (if applicable):______
ADDRESS:______
CITY:______STATE:______ZIP:______
PHONE:( )______
3004 Lee Hwy. D-111, Arlington, VA22201 Phone: (703)671-6038 Fax: (703)671-6048
HEALTH HISTORY
3004 Lee Hwy. D-111, Arlington, VA22201 Phone: (703)671-6038 Fax: (703)671-6048
What treatment have you already received for your condition?
□ Medications □ Surgery □ Physical therapy □ Chiropractic Services □ None □ Other
Name and address of other doctor(s) who have treated you for your condition:
______
Date of Last:
Physical Exam ______Spinal X-Ray______Blood Test______
Spinal ExamChest X-RayUrine Test
Dental X-RayMRI, CT, Bone Scan
Place a mark on “Yes” or “NO” to indicate if you have had any of the following:
AIDS/HIV / □YES□NO / DIABETES / □YES□NO / MEASLES / □YES□NO / SCARLET FEVER / □YES□NOALCOHOLISM / □YES□NO / EMPHYSEMA / □YES□NO / MIGRAINES / □YES□NO / STROKE / □YES□NO
ALLERGY SHOTS / □YES□NO / EPLLEPSY / □YES□NO / MISCARRIAGE / □YES□NO / SUICIDE ATTEMPT / □YES□NO
ANEMIA / □YES□NO / FRACTURES / □YES□NO / MONONUCLEOSIS / □YES□NO / THYROID PROBLEMS / □YES□NO
ANOREXIA / □YES□NO / GLAUCOMA / □YES□NO / MULTIPLE SCLEROSIS / □YES□NO / TONSILLITIS / □YES□NO
APPENDICITIS / □YES□NO / GOITER / □YES□NO / MUMPS / □YES□NO / TUBERCULOSIS / □YES□NO
ARTHRITIS / □YES□NO / GONORRHEA / □YES□NO / OSTEOPOROSIS / □YES□NO / TUMORS, GROWTHS / □YES□NO
ASTHMA / □YES□NO / GOUT / □YES□NO / PACEMAKER / □YES□NO / TYPHOID FEVER / □YES□NO
BLEEDING DISORDERS / □YES□NO / HEART DISEASE / □YES□NO / PARKINSON’S DISEASE / □YES□NO / ULCERS / □YES□NO
BREAST LUMP / □YES□NO / HEPATITIS / □YES□NO / PINCHED NERVE / □YES□NO / VAGINAL INFECTIONS / □YES□NO
BRONCHITIS / □YES□NO / HERNIA / □YES□NO / PNEUMONIA / □YES□NO / VENEREAL DISEASE / □YES□NO
BULIMIA / □YES□NO / HERNIATED DISC / □YES□NO / POLIO / □YES□NO / WHOOPING COUGH / □YES□NO
CANCER / □YES□NO / HERPES / □YES□NO / PROSTATE PROBLEM / □YES□NO / OTHER / DESCRIBE
CATARACTS / □YES□NO / HIGH CHOLESTEROL / □YES□NO / PROSTHESIS / □YES□NO
CHEMICAL DEPENDENCY / □YES□NO / KIDNEY DISEASE / □YES□NO / PSYCHIATRIC CARE / □YES□NO
CHICKEN POX / □YES□NO / LIVER DISEASE / □YES□NO / RHEUMATIC REVER / □YES□NO
ARE YOU PREGNANT?□YES □NODUE DATE______
EXERCISE / WORK ACTIVITY / HABITS□ NONE / □ SITTING / □ SMOKING / PACKS/DAY
□ MODERATE / □ STANDING / □ ALCOHOL / DRINKS/WEEK
□ DAILY / □ LIGHT LABOR / □ COFFEE/CAFFEINE / CUPS/DAY
□ HEAVY / □ HEAVY LABOR / □ HIGH STRESS LEVEL / REASON
INJURIES/SURGERIES YOU HAVE HAD / DESCRIPTION / DATE
FALLS
HEAD INJURIES
BROKEN BONES
DISLOCATIONS
SURGERIES
MEDICATIONS / ALLERGIES / VITAMINS/HERBS/MINERALS
CONSENT TO TREAT
Patient Name ______Date______
I have been informed of the nature of my disorder(s) and of the nature and purpose of chiropractic/physical therapy procedures proposed as treatment. I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of therapy modalities on myself (or on the patient named below for whom I am legally responsible) by the licensed doctors of chiropractic of Arlington Pain & Rehab or any doctor, who now or in the future, works as a doctor of chiropractic/physical therapist. I have had the opportunity to discuss with my doctor the nature and purpose of chiropractic adjustments and other procedures and understand that spinal manipulation involved the doctor placing his or her hands on my spine and delivering a quick thrust or impulse to the involved area(s). I also understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to: fractures, disc injuries, strokes, dislocations, sprains, soreness, and physical therapy burns. I understand and comprehend all such risks and complications. I do not expect the physician to be able to anticipate and explain all risks and complications. Further, I wish to rely on the physician to exercise judgment during the course of the procedure which the physician feels are in my best interests at the time, based upon the facts then known. I, by my signature below, confirm and accept care and therefore consent to and agree to those treatments deemed necessary by my doctor to be in my best interest.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to and authorize the treatment recommended by my doctor. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at this facility.
