masulachiropractic.com-new-patient-forms

30 Philadelphia Drive Suite A
Chico, CA 95973
Work: (530)342-6441
Fax: (530)342-5441
Demographics
Today’s Date*

MonthDayYear
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Birth Date*

MonthDayYear
Age
Sex

MF
Secondary Phone

Area CodePhone Number
Email Address*
example@example.com
Cell Carrier for text reminders
Social Security #*
Select ALL that apply*

MarriedSingleWidowedDivorcedEmployedRetiredHomemakerStudent
Referred to this office by
Employment Information
Employer*
Job Title*
City, State*
Name of Spouse

First NameLast Name
Spouse’s Occupation
Employer
Health Insurance
Name/Policy Number*
Emergency Contact Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Relationship*

	Yes	No
Is this visit related to worker’s compensation?
Is this visit related to any legal actions?
Is this visit related to any sort of motor vehicle accident?

Please Describe the Major Problem That Brings You in Today to See a Chiropractic Neurologist:*
Please circle if you have the pain or difficulty performing the following:

BendingExtended computer useLifting childrenSexual activitiesCarrying GroceriesFeedingPet careSleepingChange position (sit-stand)Household choresReading (concentration)Static SittingClimbing stairsKneelingSelf-care (bathing)WalkingDrivingLiftingSelf-care (dressing)Yard work
When did this condition begin:*
Have you ever experienced a similar problem in the past?*

YesNo
When*
How long has it been since your last medical/chiropractic evaluation?*
If you follow a specific diet, please describe:
By using the key below, indicate on the body diagram where you are experiencing pain:
Annotate Image*
On average rating from 0-10, how much pain are you experiencing? 0 = no pain and 10= the worst pain imaginable? Please select :*
How are your symptoms changing? Please Select :*
Other
Family History

Do you have a family member affected with:

	Condition	Relative	Condition	Relative
Alcoholism
Diabetes
Depression
Heart Disease
Hypertension
Migraines
Neuromuscular junction disease
Multiple Sclerosis
Neuropathy
Neurological Disorder
Osteoporosis
Parkinson’s disease
Seizures or Epilepsy
Stroke
Thyroid Disease
Any Other Condition

Please list all medications and supplements you take routinely, prescribed or over-the-counter, along with the dosages:*
Review of Symptoms
Do you currently, or have you had a problem with (please Select):
Allergic / Immunologic:*

Autoimmune disease (i.e. lupus)CancerFood, Inhalant (nasal) allergiesN/A
Constitutional*

Excessive fatigueFeverHistory of fallsWeight loss >5 lbs.N/A
Cardiovascular:*

Chest pain or anginaCirculation problemsHeart MurmurHigh blood pressureHigh cholesterolIrregular pulseLow blood pressurePacemakerSwelling in hands or feetN/A
Ear, Nose, Throat & Mouth*

Balance (vertigo, spinning, etc.)Ear pain/InfectionsHearing lossInability to smellNasal congestion/DrainageNose bleedsRinging in earsSinus problemsWear hearing aid(s)N/A
Endocrine:*

DiabetesExcessive thirst/urinationThyroid diseaseN/A
Eyes:*

CataractsGlaucomaWear glasses/contactsN/A
Gastrointestinal:*

Abdominal painBlood in vomitChange in bowel habitsJaundice / liver diseaseNausea / vomitingUlcers or gastritisN/A
Genitourinary:*

Bladder control / incontinenceBlood in your urineDifficult starting/stopping streamKidney stonesPainful urinationUrinary tract infectionsN/A
Hematologic/Lymphatic:*

AnemiaBlood transfusionFainting spells / blacking outHemophiliaPersistent swollen glands/lymph nodesN/A
Musculoskeletal:*

Arm or leg pain/ weakness/numbnessBack painBroken bonesJoint pain or swellingNeck painPadgett's diseaseTMJ painN/A
Neurological:*

Difficulty with balanceDifficulty with memoryDifficulty with speechDisorientationDouble or blurred visionFainting spells / black outsHeadaches / migrainesInability to concentrateLoss of sensationSeizuresStrokeWeakness in arms or legsN/A
Psychiatric:*

