New Patient Contact, Demographic and History Information Harris Chiropractic PLC

Date: ______Patient Information Page 1

Legal First Name: ______MI: ______Last Name: ______

Street: ______Apt: ______

City: ______State: ______Zip: ______

Social Security #:______Marital Status: S M W D Spouse:______

Language: _____English, _____ Spanish, _____ Indian, _____ Japanese, _____ Chinese, _____ Korean, _____ French,

_____ German, _____ Russian, Other______

Race: _____ White, _____American Indian or Alaska Native, _____ Asian, _____ Black or African American,

_____ Hispanic or Latino _____Native Hawaiian/Other Pacific, Islander, _____ Decline to Answer, Other______

Ethnicity: _____ Hispanic or Latino, _____Not Hispanic or Latino, _____ Decline to Answer

DOB: ______Home Phone: ______Work Phone:______

Cell Phone: ______Cell Carrier______

Please check your contact preference: _____Home, _____ Work, _____ Cell, _____Email, _____ Postal Mail

Email home: ______Email work: ______

Emergency Contact:______Phone Number: ______

Whom may we thank for referring you to our office? ______

Occupation: ______Employer: ______

Employer Address: ______

Insurance Information

We will make a copy of your insurance card/s. However, please complete the following information.

Are you the policy holder? Y N If no, who is policy holder: Spouse Parent Employer Other

Primary Policy Holder's Name: (if its you write: same)

First Name: ______M.I. ______Last Name: ______

Policy Holder's Date of Birth: ______Policy Holder's SS#: ______

Policy Holder's Employer: ______

Do you have SECONDARY insurance coverage? Y N If yes, please complete the following:

Policy Holder's Name:

First Name: ______M.I. ______Last Name: ______

Policy Holder's Date of Birth: ______Policy Holder's SS#: ______

Policy Holder's Employer: ______

Patient History Page 2

Are you seeing anyone else for other problems or health conditions? □ Yes □ No

Please list the problem/s, date problem/s began, and Provider/s treating you for the condition/s:

______

Past health history

Have you…ly Yes No If yes, include date & provider seen

...been hospitalized in the last 5 years? □ □ ______

...been diagnosed with Diabetes? □ □ ______

Type I____or Type II_____

…been treated for hypertension? □ □ ______

Do you smoke? □Never □Former Smoker □Current/Every Day Smoker □Current Some Day Smoker

Medications

What medications are you currently taking? Include vitamins, herbs, minerals…

List Date Started, Brand Name, Generic Name, Strength, Dosage, Frequency, Duration, Quantity, Refills Available, Prescribed by ______

Please be as specific as possible. We can copy a list if you have one.

______

Do you have allergies? □Food □Environmental □Medication

List Type of Allergy and Reaction (example: hives, itching, anaphylaxis)

______

Assignment & Release

Insurance Information

I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this doctors office will be credited to my account upon receipt. 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 or outstanding balances for services I have received will be immediately due and payable.

Patient's/Parent's/Guardian's Signature: ______

Consent of Professional Services and Release of Information

I herby authorize and release the doctor and whomever he/she may designate as his/her assistants, to administer treatment, physical examination, x-ray studies, laboratory procedures, chiropractic care or any clinic services that he/she deems necessary in my case; I furthermore authorize him/her to disclose all or any part of my patient record to any person or corporation which is or may be liable under a contract to this office or to the patient or to a family member or employer of the patient for all or part of the clinic's charge, including, and not limited to hospital or medical service companies, insurance companies, worker's compensation carriers, welfare funds, or the patient's employer.

Patient's/Parent's/Guardian's Signature: ______

Past Health History

Name ______Date______

Auto crashes ever? No Yes if so when ______

Other injuries including falls ______

Prior fractures/ broken bones ______

Prior illnesses ______

Hospitalizations: dates and reason______

______

Surgical history ______

Current prescription medications (or give a list)______

______

Current non-prescription medications ______

Herbal remedies/ vitamins ______

Treated by a doctor for any health condition in the last 12 months? No Yes if so specify______

Serious childhood illnesses ______

Birth defects______

Family and Social History

Do you smoke? Yes No Occasionally Do you drink alcohol? Yes No Occasionally

Indicate the presence of these diseases in family member or cause of death if deceased.

Alive / Age at death / Stroke / Heart or lung disease / Cancer / Diabetes / High blood pressure / Kidney disease / Accident or other / Spinal problems
Father
Father’s Mother
Father’s Father
Mother
Mother’s Mother
Mother’s Father
Sibling 1
Sibling 2
Sibling 3

Steven R. Harris DC ______

Patient's name ______Date ______

Problem Descriptions

[Please mark all sites on the reverse side picture]

1. Circle ALL your problem areas: Headache Neck Upper-back Mid-back Low-back Left-Shoulder Right-Shoulder Arm Hand Wrist Buttock Hip Knee Foot Other

Circle and Describe for your #1 problem only

2. The single #1 one worst problem area is: Headache Neck Upper-back Mid-back Low-back Left-Shoulder Right-Shoulder Arm Hand Wrist Buttock Hip Knee Foot Other: ______

