ParenvLegal Guardian Signature
Today's Date
*
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Sex:
*
M
F
Age
*
Parent/Guardian Name & Relationship (if Patient is a minor)
First Name
Last Name
Preferred Name/Pronoun
Preferred Name
Preferred Pronoun
Permanent Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permanent address same as local address?
*
Yes
No
Local Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
SS#
Marital Status
*
S
M
P
D
W
Cell Phone Number
*
-
Area Code
Phone Number
Best Time to reach you?
Email
*
example@example.com
Employer/School Name:
Occupation
Full Time Student?
Yes
No
Emergency Contact
*
Emergency Contact Relation to Patient
*
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Primary Care Physician
Referring Physician
Referring Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Physician Phone Number
-
Area Code
Phone Number
When is your follow up visit with your Referring Physician?
Whom may we thank for referring you? (Other than your physician)
*
Primary Insurance Company
*
Covered by additional insurance?
Yes
No
Policy ID #/Claim #
*
Group #
Is Patient the Subscriber?
*
Yes
No
If No, then:
Subscriber's Name
First Name
Last Name
Subscriber's Employer
Relationship to Patient:
Subscriber's Date of Birth
*
-
Month
-
Day
Year
Date
Date of Injury
*
-
Month
-
Day
Year
Date
Injury Information
*
Work Comp
Motor Vehicle Accident
Home
Other
Attorney/Claim Adjuster/Vocational Rehab Counselor Name:
First Name
Last Name
Attorney/Claim Adjuster/Vocational Rehab Counselor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attorney/Claim Adjuster/Vocational Rehab Counselor Phone Number
-
Area Code
Phone Number
Attorney/Claim Adjuster/Vocational Rehab Counselor Fax Number
-
Area Code
Phone Number
Attorney/Claim Adjuster/Vocational Rehab Counselor Email
example@example.com
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Patient Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
What Condition are you here for?
*
Date of Injury/Onset?
-
Month
-
Day
Year
Date
Have you ever had these symptoms before?
*
Yes
No
If Yes, When?
Have you ever had physical therapy or any other treatment for this condition?
*
Yes
No
If Yes, when and where?
Have you had related surgery?
*
Yes
No
If yes, Describe:
Check all which apply to your symptoms:
*
Work Related injury
Motor Vehicle Accident
Cause Unknown
Recurrence of previous injury
injury related to lifting
athletic/recreational injury
Rate your average pain intensity (10 being the worst)
*
0
1
2
3
4
5
6
7
8
9
10
Do you know, or have you ever had any of the following: (Please check all that apply)
Arthritis (Osteo or Rheumatoid)
Diabetes (DM/DI)
Heart Attack
Heart Palpitations
Heart Disease/Chest pain/Angina
Pacemaker
High/low blood pressure
Headaches/Migraines
Dizziness/Fainting
Nausea/Vomiting
Ringing in ears
Asthma/Breathing Difficulties
Infectious diseases (TB, Hepatitis, AIDS)
Are you pregnant?
Hernias
Allergy to aspirin
Allergy to Heat/Cold
Intolerance to Tylenol/Advil/Naprosyn
Other Allergies (list below)
Lyme Disease
Infections
Ehlers-Danlos
Stroke/Circulation/Vascular Issue
Parkinson Disease
Multiple Sclerosis
Seizures/Epilepsy
Cancer
Kidney/Liver Disease
Vision problems
Hearing problems
Difficulty walking
Joint Pain or swelling
Loss of Balance
Coordination Problems
Low Blood sugar
Head injury/TBI/Concussion
Skin abnormalities
Metal/Wire Implants
Recent fractures
Bowel/Bladder problems
Prior Surgeries
Neurological problems
If you answered yes to any of the previous conditions, please briefly explain and give approximate dates of condition(s)
Are you presently taking any medication?
*
Yes
No
If Yes, please list the type of medications and for what condition:
Functional Status/ Activity Level: (Check all that apply)
Difficulty with locomotion/mobility: Bed Mobility, Transfers (such as moving from chair to bed), Gait, (walking)
Difficulty with self care (such as bathing, dressing, eating toileting)
Difficulty with community or work activities: work/school, recreational activities
Difficulty with home management (such as household chores, shopping, driving, care of dependents)
Difficulty with sleeping
Please indicate with the abbreviations of pain types where on your body the pain is located. S=Sore A=Achy B=Burning tt=tight T=Tingling N=Numbness SP=Spasms
Does the pain travel?
*
Yes
No
What are your goals for therapy?
*
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Have you read our Payment Policy and Financial Agreement above?
*
Yes
No
Patient Signature
*
Print Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Parent/Guardian Signature (if applicable)
Print Parent/Guardian Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
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Have you read our Attendance Policy, Consent to Treat, and HIPPA Privacy Policy on the page above?
*
Yes
No
Name of Patient
*
First Name
Last Name
Name of Parent/Guardian
First Name
Last Name
Name of Parent/Guardian
First Name
Last Name
Name of Minor
First Name
Last Name
Minor Date of Birth
-
Month
-
Day
Year
Date
Patient Signature
*
Date
*
-
Month
-
Day
Year
Date
Parent/Legal Guardian Signature
Date
-
Month
-
Day
Year
Date
Please upload a picture of the Front of your insurance card.
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Please upload a picture of the Back of your insurance card.
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of
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Due to HIPPA, we cannot disclose any of your information to anyone without your consent. If you would like us to grant permission for a family member, coach, personal trainer, or another party to discuss your treatments, appointments or payments, please select yes and complete the following section.
*
Yes
No
Patient Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
I give Permission to Aegis Chiropractic and Physical Therapy to discuss ( via verbally, email, text) my medical information (i.e. symptoms, diagnosis, treatment plan, scheduling appointments, billing information, etc.) with the following person(s) below:
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Patient
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Patient
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Patient
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship to Patient
Medical records are defined as: All health information, whether oral or recorded in any form or medium that identifies the patient or can readily be associated with the patient and relates to the patient's care. This includes all health care information in your/our possession, whether generated by you/us or any other source, as well as health care information. I understand that this authorization may be revoked by me at any time, provided that I do so in writing and submit it to the Medical Records Department, up to the extent that the disclosure has not already been made. I also understand that my protected health information may be re-disclosed by the recipient and no longer protected under federal law. Authorization will expire in 12 months unless otherwise specified. Expiration Date
-
Month
-
Day
Year
Date
Patient Signature
Date
-
Month
-
Day
Year
Date
Legal Representative/Guardian Signature
Date
-
Month
-
Day
Year
Date
Relationship to Patient
Submit
Should be Empty: