advancedchiroclinics.com

CAROLYN DAVIS-WILLIAMS, D.C. - ADVANCED CHIROPRACTIC CLINIC, PC

2408 Wheeler St, Houston TX 77004

Clinic: (713) 529-6760

Fax: (713) 526-0655
PATIENT DEMOGRAPHIC INFORMATION
How Did You Hear About Us:
Full Name

First NameMiddle NameLast Name
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Date Of Birth

MonthDayYear
Date
Sex

MaleFemale
Marital Status

MarriedSingleDivorcedWidowed
Driver's License #
Employer
Work Number

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY CARE PHYSICIAN
Name

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Specialty
Date Last Seen

MonthDayYear
Date
RESPONSIBLE PARTY (PLEASE FILL OUT IF NOT SAME AS PATIENT)

(INSURED POLICY HOLDER, OR PARENT/GUARDIAN)
Name

First NameLast Name
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Of Birth

MonthDayYear
Date
Sex

MaleFemale
Relationship to Patient

SelfSpouseChild
Employer
Work Phone

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE INFORMATION
Medicare Ins Co & Number
Medicaid Ins Co. & Number
Primary Insurance Name
Insurance Phone #
Insurance Policy/ID Number
Group #
Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT INFORMATION
Name

First NameLast Name
Relationship
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
I GIVE CAROLYN DAVIS-WILLIAMS, D.C. PERMISSION TO RELEASE DEMOGRAPHIC INFORMATION TO HOSPITAL, LABORATORIES, AND RADIOLOGY AS NEEDED TO SCHEDULE TESTS OR OTHER MEDICAL PROCEDURES FOR ME.

I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.
Patient Signature

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Patient Printed Name
Date

MonthDayYear
Date
I AUTHORIZE CAROLYN DAVIS-WILLIAMS, D.C. AND STAFF TO RENDER SERVICES TO ME.
Patient Signature

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Patient Printed Name
Date

MonthDayYear
Date
I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS ANY INSURANCE CLAIM SUBMITTED BY THE CLINIC. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL. I ALSO GIVE CAROLYN DAVIS-WILLIAMS, D.C. PERMISSION TO RELEASE DEMOGRAPHIC INFORMATION TO HOSPITAL, LABORATORIES, AND RADIOLOGY AS NEEDED TO SCHEDULE TESTS OR OTHER MEDICAL PROCEDURES FOR ME.
Patient Signature

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Patient Printed Name
Date

MonthDayYear
Date
PATIENT PERSONAL, FAMILY & SOCIAL HISTORY
Information contained herein will not be released except as you have authorized and will be used by your doctor in decisions regarding your care, so please answer all questions honestly and to the best of your knowledge.
Name

First NameMiddle NameLast Name
Marital Status

MarriedSingleWidowedDivorced
Age
Height
Weight
Do you have or have you had: (please check all that apply)

StrokeHay FeverBleeding TendencyBronchitisSeizuresDiabetesKidney DiseaseLeukemiaRheumatic HeartMigraineTuberculosisThyroid ProblemsBladder InfectionArthritisTonsillitisBroken BonesCongenial HeartAsthmaBlood ClotsHigh Blood PressureHigh CholesterolAIDS/+HIVDepressionColitisDiarrheaPneumoniaCancerHeart AttackStomach UlcersGlaucomaAnxietySleep ApneaExcessive DrowsinessLoud SnoringShortness of BreathChest PainHeart FailureGall StonesSuicide Attempt
Is this visit result of:

InjuryAccidentsOther
Describe Details
Date

MonthDayYear
Date
Primary reason for visit
Other reasons for visit
Have you had treatment for this condition?

YesNo
Tell us more about treatment
Doctor's Name

First NameLast Name
Specialty
When Seen?