Anxiety / DepressionPanic AttacksN/A
Respiratory:*

AsthmaEmphysema / lung diseaseShortness of BreathN/A
Childhood Illness

MeaslesMumpsChicken PoxWhooping CoughEar InfectionRubellaPolioGastroenteritis
Surgical History Please list all operations you have had:*
Please List Any Other Active Medical Condition:*
Social History
Occupation:*
Marital Status:*
Hobbies:*
Please list all allergies and sensitivities (E.g. medications, foods, latex, iodine, etc.)*
Are you taking any blood thinning medications including aspirin?*

Yes- indicate belowNo
Other
Do you smoke cigarettes?*

YesNo
How many a day?
At what age did you start?
At what age did you stop?

	Yes/No	If yes, how much daily?
Do you drink alcohol?

	Yes/No	Type ?
Do you use recreational drugs?

	Yes/No	How frequently?
Do you exercise regularly?

Female Medical History
Are you pregnant?

YesNo
If yes, how many weeks?
Age at first menstrual period?
Age at last?
Have you ever used oral contraceptives?
Have you ever used hormone replacement therapy?

YesNo
Most patients that come to our office have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.
Relief Care is the care necessary to get rid of your symptoms or pain, but not the cause of it. It is the same as drying a floor that was getting wet from a leak, not fixing the leak, or cause of the symptom.
Corrective Care differs from relief care in that its goal is to get rid of the symptoms or pain while correcting the cause of the problem. Corrective care varies in length of time but is longer lasting.
Check here if you want the Doctor to select the type of care appropriate for your condition.
Financial Agreement
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Furthermore, I understand that Dr. Masulas’ Office will prepare any necessary reports and forms to assist me in making collection from my insurance company and that any amount authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable. The patient also agrees that he/she is responsible for all bills incurred at this office. Parental Consent for Minor Patient.

My signature below indicates that I have read, understand and agree to all of the above listed information.
Responsible Party/Guardian Signature*

Clear
Date*

MonthDayYear

Masula Chiropractic Neurology and Family Wellness Center
Financial Policy

We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility.

Please Initial at Each Line Below:

Regarding Insurance If you have insurance; we will bill them as a courtesy and assist you in receiving the maximum reimbursement benefits possible.
I understand I am financially responsible to the physician for all charges rendered to me. I hereby promise to pay the physician for the services I receive.*
Assignment of Benefits (Personal Injury case or Worker’s Comp case) I hereby authorize payment directly to the physician of all benefits otherwise payable to me, but not to exceed the total charges for the services rendered.*
Authorization to Release Information*
I authorize the physician and/or his or her representatives to release any and all information contained in my complete medical and billing record to:
• My insurance company or its representatives.
• Other persons or entities financially responsible for my care or treatment.
• The Medicare program and its fiscal intermediaries, if applicable or otherwise required/permitted/regulated
by law.
• Federal and state agencies, as required or permitted by laws and regulations.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Masula Chiropractic Neurology and Family Wellness Center is required by law to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Would you like a copy of our Notice of Privacy Act Form?*

Yes (Patient needs to sign NPP form)No – I decline a copy of the NPP form
Patient’s Signature*

Clear

Informed Consent

We encourage and support a shared decision-making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent. Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. In addition, there are reported cases of stroke associated with visits to Medical Doctors, Osteopaths, Chiropractors, Physical Therapists, and Occupational Therapists.
Would you like a copy of our Informed Consent Form?*

Yes (Patient needs to sign Consent form)No – I decline a copy of the (ICF) form
Signature*

Clear
I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAS BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE MASULA FAMILY CHIROPRACTIC TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.
Patient Signature*

Clear
Parental Consent for Minor Patient

In addition, by signing below, I give permission for the above-named minor patient to be managed by the doctor even when I am not present to observe such care.
Patient Name

First NameLast Name
Patient age
DOB

MonthDayYear
Printed name of person legally authorized to sign for Name

First NameLast Name
Relationship to Patient
Signature

Clear
Should be Empty:

Demographics