NAME OF PATIENT (print)______
PATIENT’S SIGNATURE______
DATE______
To be completed by the patient’s representative, if necessary, (e.g.: if the patient is a minor or is physically or mentally incapacitated):
NAME OF REPRESENATIVE (print) ______
Signature of Patient Representative______
DATE______
Financial Policy
Health Insurance Coverage
Please note that any health insurance policy is an agreement between the insured and the insurer, not between the insurer and this clinic. Like all types of care, coverage and benefits for chiropractic and physical therapy services can vary. Most insurance policies require the beneficiary to pay a co-insurance, co-payment and/or a deductible. For example: if you have a deductible of $100, and your insurance pays 80%, you are responsible for 20% of all charges incurred during the year after you have paid the $100 deductible. Even if you have a copay, you may sometimes need to meet the deductible first. Our clinic will contact your insurer to verify your benefits; however, the information provided to us is not a guarantee of payment and we are not responsible for your insurer’s final payment and benefit determinations. It is always best to verify your own coverage and benefits with your insurance company in order to avoid unexpected bills. When verifying benefits, request information for both chiropractic and physical therapy.
Payments
In order to help you determine your responsibility toward payment for services, please read the following, and initial your preference for the method of payment of your account. Please notify this office if the status of your insurance changes.
Private Pay: (please initial)
AAs I have no insurance, I agree to assume all responsibility and to keep my account current by paying for services when they are rendered.
BI have insurance, but I wish to file my claims personally, and I agree to assume all responsibility and to keep my account current by paying for each visit at the time services are rendered.
Health Insurance: (please initial)
CI would like this clinic to bill my insurance. I understand I am responsible for the costs of treatment.
Missed Appointments
It is the policy of Arlington Pain and Rehab to assess a $35.00 missed Chiropractic visit fee, and $50.00 miss Physical Therapy fee to patients who cancel follow up appointments with less than a 24-hour notice or who fail to show up for their scheduled appointment. Two (2) or more missed appointments will result in a $75.00 fee for each missed appointment thereafter. A $75.00 fee will be assessed for all new patient, reactivation, GAIT analysis and massage appointments. This clinic provides care for many individuals and missed visits result in time lost that could have been used to provide care for others.
My initials here indicate that I understand the above missed visit policy.
I understand that if there is any change in my schedule, treatment plan, or in any insurance coverage I have, I will notify the office staff as soon as possible so that they may make the necessary changes. Failure to do so may result in insurance complications and possible discharge from the clinic.I understand that all health services rendered to me and charged to me are my personal financial responsibility. I understand and agree to the conditions of this financial policy.
Signature Date
3004 Lee Hwy. D-111, Arlington, VA22201 Phone: (703)671-6038 Fax: (703)671-6048