MonthDayYear
Date
Dr. Phone Number

Area CodePhone Number
PAIN LEVEL TODAY (0 NO PAIN / 10 WORST PAIN, W OR W/O MEDS)

12345678910
Type of pain/condition?

DullAchingSharpBurningThrobbingNaggingNumbnessTinglingRadiateMove Around
Name and Dates of all operations you have had
Name any drugs to which you are allergic
Serious illnesses you have had
Serious injuries or accidents
ARE YOU PRESENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? (Check all that apply)

Aspirin, Advil, AnacinSleeping pillsWater pillsDigitalisTranquilizersPain medicineOver the counter medUlcer medicineLaxativesShotsCough medicineMedicine for arthritisBirth control pillsIronVitaminsCholesterol medicineSeizure medicineCortisoneHeadache pillsCold medicationInsulin or diabetic pillsPoor blood medicationMedicine for depressionOther drugs not listedBlood pressure pillsThyroid medicineAntibioticsHormonesWeight reducing pillsBlood thinning pillsEye dropsOther medicine
Do you smoke or have you ever smoked?

YesNo
How much?
How many years?
If you quit, when?
Date of last chest X-Ray

MonthDayYear
Date
Do you usually drink over 6 cups of caffeinated beverages per day?

YesNo
Do you regularly drink alcohol, wine, or beer?

YesNo
How much?
Do you exercise regularly?

YesNo
What and how often?
Do you exercise regularly?

YesNo
Mattress Age
Do you have pets?

YesNo
Birds
Cats
Dogs
Other
Do you use recreational drugs?

YesNo
What do you use?
Do you eat regularly?

YesNo
How many times a day?

123
Do you eat healthy?

YesSometimes
Do you eat fast food?

YesNo
Do you have regular recreation time?

YesNo
Type?
Do you spend time in Nature or Fun?

YesNo
How do you spend your time?

BeachFishingGolfLakesTennisWalking
What type of work do you perform?
Work schedule
Are you a student?

YesNo
Level of education

ElementaryMiddle SchoolHigh SchoolCollegeHighest level
Do you have many friends?

YesNo
What do you do with them?
Do you vacation?

YesNo
Where?
When last time?
Do you visit the country or farms?

YesNo
When?
Pet or See Farm Animals

YesNo
When do you feel the best?
When do you feel the worst?
Foods and Drinks

Artificial SweetenersCrave Salt or SugarsFast FoodsBreadPastaFishRead MeatFruitVegetablesSweetsEnergy DrinksSodasWater
Describe how often, how much daily?
WOMEN ONLY
Are you NOW pregnant?

YesNo
Are you having regular monthly menstrual cycles?

YesNo
Last cycle?
Are you having symptoms of the menopause?

YesNo
Have you ever had bleeding between your cycles?

YesNo
When?
Do you have very heavy bleeding with your cycles?

YesNo
When?
Have you ever or do you now had any vaginal infections?

YesNo
When?
Are you now or have you ever taken birth control pills?

YesNo
When?
Do you now or ever had a hernia?

YesNo
Where?
Surgery repair?
Date of last pap smear test

MonthDayYear
Date
Results
How many:
Children born alive
Miscarriages
Stillbirths
C-Sections
Premature births
Any complications of pregnancy?
MEN ONLY
Have you ever had problems with your testicles or scrotum?

YesNo
Have you ever had a discharge from your penis?

YesNo
Do you now or ever had a hernia?

YesNo
Where?
Surgery repair?
Have you had trouble with your prostrate (urinary frequency, hesitancy, or dribble)?

YesNo
Any of your blood relatives have or had (Please check all that apply)

StrokeHay FeverBleeding TendencyBronchitisSeizuresDiabetesKidney DiseaseGlaucomaRheumatic HeartMigraineTuberculosisThyroid ProblemsBladder InfectionArthritisTonsillitisGall StonesCongenital HeartAsthmaBlood ClotsHigh Blood PressureAnxiety or DepressionHigh CholesterolAIDS/+HIVLeukemiaColitisDiarrheaPneumoniaCancerHeart AttackStomach UlcersHeart FailureSuicide Attempt
Date of occurrence and relationship
Patient Signature

Clear
Patient Printed Name
Date

MonthDayYear
Date
REVIEW OF SYSTEMS
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Cardiovascular

AnginaAnkle SwellingAwakening At NightCardiac CatheterizationChest PainsCongenital Heart DefectsCold Hands or FeetDizzy When Standing QuicklyHeart AttacksHeart FailureHeart MurmursHeart PalpitationsHigh Blood PressureLow Blood PressureIrregular Heart RateLeg CrampsLeg Pain That Stop with RestNight SweatsPain Left Side Arm/Face/NeckPounding HeartbeatRapid HeartbeatPurple Fingers or LipsShort of BreathVaricose Veins
Ears and Eyes

Ear AchesEar DischargeEar InfectionsEar PainHearing LossRinging In EarsCataractsDouble VisionEye ProblemsGlasses/ContactsGlaucomaItchy, Red or WateryNight Vision PoorPain In, Behind, Near
Endocrine

Abnormal Blood CountsAnemiaArthritisChanges In Skin TextureDiabetesDecrease/Increase Body HairDecrease/Increase Facial HairDecrease Head Hair (not male baldness)History of "Borderline" DiabetesFlushing/Hot FlashesIntolerance ColdIntolerance HeatSickle Cell
Gastrointestional

Abdominal PainAnal FissuresBelchingIntestinal BloatingGas/FlatulenceBlack Tarry StoolsConstipationDiarrheaFeel Fatigue or Lethargic After EatingGall StonesHeart BurnHiatal HerniaHemorrhoidsIndigestionIntestinal ObstructionLiver DiseaseLoss of Bowell ControlNauseaPain in Stomach, Intestines or ColonPoor DigestionProblems SwallowingRed Blood After Bowel MovementRectal Bleeding, Itching or BleedingRefluxUlcersVomiting BloodVomiting
General

Appetite Increased/DecreasedBinge/Compulsive EatingChange In ActivityChange In Sleeping PatternsExcessive TirednessEnlarged Lymph NodesFatigue (lack of energy or stamina)Frequent InfectionsHypoglycemia (Low Blood Sugar)Increased Need for SleepInsomniaTired or Not Hungry When WakingWeight GainWeight Loss
Kidneys & Urinary Tract

Bladder ProblemsBlood In UrineBrown UrineDribbling After UrinationExcessive ThirstFrequent Bladder InfectionInvoluntary UrinationKidney DiseaseKidney StonesPainful (or Burning) UrinationUrination Frequency (Day)Urination Frequency (Night)Urine HesitancyUrinary IncontinenceUrinary Tract Infections (UTI)Weak Flow
Lungs

AsthmaBlood Clots in LungsBronchitisCoughChest CongestionCOPD
Mouth, Nose, Teeth and Throat

Decrease taste/smellGum ProblemsOral HerpesSores Mouth/LipsSwollen/Tender Tongue/GumsSwollen GlandsAllergies to AnimalsFoodEnvironment/ChemicalsHay/FeverNose Bleeds FreqNasal PolypsNose RunsSinus InfectionsSinus PainBad BreathDenturesRegular Dental Check-upsMercury fillingsRoot CanalsCoughingDrainageExcess MucusGoiterHoarsenessPolypsSore ThroatsSwollen GlandsVoice Changes
Please describe (what animals, food or chemicals)
Musculoskeletal

Areas of numbnessAreas of PainAreas of TinglingBack PainBlood Clots in LegsBone Marrow BiopsyBursitisEasy BleedingEasy BruisingGoutJoint AchesJoint PainJoint SwellingLimited Motion in JointsMorning StiffnessMuscle Aches/PainMuscle WeaknessMuscle CrampsNeck PainNight PainTendonitis
Provide more details about those areas
Neurological

AnxietyBlackoutsChange in Sensation On Your BodyConfusionDepressionDifficulty In TalkingDizzinessEpilepsyFainting SpellsHeadachesHead InjuriesHyperactivityLearning DifficultyLoss of ConsciousnessMemory LossMeningitisNear BlackoutsParalysisPressure feeling in HeadSeizuresStrokesTinglingTremorsWeakness or Numbness
Respiratory

AsthmaBreathlessness When Lying FlatCoughing Up BloodEmphysemaFrequent BronchitisPleurisyPneumoniaProlonged CoughShortness of BreathTuberculosisWheezing
Skin & Nails

AbscessAcneAthlete's FootBoilsChange in Skin ColorDandruffDry Skin/Oily SkinEczemaExcessive Body OdorExcessive/Not SweatingFungal InfectionsHivesItchy Skin W or W/O RednessJaundiceLumpsMoles - ChangeMoles - IrregularMoles - NewPsoriasisRashesSmall Rough Bumps on SkinNail ProblemsWeak NailsRidged Nail
Male & Female

Genital HerpesGroin ItchingLoss of Sexual InterestPainful Sexual IntercourseSexually Transmitted Disease (STD)Unprotected Sex
Tested for HIV?

