Integrative Medical Group - General Patient Information

Patient Information Form
Patient Information
Patient

Last NameFirstMI
Address

Street Address

Street Address Line 2

CityState / Zip

Postal / Zip Code
Home Phone:
Cell Phone:
# of Children:
SSN:
Patient DOB:

MonthDayYear
Date
Age
Marital Status
Email Address:
example@example.com
Would you like text message and/or email reminders of your appointments?
If you would like text message reminders, please write your mobile carrier
Patient Occupation:
Employer:
Employer Address:
Work Phone:
Emergency Contact Information
Contact Name:
Relationship:
Address

Street Address

Street Address Line 2

CityState / Zip

Postal / Zip Code
Home Phone:
Work Phone:
Cell Phone:
Insurance Information
Do you have insurance?
Would you like us to bill your insurance for you?
If yes to both questions, please provide us your card to take a copy of.
Referral/Purpose
How were you referred?
Purpose of this appointment
Have you ever had same/similar conditions? Describe:
Days lost from work?
AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA Notice that is available to you at the front desk before signing this consent. If there is anyone that you do not want to receive your medical records, please inform the office.
Patient’s Signature:

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature:

Clear
Date

MonthDayYear
Date

Case History
Review of Systems
Do you have skin, hair, or nail problems?
Do you have mouth and/or throat problems?
Do you have nose and/or sinus problems?
Do you have ear problems?
Do you have eye problems?
Do you have chest or lung (breathing) problems?
Do you Smoke?
Cigarettes per day?
How long have you smoked?
Do you have heart and/or blood vessel problems?
Do you have blood or lymph node problems?
Do you have digestive problems?
Do you have genital problems? (Ex. Prostate, testicular, vaginal)?
Do you have urinary (including kidney or bladder) problems?
Do you have any gland and/or hormone problems?
Do you have allergy or immunity problems?
Do you have any muscle, tendon, or ligament problems?
Do you have any bone or joint diseases (Ex. osteoporosis, arthritis)?
Do you have any nervous system, disease and/or mental health problems?
Females Only
Have you had menstrual problems?
Have you ever taken birth control?
Is there any chance you could be currently pregnant?
Do you have any breast problems?
Past History
List any diseases that you have had in the past, including childhood disease:
Tell us if you have ever been diagnosed as having a particular condition such as diabetes, AIDS, ect.:
Have you suffered any physical injuries, such as falls or blows, auto accidents, whiplash, concussion or head injury, lacerations, sprains, strains, dislocations, broken, or cracked bones?
List any surgeries you have had. (Including appendix, tonsils, ear tubes, and wisdom teeth):
Have you ever been hospitalized for any reason other than surgery?
Medications: Please list all prescriptions/non-prescriptions medication you are taking on a regular and/or occasional basis:
Patient Name:
DOB:

MonthDayYear
Date

Social History
In what position do you usually sleep and how well?
Do you exercise on a regular basis?
How do you spend your spare time?
Do you use: Caffeine?
Tobacco?
Nicotine?
Recreation drugs?
Alcohol?
Please describe your work type: Physical labor?
Driver?
Clerical?
Factory?
Homemaker?
Describe your physical demands: Heavy?
Moderate?
Mild?
Sedentary?
Please describe your work stress level: High?
Medium?
Low?
Your diet is:

BalancedFairPoorExcessiveRestricted
Family History
Are there any diseases or conditions that are common among your family members?
Additional Questions
Do you have a problem with recurring headaches?
Are you losing weight without trying?
Does your pain wake you up at night?
Have you had a sore throat that doesn’t heal?
Do you have indigestion or difficulty swallowing?
Have you had an obvious change in a wart or mole?
Do you have a nagging cough or hoarseness?
In the space below, please explain or give additional details regarding the information you have given above. Also, if there is any information about your health history that was not requested, please fill it in below:
Patient Health History

Have you ever (at any time) experienced any of the following?

	Y	N
Difficulty urinating
Loss of bladder control
Loss of bowel control
Temporary loss of vision (one eye)
Blood in urine
Claustrophobia (fear of small spaces)
Spinal surgery
Common cold/flu
Carotid artery surgery
Breast removal

Have you ever been diagnosed with or told you have one of the following?

	Y	N
Detached retina
Hardening of the arteries
Stroke
Rheumatoid arthritis
Slipped disc
Fractured/broken vertebra
Herniated disc
Bleeding disorders
Osteoporosis
High blood pressure
Drop attacks
Blood in stool
TIAis (pin or mini strokes)
Cancer
Kidney disease
Prostate Disease
AIDS
Partial or complete paralysis

Do you currently have or could be, any of the following?

