ALLIED HEALTHCARE, PLLC PATIENT INFORMATION 

  Name:_______________________________________________________ Date:_________________ Address:_____________________________________ City:__________________ State:____ Zip:________ Birthday:____________________ Sex:______ Social Security Number: ________________________ Home Phone:_________________ Cell Phone:__________________ Work Phone:_________________ Email Address:___________________________________ Occupation:______________________________ Hobbies:_________________________________________________________________________________ Emergency Contact:____________________________________ Phone:_____________________________ Marital Status: Single Married Widowed Divorced  

WHO IS RESPONSIBLE FOR THE BILL Responsible Party Name:__________________________ Responsible Party Birthday:_________________ Insurance Company:______________________________ Policy Number:___________________________ Who referred you to our office? How did you hear about us?_______________________________________ Who is your Primary Care Physician?__________________________________________________________ Are you pregnant: YES NO If so, (congrats!) please list your due date:_______________________ CURRENT CONDITION Your present complaint/describe your symptoms:_________________________________________________ Is your visit due to an auto or work-related accident? YES NO Date of accident:________________ How long have you had this condition?_________________________________________________________ Have you had this or similar conditions in the past?_______________________________________________ Does anything make it feel worse?_____________________________________________________________ Does anything make it feel better?_____________________________________________________________

Is this condition: Improved Unchanged Getting Worse Is this condition interfering with: Work Sleep Daily Routine Other:________________________ Other doctors or therapists who have treated THIS condition:_________________________________________ __________________________________________________________________________________________ 

What do you think caused this condition? ________________________________________________________ Have you had an x-ray or CT scan or MRI in the past 28 days? YES NO If Yes, Where?_____________________________________________________________________________ HEALTH HISTORY Exercise: None Moderate Daily Heavy Work Activity: Sitting Standing Light Labor Heavy Labor Habits: Smoking-packs/day____ Alcohol-drinks/week____ Coffee/Caffeine Drinks-cups/day____ List Medications, Including dosage and frequency if known. If no medications, check here: __________________________________________________________________________________________

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List any known allergies you have had to any medications. If no allergies are known, check here: __________________________________________________________________________________________ 

List any surgical operations and years: __________________________________________________________ __________________________________________________________________________________________ 

Signature:____________________________________________ Date:___________________

Parent / Guardian Signature:_________________________________________

INFORMED CONSENT FOR EXAMINATION AND TREATMENT     I  (we)  hereby  consent  to  the  performance  of  examination  and  treatment  on  me  or  on ________________________________,  by  the  licensed  doctors  of  chiropractic,  medical  doctors, and/or licensed physical therapists who may be employed by or engaged in practice in this clinic.    I have had an opportunity to discuss with the doctor(s) or other clinic personnel the nature and purpose  of  the  different  physical  therapy  procedures  and  chiropractic  treatment (manipulation/adjustment). I understand that neither chiropractic nor medical treatment is an exact science  and  that my  care may  involve  judgments  based  upon  facts  and  information  known  to  the doctor. The doctor uses this judgment to attempt to anticipate or explain risks and complications and an undesirable result does not necessarily indicate an error in judgment. No guarantee for results can be made or expected but rather I wish to rely on the doctor to choose and recommend a best course of treatment based upon facts known that are in my best interests.    I further understand that there are certain degrees of risk associated with chiropractic health care and physical therapy, which includes rarely, but not limited to fractures, disc injuries, strokes, and strain/sprains and am therefore willing to accept and consent to the risk associated with the care that I am about to receive.    I have  read, or  the above  information has been explained  regarding consent.  I have had an opportunity  to  ask  questions  about my  examination  and  treatment.  By  signing  below,  I  agree  and intend  this  consent  form  to  cover  the  procedures  prescribed  for my  condition  and  for  any  future conditions for which I seek treatment.  Female Patients: By my signature of this form I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time.  Date of last menstrual period: ______________    Patient’s Name (Print): ________________________________    Date: ____________________   

Patient’s Signature: _____________________________________________________________     

Relationship or authority if not signed by patient: _____________________________________  

 Witness: _________________________________  

REVIEW OF SYMPTOMS     Check only the ones you now have, or have had in the past.      