YesNo
Males Only

Bloody EjaculationHerniaInability to Complete IntercourseLump On TesticlePenile DischargeProblems Maintaining or Keeping ErectionProstate DiseaseSlow Urine StreamSores on PenisSterilityTesticular PainTestes Undescended, In Abdomen or PelvisTesticular SwellingWarts on Penis
Family History of Prostate Cancer

YesNo
Females Only

Abnormal Bleeding Between CyclesAbnormal PapTestBleeding After IntercourseComplications With PregnancyD&CDischarge From BreastEndometriosisExcessive BleedingFibroidsHeavy Bleeding During CyclesHerniaHot FlashesInfertilityIrregular PeriodsPain in BreastsPainful PeriodsPain Between PeriodsOvarian CystPelvic Inflammatory DiseasePost-Menopausal SymptomsPMSVaginal DischargeVaginal DrynessVaginal WartsWater RetentionYeast Infections
CHIROPRACTIC INFORMED CONSENT
The doctor after examination has explained the prescribed treatment plan to me (for myself or for my minor child) including the nature and purpose of the chiropractic adjustments as well as other treatments or procedures appropriate for the condition. I hereby request and consent to treatment from ADVANCED CHIROPRACTIC CLINIC, P.C. doctors and staff including chiropractic adjustments, manual therapy techniques and physical modalities including hydroculation (heat), cryotherapy (ice), ultrasound, neuromuscular reeducation, massage, rehab, examinations or other treatments and testing that the doctor determines to be appropriate for my condition or for my minor child’s condition.

In particular you should note:
1. While rare, some patients have experienced rib fractures, muscle strains and/or ligament sprains following spinal manipulation.
2. There have been reported cases of injury to a vertebral artery following cervical spinal adjustments. Vertebral artery injuries have been known to cause stroke, sometimes with serious neurological impairment, and may on rare occasion result in death.
3. Hydroculation (heat) and cyrotherapy (ice): skin reactions or burns
Chiropractic treatments, including spinal adjustments, have been the subject of government reports and multi-disciplinary studies conducted over many years and have been demonstrated to be highly effective treatment for spinal pain, headaches being and other similar symptoms. The risk for injuries or complications from chiropractic treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms.

I acknowledge I have discussed, or have had the opportunity to discuss, with my doctor the nature and purpose of the treatments in general and myself or my minor child’s treatment in particular (including spinal adjustments) as well as the contents of this Consent and I fully understand that there are no guarantees in medicine as to the outcome of any treatment. I consent to the treatment offered or recommended to me for myself or my minor child including spinal adjustments. I intend this consent to apply to all of my or my minor child’s present and future care.

I understand and am informed that, as with any medical treatment and care, in the practice of chiropractic there are some risks. I do not expect the doctor to be able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of treatment and procedures that the doctor feels appropriate for me at the time based on the facts know at the time, in my or my minor child’s best interest.
I have read (or have read to me) the above consent. I have had an opportunity to ask any questions I had about its content, and by signing below I agree to begin treatment for myself or for my minor child, .
I intend this consent form to cover the entire course of treatment for myself and/or my minor child’s present condition and for any future condition (s) for which I may continue to seek treatment here at ADVANCED CHIROPRACTIC CLINIC, P.C.
Patient Signature

