Panama City Chiropractic

Patient Information

Preferred/Nick Name: Legal Name:
Case Type: Cash Medicare Medicaid MVA WC BCBS Cigna UHC Aetna Other Insurance
Address: City: State: Zip:
Cell #: Home #: Preferred Contact: Home Cell Text Work
Email Address:
DOB: Sex: Marital Status: SS#:
How did you hear about our office? Friend/Family Dr. Yellow Pages Sign Internet Other
Name of Friend/Family/Dr. who referred you: If Internet, What Sight:
Employment Status: Employed Unemployed Retired Student
Occupation: Employer:
Preferred Language: Ethnicity: Non Hispanic Hispanic
Race: American Indian Asian African American Caucasian Pacific Islander Other
Smoking Status: Every Day Smoker Occasional Smoker Former Smoker Never Smoked
Next of Kin for Emergency (Name & Phone):

Health History

Is your current condition related to an injury at: Work Auto Accident Other Accident None
If Injured what was the date of the injury? _____ / _____ / _____
Have you been unable to work due to your current condition? Y N If Yes. Dates out of work: ___/___/___
Have You Been in a Car Accident in the Past 2 Years? Y N Date:
Have You Ever Seen a CHIROPRACTOR? Y N When? ______Name of Dr. ______

Is there a chance you are pregnant? Y N When was your last period? ______

Are You Interested in: Just Relieving the Pain or Resolving the Problem and Maintaining Health

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Panama City Chiropractic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.

I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses.

I understand that there will be no fees charged if I give 24 hours notice to cancel or reschedule an appointment.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.

Signature: ______Date: ______

Printed Name: ______

Patient Name: ______Date: ______

Please check any of the following conditions that you have experienced

Neurological/Musculoskeletal

□ Neck or Back Pain □ Hip Pain □ Leg Pain □ Knee □ Ankle/Foot Pain □ Shoulder □ Elbow □Wrist Pain/Hand Pain

□Jaw Pain □ Numbness/Tingling □ Dizziness/Fainting/Vertigo □ Headaches/Migraines □ Anxiety □ Fatigue □ Sleep Problems

Ear/Nose/Throat

□ Allergies □ Sinus Headaches □ Earaches □ Other ______

Gastro-Intestinal

□ Excessive Thirst □ Nausea/Vomiting □ Diarrhea/Constipation □ Abdominal Pain □ Other ______

Genito-Urinary

□ Bladder Infections □ Menstrual Problems □ Kidney/Bladder Stones □ STD □ Other ______

Respiratory

□ COPD □ Lung Problems □Short Breath □ Other ______

Cardio-Vascular

□ Heart □ Chest Pain □ Blood Pressure Problems □ Stroke □ Ankle Swelling □ Other ______

Pathological

□ HIV/AIDS □ Cancer □ Tuberculosis □ Diabetes □ Heart Problems □ Hepatitis □ Other: ______

Family History

List any diseases or problems that your mother or father has experienced:

Mother: ______

Father: ______

Please list any medications you currently taking and dosage: ______

______

List any medications you are allergic to and your reaction to that medication:______

______

Past surgeries and the year they were performed: ______

______

Family doctors name and your last visitdate:______

Would you like to receive a clinical summary after every visit? DECLINE ACCEPT

(These summaries are often blank as a result of the nature and frequency of chiropractic care.)
Patient name: ______Date: ______

Signature: ______

Please mark the drawings on where your symptom is and fill out the information regarding that symptom

Complaint #1: ______

How Long Ago Did It Start? ______

What caused it To Start? ______

Since it started is it getting: better same worse intermittent

What is the quality? Aching burning catching deep dull numb radiating sharp stabbing stiff tender

What makes your symptom worse? ______

What makes it feel better? ______

What Activities is the symptom affecting? ______

What is your pain Right Now? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What is your TYPICAL or AVERAGE pain? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What is Your Pain at its BEST? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What Percent of your AWAKE hours is it at its best? _____%

What is your pain at its WORST? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What percent of your AWAKE hours is it at its worst? _____%

Complaint #2: ______

How Long Ago Did It Start? ______

What caused it To Start? ______

Since it started is it getting: better same worse intermittent

What is the quality? Aching burning catching deep dull numb radiating sharp stabbing stiff tender

What makes your symptom worse? ______

What makes it feel better? ______

What Activities is the symptom affecting? ______

What is your pain Right Now? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What is your TYPICAL or AVERAGE pain? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What is Your Pain at its BEST? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What Percent of your AWAKE hours is it at its best? _____%

What is your pain at its WORST? (Best) 1 2 3 4 5 6 7 8 9 10 (Worst)

What percent of your AWAKE hours is it at its worst? _____%

Informed Consent

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed below or any other office or clinic.

I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I 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 and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is 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 content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Patient Signature: ______Date: ______

Witness Signature: ______Date: ______

Clinic: Panama City Chiropractic

8406 PC Beach Pkwy

Unit #D

Panama City Bch, FL 32407

Practicing Physician: Dr. Jon Sherman

Dr. Signature: ______Date: ______