GENERAL   NOW   PAST Weakness                 Fatigue               Fever                Chills                Night Sweats              Fainting               SKIN Color Changes              Nail Changes              Hair Changes              Moles                Rashes                Sores                HEAD Headaches              Injuries               Bumps                Last Eye Exam: ___________ Glasses               Contacts              Cataracts              EARS Hard of Hearing             Deafness              Ringing               Discharge              Earache               Itching                Dizziness              Room Spins              NOSE Decreased Smell           Bleeding              Pain                Discharge              Obstruction              Post Nasal Drip              Deviated Septum          Runny Nose              Sinus Congestion           MOUTH Bleeding Gums              Sores                Dental Problems           Bad Breath              Loss of Taste              Dry Mouth              Ulcers                Blisters                         

 

THROAT      NOW   PAST Soreness                    Bad Tonsils                    Hoarseness                           Pain                      Trouble Swallowing            Recurrent Infections           NECK Neck Enlargement              Stiff Neck                    Soreness                    Lumps                      Masses                     BREASTS Discharge                    Lumps                      Pain                      Bleeding                    Nipple Changes                   Skin Changes                    Bloated                     LUNGS Cough                      Phlegm                     Blood                      Short of Breath                    Wheezing                    Pain                      Congestion                    Inhalant Exposure                HEART Murmur                    Palpitations                    Rapid Heartbeat                   Swollen Extremities            Cold Extremities                  Chest Pain/Pressure           Varicose Veins                    Blood Clots                    Blue Extremities                  BLOOD Anemia                     Low Blood Iron                    Easy Bruising                    Easy Bleeding                    Swollen Nodes                    Painful Nodes                    Sugar in Blood                    Red Spots                          

 

GASTROINTESTINAL   NOW   PAST Abdominal Pain             Nausea               Bloated               Belching              Heartburn              Indigestion              Irregular Bowel Habits            Constipation              Diarrhea              Gas                Hemorrhoids              Poor Appetite              Food Intolerance            Bloody Stools              Black Stools              GENITOURINARY Urgency              Incontinence              Straining              Back Pain              Frequent Voiding            Stones                Burning               Bed Wetting              Small Stream              Discharge              Impotence              Dribbling              Cloudy Urine              Urine Color: _________________ Spotting Between Periods            Menstrual Cramps            Discharge              Itching                Painful Intercourse            Irregular Periods            Hot Flashes              Contraception Type: ___________ Age at First Period: ____________ Duration of Cycle: _____________ Duration of Flow: ______________ No. of Pregnancies: ____________ No. of Births: _________________ No. of Miscarriages: ___________ No. of Abortions: ______________ Menstrual Flow:  Heavy  Mod  Light     Last Period: __________________ Last Pap smear: _______________ Last Vaginal Exam: ____________ Last Mammogram: ____________ Last Prostate Exam: ____________  

REVIEW OF SYMPTOMS     Check only the ones you now have, or have had in the past.     

 NEUROLOGIC   NOW   PAST Seizures             Vertigo              Dizziness             Hand Trembling            Loss of Sensation         Incoordination             Loss of Facial             Weak Grip             Paralysis             Difficulty Speech          Tingling              Loss of Memory            Numbness              ENDOCRINE Weight Loss             Weight Gain             Extremely Thin             Heat Intolerance          Cold Intolerance          Hair Changes             Breast Changes             IMMUNIZATION / VACCINATION DPT         Mumps        Smallpox       Typhoid       Tetanus        Measles       Pneumococcal       Influenza       Polio         MMR          BLOOD TYPE A+                A‐        B+                B‐        AB+             AB‐     O+              O‐       Other: ___________  BLOOD TRANSFUSIONS  