3. If painful, it is: Sharp Dull/achy Burning Numbness Pins and needles Throbs

4. Mark the Worst Pain level recently: no pain- 0 1 2 3 4 5 6 7 8 9 10 -extreme

5. Your problem is worse on which side? Left Right Center Both

6. The pain goes down your arm or leg? No Yes If yes-describe______(over)

7. Date the problem recently started or worsened: ______***

8. Caused by: A fall Car accident Old injury Sudden movement Over doing Traveling Work injury Exercise lifting Other ______

9. During waking hours, the pain or problem is present: 0-25% 25-50% 50-75% 75-100%

10. Pain came on: suddenly over-hours over days over weeks over months

11. The problem is Worse with: Walking Standing Getting up from sitting Sitting Movement Exercise Rest Other ______

12. Better with: Walking Standing Getting up from sitting Sitting Movement Exercise Rest Other ______

13. For relief you have tried: Ice Heat Prescription-drugs Drugs Exercise Other ______

14. For this problem you have had: X-ray MRI CAT-scan other ______

15. Have you had treatment for this exact same problem in the last three years? No Yes

16. May we send a report to your local family doctor? Yes No

If so: Dr's name ______

17. The #2 worst problem area: Headache Neck Upper-back Mid-back Low-back Left-Shoulder Right-Shoulder Arm Hand Wrist Buttock Hip Knee Foot

Other ______

18. The doctor should also be aware of: ______

Signature X ______

How Often Does Your Pain Occur?

Patient Name: ______Date:______

PLEASE CIRCLE ALL THAT APPLY:

1. How often is the pain present :

Constant Frequent Intermittent Occasional

2. What time of day does your pain bother you :

No Change Morning After Noon Evening At Night As Day Progresses

3. What time of day does your pain seem to go away or is not as severe:

No Change Morning After Noon Evening At Night As Day Progresses

4. Do you have any Weakness or Numbness? YES NO

If yes please describe:______

5. Have you noticed any swelling? YES NO

6. Are you having any pain when bending forward or leaning backwards? YES NO

If yes please describe:______

7. Do you have any pain twisting your neck or back to the LEFT or RIGHT? YES NO

If yes please describe:______

8. Do you have spasms? ______

9. Please give a brief description of what activities may be aggravating your pain. ______.

10. Is there anything else you would like to tell Dr. Harris so that he might be able to help you with your treatment process? ______.

11. What kids of adjustments have worked for you in the past?______.

Harris Chiropractic PLC Finical Policy Statement

PATIENT FINANCIAL RESPONSIBILITY AGREEMENT

Thank you for allowing Harris Chiropractic PLC to assist you with yourhealth care. In the interest of good practices, it is desirable to establish a credit policy toavoid misunderstandings. Our primary responsibility is to help our patients experience good health andwe wish to spend our time and energy toward that end. Our goal is to make the financial aspect of yourrecovery as stress‐free as possible. As a courtesy to you, we will bill your insurance. If there are any changes in your insurance, please letus know immediately so we can submit your claim properly, avoiding delays and possible lack of payment.
AtHarris Chiropractic PLC we will do everything we can to verify your insurance policy prior to your visit if possible. Most verifications can be done within 24 hours.
We cannot accept responsibility forcollecting on an insurance claim after 60 days or for managing a disputed claim.Insurancereimbursement is a contract between you, your employer and your insurance carrier. You areresponsible for portions of charges that your insurance does not pay.

1. Payment of co-pays and deductibles are due at the time of service. We do NOT bill these. If you have any questions about your charges orstatement, please contact our office at 623-972-9223. Balances are due within thirty(30) days.

2. *Please contact the Harris Chiropractic PLC if you are not able to keep your scheduled appointment. Appointments shouldbe cancelled at least 24 hours in advance. There will be a missed appointment charge of 15.00 dollars for repeat no-show/no cancel. Yourappointmenttime is reserved for you. You can request a reminder call if needed to help you keep your appointments.

Please bring the Patient Financial Responsibility Agreement

form below with you to your appointment.

Financial Responsibility Agreement
I, the undersigned: (Patientsname)______have insurance coverage, and authorize direct payment from that insurance carrier to Harris Chiropractic PLC . I agree to be responsible for charges for services, explained to me before the service is delivered, if not paid by the insurance company.

Harris Chiropractic PLC cannot accept responsibility forcollecting on an insurance claim after 60 days or for managing a disputed claim, you the patient arethereforeresponsible to Harris Chiropractic PLC for the payment of all charges or portion of the charges your insurance does not payregardlessof the reason.
I, the undersigned: (Patients name)______accept fullresponsibilityforpaymentof the sum of my care at Harris Chiropractic PLC and understand the above statement and will cooperate with payment for Chiropractic care rendered.
Note: Harris Chiropractic PLC willmake an effort to inform you if a supply or service is not covered by your insurance.

OR
If you do not have insurance: I (Patients name)______do not have insurance coverage and understand that I am responsible for payment of charges explained to me before services are rendered.

Patient:______Print name:______

DATE:______

Staff Signature: ______Date:______