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Patient Printed Name
Date

MonthDayYear
Date
Witness Signature

Clear
Witness Printed Name
Date

MonthDayYear
Date
HIPAA POLICIES AND PROCEDURES

NEW PATIENT CONSENT TO THE USE AND DISCLOSURE OFPROTECTED HEALTH INFORMATION (PHI) FORTREATMENT, PAYMENT OR HEALTHCARE OPERATONS
I , understand that as part of my health care, Carolyn Davis-Williams, D.C. – Advanced Chiropractic Clinic, P.C. originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
- A basis for planning my care and treatment,
- A means of communication among the many health professionals who contribute to my care,
- A source of information for applying my diagnosis and surgical information to my bill
- A means by which a third-party payer can verify that services billed were actually provided,
- A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to review the notice prior to signing this consent,
- The right to object to the use of my health information for directory purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations
I understand that, Carolyn Davis-Williams, D.C. – Advanced Chiropractic Clinic, P.C. is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that, Carolyn Davis-Williams, D.C. – Advanced Chiropractic Clinic, P.C. reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations.
I wish to have the following restrictions to the use or disclosure of my health information:
I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax.
I fully understand and accept / decline the terms of this consent

AcceptDecline
Patient Signature

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Patient Printed Name
HIPAA POLICIES AND PROCEDURES

HEALTH CARE AUTHORIZATION FORM
Patient's Name

First NameLast Name
Patients SS#
Date of Birth

MonthDayYear
Date
THE PATIENT IDENTIFIED ABOVE AUTHORIZES, CAROLYN DAVIS-WILLIAMS, D.C. – ADVANCED CHIROPRACTIC CLINIC, P.C. TO USE AND OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING:
SPECIFIC AUTHORIZATIONS

I give permission to CAROLYN DAVIS-WILLIAMS, D.C. – ADVANCED CHIROPRACTIC CLINIC, P.C. to use my address, phone number and clinical records to contact me with birthday cards, emails, holiday related cards and information about treatment alternatives or other health related information.
OPEN ROOM AUTHORIZATION

I give CAROLYN DAVIS-WILLIAMS, D.C. – ADVANCED CHIROPRACTIC CLINIC, P.C. permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with doctor at any time in private; the doctor will provide a room for these conversations.By signing this form you are giving CAROLYN DAVIS-WILLIAMS, D.C. – ADVANCED CHIROPRACTIC CLINIC,P.C. permission to use and disclose your protected health information in accordance with the directives listed above.
The Authorization shall expire on the following date:

MonthDayYear
Date
RIGHT TO REVOKE AUTHORIZATION

You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy Official
of CAROLYN DAVIS-WILLIAMS, D.C. – ADVANCED CHIROPRACTIC CLINIC, P.C. A clear statement of your intent to revoke this AUTHORIZATION; requires the date of your request, your signature and the revocation is not effective until it is received by the Privacy Official. This AUTHORIZATION is requested by CAROLYN DAVIS-WILLIAMS, D.C. –
ADVANCED CHIROPRACTIC CLINIC, P.C. for its own use/disclosure of PHI. You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION, CAROLYN DAVIS-WILLIAMS, D.C. – ADVANCED CHIROPRACTIC CLINIC, P.C. will not refuse to provide treatment. You have the right to inspect or copy the PHI to be used/disclosed.
Patient Signature

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Patient Printed Name
Date

MonthDayYear
Date
Signature of Guardian

Clear
Name of Guardian
Date

MonthDayYear
Date
HIPAA POLICIES AND PROCEDURES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I , , understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
- The right to review the notice prior to signing this consent,
- The right to object to the use of my health information for directory purposes, and
- The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations
Patient Signature

Clear
Patient Printed Name
Date

MonthDayYear
Date
Consent received by on .
Consent added to the patient’s medical record on .
Attempt was made to obtain written acknowledgement of receipt of out Notice of Privacy Practices, but acknowledgement could not be obtained due to:
Consent refused by patient treatment was rendered.
Consent refused by patient, and treatment refused as permitted.
Communication barrier prohibited the acknowledgment.
Emergency situation prevented obtaining acknowledgment.
Other specify situation
Should be Empty:

PATIENT DEMOGRAPHIC INFORMATION

PRIMARY CARE PHYSICIAN

RESPONSIBLE PARTY (PLEASE FILL OUT IF NOT SAME AS PATIENT)

INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION

PATIENT PERSONAL, FAMILY & SOCIAL HISTORY

REVIEW OF SYSTEMS

CHIROPRACTIC INFORMED CONSENT

HIPAA POLICIES AND PROCEDURES

HIPAA POLICIES AND PROCEDURES

HIPAA POLICIES AND PROCEDURES