Date: _____________  

Date: _____________  

Date: _____________  

Date: _____________  

 PSYCHIATRIC     NOW   PAST Hyperventilation                Insecurity                   Depression                   Troubled Sleep                   Irritable                    Undecidedness                   Timid                     Hallucinations                   Loss of Memory                  Alcoholism                   Drug Addiction                   Drug Dependent                 Suicidal Thoughts                 Extreme Worry                   Sexual Problems                 MUSCULOSKELETAL Muscle Pain                   Muscle Weakness              Muscle Cramps                   Muscle Twitching               Joint Stiffness                   Joint Pain                    Date of Last Chest X‐Ray:___________      Results:   Normal     Abnormal  Date of Last TB Skin Test: __________      Results:   Normal     Abnormal  Allergies: _______________________  _______________________________ 

_______________________________  _______________________________  _______________________________  _______________________________  _______________________________         

 PAST MEDICAL HISTORY (Check only the ones you have had in the past) 

Hay Fever     Mumps      Rheumatic Fever   Allergies     Angina       Cancer       Tumor       Blood Disease     Leukemia     Heart Trouble     Varicose Veins     Phlebitis     Hypertension     Stroke       Ulcers       Jaundice     Skin Trouble     Gallstones     Liver Trouble     Hepatitis     Parasites     Epilepsy     Paralysis     Polio       Mental Illness     Alcoholism     Depression     Nervous Breakdown   Migraine     Gout       Hemorrhoids     Prostate Problems   Sexual Problems   Gonorrhea     Syphilis      Diabetes     Bladder Trouble    Kidney Stones     Kidney Infections   Dysentery              

OFFICE FINANCIAL POLICY  Our policy is to extend to you the courtesy of allowing you to assign your insurance benefits directly to Allied Healthcare. This policy reduces your out-of-pocket expense and allows you to place your family under care. 1. If You Do Not Have Insurance: All payments are expected at the time of service or by an authorized payment plan. Your personal balance may not exceed $100 at any time, or care may be terminated. Our payment plans make care an affordable part of your family budget. 2. If You Have Insurance: All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Your co-insurance balance may not exceed $100, or care may be terminated. Our payment plans make care an affordable part of your family budget. You are considered a cash patient until you bring in your complete insurance information, and we qualify and accept your insurance coverage. Our fees are considered usual, customary, and reasonable by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This statement does not apply to companies who reimburse based on an arbitrary schedule of fees bearing no relationship to the current standard and care in this area. If your carrier has not paid a claim within sixty (60) days of submission, you agree to take an active part in the recovery of your claim. If your insurance carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of any outstanding balance and authorize us to use your credit card to collect full payment. You further agree to pay a collection fee of 33% of the principal amount to reimburse Allied Healthcare its collection costs if your account is assigned to a collection agency. Personal Injury Cases: If account balance is not Paid In Full within 6 months of the first Date of Service, the patient will be required to begin making minimum monthly payments toward account balance, regardless of settlement/claim status. If you discontinue care for any reason other than discharge by the doctor, all balances will become immediately due and payable in full by you, regardless of any claim submitted. We bill insurance carriers as a courtesy to our patients. It is not required by law for us to do so. It is ultimately the patient’s responsibility to contact their insurance carrier to determine what services may or may not be covered. It is also your responsibility to contact your insurance company regarding any questions of payment and/or denials of treatment. Patient’s Name (Print): ________________________________ Patient’s Signature (or legal guardian): ___________________________________ Date: __________________

 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY 

PRACTICES FOR PROTECTED HEALTH INFORMATION  I acknowledge that I have received or asked for a copy of Allied Health Care, PLLC’s Notice of Privacy Practices for protected health information. Patient’s Name (Print): _________________________________ Date: ________________ Patient’s Signature (or legal guardian): __________________________________________