	Y	N
Pregnant
Taking birth control pills
Receiving hormone therapy (male)(female)
Receiving chemotherapy
Receiving radiation therapy
Taking blood thinners
Head Trauma
A heavy smoker (1 or more packs a day)
Surgical/medical implanted devices:
Aortic clips
Brain clips
Artificial heart valves
Rods, pins, screws
IUD
Surgical clips/wires
Shunt
Neurostimulator
Dentures
Pacemaker
Hearing aid
Insulin pump
Joint replacement
Cochlear implants (ear)
Other implanted devices:
Metal fragments
Bullets/shrapnel
Body piercing

In the past 14 days, have you experienced any of the following?

	Y	N
Nausea
Vomiting
Vertigo (spinning)
Difficulty walking
Uncoordinated
Numbness or other sensory complaints
Abnormal period
Loss of consciousness
Double vision
Blurred vision
Tinnitus (ringing in ears)
Speech problems
Clumsiness
Memory loss
Travel by car/truck
Personality changes
Fever
Recurrent headaches
Diarrhea
Use a tanning booth/bed
Skin rash/infection
A major fall
A minor fall
An auto accident
A work injury
Loss of strength
Pain during bowel movements

Do you currently have any of the following?

Integument System

	Y	N
Skin rash
Skin lesion
Changes in skin color
Itching (pruritus)
Hair changes
Nail changes

Endocrine System

	Y	N
Hormone problems
Hot flashes
Thyroid problems
Hormone therapy
Growth abnormalities
Metabolism changes

Digestive System

	Y	N
Abdominal pain
Nausea
Vomiting
Constipation
Diarrhea
Hormone problems
Jaundice
Abdominal distention
Cramping
Lump/mass

Cardiovascular System

	Y	N
Chest pain
Irregular heartbeat
Shortness of breath
Fainting
Fatigue
Swelling of legs
Changes in skin color
Stroke (full of pain)
Dizziness
Cool hands or feet
Varicose veins
Mitral valve problems

Pulmonary System

	Y	N
Coughing
Phlegm/expectorant
Coughing up blood
Shortness of breath
Wheezing
Blue skin (cyanosis)
Chest pain

Musculoskeletal System

	Y	N
Stiffness
Popping noises
Joint pain
Weakness
Limitation of movement
Extremity deformities
Difficulty walking

Nervous System

	Y	N
Partial paralysis
Complete paralysis
Headache
Are you right-handed?
Loss of consciousness
Dizziness
Memory loss
Numbness
Weakness
Depression

	Y	N
Lack of coordination
Psychiatric disorders
Speech abnormalities
Visual disturbances
Are you left-handed?
Gait disorders
Tremors
Tics (spasms)
Sensory changes
Mood changes

Genital/Urinary System

	Y	N
Pain during urination
Changes in urine flow
Lump or mass in groin
Kidney stones
Chronic bladder infections
Genital itching
Changes in urination frequency
Changes in urine color

Special Senses

	Y	N
Visual problems
Hearing loss
Loss of balance
Loss of taste
Loss of smell
Loss of touch sensation
Temporary vision loss in one eye

Male Reproductive System

	Y	N
Testicular pain
Prostate pain
Infertility
Impotence
Discharge
Lump or mass

Female Reproductive System

	Y	N
Abnormal vaginal bleeding
Painful menstruation
Breast lump/mass
Vaginal discharge/itching
Nipple Discharge
Infertility
Abnormal periods
Male pattern baldness

Head/Neck Region

	Y	N
Headaches
Neck stiffness
Neck lump/pain
Eye pain
Eye redness
Eye discharge
Double vision
Dry eyes
Excessive tearing
Spinning sensation

	Y	N
Ringing in ears
Ear pain
Ear discharge
Ear itching
Nasal discharge
Sinus trouble
Bad breath
Nasal obstruction
Snoring

Blood, Lymphatic, Immunology, Allergy

	Y	N
Anemia
Iron deficiency
Clotting problems
Bruise easily
Swollen lymph

	Y	N
Frequent illness
Immunity problems
Allergies
Take allergy shot

Current Treating Physicians
Primary Care Physicians:
Phone #:
OB/GYN:
Phone #:
Dentist:
Phone #:
Any Additional Information
Credit Guarantee Insurance Assignment & Personal Balance

Insurance Assignment: Our Insurance Assignment Program is designed to keep your out-of-pocket expenses to a minimum. As a courtesy to you, we will bill your insurance carrier on your behalf and wait up to 90 days for payment. Please remember, however, that you are ultimately responsible for payment. As a prerequisite, we ask that you leave a credit card to guarantee payment.

Filing Procedure: Claims for initial services are submitted within 48 hours after your visit. On day 90, if your insurance company had not paid the bill, we will change your designated credit card below for the amount of the claim. You will be sent a payment voucher. Any payments made on these claims thereafter will be immediately refunded to you. Please keep in mind this office will not bill your card without first trying to contact you.

Personal Balance: Estimated personal portions are paid at the time of service.
Patient Name:
DOB:

MonthDayYear
Date
Should be Empty:

Patient Information Form