PATIENT HISTORY

Date: ___________________

Name: ______________________________________ Referred By? __________________________________

Address: ________________________________________ City: ______________ State: _____ Zip: __________

Home Phone: ____________________ Work Phone: _____________________ Cell Phone:__________________

Date of Birth: _______________ Age: ______ Sex: F / M Marital Status: _______ # of Children: ______

Occupation: __________________________ Employer: _____________________________________________

Social Security # (for insurance purposes only): ______________________________

PLEASE FILL IN THE APPROPRIATE SPACES (All information you provide is kept confidential):

Major Complaint(s): _____________________________________________________________________________

______________________________________________________________________________________________

How long have you had this condition? ________________________________ Date Began? __________________

Have you lost work days? YES □, NO □, How many? ______________________________________________

Have you had this similar condition before? YES □, NO □, When? ___________________________________

Was the injury related to: Work Accident □, Auto Accident □, Other □:________________________________

When did you last see a chiropractor? _______________________ Dr.:____________________________________

Why did you see this chiropractor? ___________________________________ Were you helped? _____________

What spinal maintenance programs were you given to follow to maximize the future stability of your spine?

______________________________________________________________________________________________

Did you follow it? _________________ If not, why? __________________________________________________

Why are you changing chiropractors? _______________________________________________________________

PAST (O) OR PRESENT (X) CONDITIONS (Please mark with O or X; if nothing relates to you, leave blank):

A) ___ Fractured Bones

___ Auto Accidents

(a) ____ 0-1 years ago

(b) ____ 1-5 years ago

(c) ____ More than 5 year ago

___ Other Accidents/ Falls/ Slips

___ Knocked Unconscious

___ Back Curvature

___ Mental or Emotional Disorders

___ Arthritis

___ Diabetes

___ Swollen or Painful Joints

___ Convulsion/ Epilepsy

___ Skin Problems

___ Itching

___ Bruise Easily

___ Cancer

___ Frequent Colds/ Flu

B) ___ Nervous

___ Tension

___ Depressed

___ Irritable

___ Anemia

___ Excess Sweating

___ Tremors

___ Eyes Sensitive to light

___ Allergy

___ Sinus Problems

___ Light-Headed Upon Rising

___ Under Stress

___ Crave Sweets or Salt

___ Eating Disorders

C) ___ Trouble Sleeping

___ Trouble Concentrating

___ Loss of Memory

___ Learning Disability

___ Mistake sidedness (R from L)

___ Stutter

___ Dyslexia

___ Mood Changes

___ Lose Temper Easily

D) ___ Headaches/ Migraines

___ Neck Pain or Stiffness (R, L)

___ Numbness, tingling or pain in

arms, hands, fingers (R, L)

___ Jaw pain or click (TMJ)(R, L)

___ Head seems too heavy

___ Head & Shoulders feel tired

___ Difficulty in excessive (standing,

walking, sitting, bending, lifting,

twisting, household duties, etc.)

___ Shoulder Pain (R, L)

___ Dizziness

___ Ringing in ears (R, L)

___ Hearing Loss (R, L)

___ Fainting

___ Loss of Balance

___ Blurred or double vision (R, L)

___ Upper back pain or stiffness (R, L)

___ Mid Back pain or stiffness (R, L)

___ Lower back or stiffness (R, L)

___ Numbness, tingling or pain

in buttocks, thighs, legs,

feet, toes (R, L)

___ Pain with coughing, sneezing

or strain at stools

___ Hip Pain (R, L)

WHAT IS YOUR HEALTH PHILOSOPHY? (What should you do to be healthy?): __________________________

______________________________________________________________________________________________

HOW DO YOU WANT US TO HANDLE YOUR PROBLEM?

______ Temporary Relief (Help the symptom but not fix the cause of the problem).

______ Maximum Correction (Correct the cause of the problem for maximum stability in the future).

WHY DID YOU COME INTO OUR OFFICE & WHAT ARE YOUR EXPECTATIONS OF US: ______________

______________________________________________________________________________________________

1. What are your favorite hobbies or activities to do now? ___________________________________________

2. Are your current problems affecting these hobbies or activities? _____________________________________

ON A SCALE OF 1-10 (10 being the most, and 1 being the least)…

_______ How committed are you at being at your maximum health potential?

_______ How important is it for your family to be at their optimum health potential?

_______ How committed are you to preventing arthritis & maximizing your spinal stability?

What surgeries have you had? _____________________________________________________________________

Please list drugs you now take (prescription & non-prescription); Use 3rd

page to write more medications:

______________________________________________________________________________________________

___ Foot Trouble (R, L)

E) ___ Chest Pain

___ Asthma

___ Lung Problems

___ Difficult Breathing

___ Wheezing

___ Heart Problems

___ Stroke

___ High or low blood

pressure

___ Varicose Veins

___ Liver Trouble

___ Gall Bladder Trouble

F) ___ Digestive Problems

___ Excessive Gas

___ Belching/ bloating after

meals

___ Heartburn

___ Ulcers

___ Diarrhea/ Constipation

___ Colon Trouble

___ Hemorrhoids

___ Prostate Problems

___ Impotence

G) ___ Kidney Trouble

___ Kidney Stones

___ Frequent Urination

___ Discharge

___ Menstrual problems/ PMS

___ Menopausal problems

___ Breast Lumps, soreness,

discharge

___ Pregnant (currently)

___ Bedwetting

___ Ear infections

___ Hepatitis

___ Venereal Disease (VD)

___ AIDS/ HIV

Cont. of Medication/Drug List:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Name other doctors you have seen for this condition: What was done, and for how long?

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Are you currently wearing: Heel lifts ( Y / N ) Arch Supports ( Y / N )

Are you interested in: Weight Loss ( Y / N ) Anti-Aging ( Y / N ) Chemical-Free Cleaners ( Y / N )

Email Address: (You will receive monthly e-newsletters, chiropractic tips, massage discounts, etc.)

____________________________________________________________________

Please sign and date below stating all information written

above (provided by you, the patient) is accurate and current information:

Signature: __________________________________________________________ Date: ___________________

NOTE: PLEASE FEEL FREE TO ASK ABOUT OUR FEES. FEES ARE PAYABLE WHEN

SERVICES ARE RECEIVED UNLESS ARRANGEMENTS ARE MADE IN ADVANCE.

SEE “POLICY & CHIROPRACTIC CARE FEES” FORM.

YOUR PERSONAL INFORMATION & EMAIL IS NOT RELEASED TO ANYONE OR

ANY COMPANY; YOUR INFORMATION IS FOR OUR RECORDS ONLY.

SEE “NOTICE OF PRIVACY” FORM.

Patient Name(Print) Date

Patient lD #Please draw the location of your pain or discomfort on the images below. Use the symbols

shown to represent the type(s) of pain:

D= Dull S= Stabbing/CuttingB = Burning T=Tingling (Pins & Needles)N=Numb C=Cramping

On the scales below, please draw a vertical line representing your pain or discomfort:Rate the pain you have right now: Rate your pain at its best in the past week:

No Pain Unbearable Pain No Pain Unbearable Pain

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/#\ 'l),1

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Rate your average pain in the past week: Rate your worst pain in the past week:No Pain Unbearable Pain No Pain Unbearable Pain

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Migraine/Headache Questionnaire 1 / 2 pages

Migraine / Headache Questionnaire

Migraine Headache Patients: What Have You Tried Already?

Medication (please circle the items if you took it, and it helped you OR put a line

through it if you took it, but it didn’t help you):

Ibuprofen

Tylenol

Excedrin Migraine

Fioranol

Imitrix

Herbal Supplements (please circle the items if you took it, and it helped you OR put a

line through it if you took it, but it didn’t help you):

Magnesium

Feverfew

Vitamin D

I have tried the following therapies for my migraines: (please circle the items if you

took it, and it helped you OR put a line through it if you took it, but it didn’t help you):

Chiropractic: __________________ (technique)

Massage: _____________________ (technique)

Acupuncture

Cranial Sacral

Other:__________________________________

My “prodrome” (the signs that your headache is starting) signs are:

Light sensitivity

Sound sensitivity

Nausea

Vomiting

Flexarol

Vicodin

Demerol

Neurontin

Other: _________________________________________

Reiki

Trigger Point Therapy

ART

Hypnotherapy

Poor sleep

Fatigue

Loss of memory

Inability to concentrate

Multivitamin _____________

Fish Oil

Vitamin B complex__________________

Pain

Clumsiness

Other: _________________

_______________________

Patient Name:__________________________

Date: _______________________

Migraine/Headache Questionnaire 2 / 2 pages

My migraine usually is:

One sided

All over

Mild

Finish the Statement (fill in the # of migraines and or headaches):

Today’s date is _______________. In the past 4 weeks, I have had _________

migraines and ________ tension headaches, ________ sinus headaches and (for women

only) _________ menstrual headaches.

My diet is: Balanced Poor Excellent

The foods that trigger my migraines are (circle all that apply):

Wine

Chocolate

Wheat

Sugar

Fruits

Other:__________________________________________________________________

________________________________________________________________________

Are you willing to try making changes to your diet, exercise, work style and living

style if it will get rid of your headaches?

Yes

Maybe

No (and here’s why):______________________________________________________

Moderate

Severe

Painful, but the intensity varies from time to time

Fruit Juice; Pineapple, Orange, etc.

Processed meats like pepperoni, salami or bologna

Processed foods like Doritos, chips, pretzel, other

Nuts; What kind?__________________________________________

POLICY & CHIROPRACTIC CARE FEES

Cancellation Policy:

Your appointments are scheduled to provide the best possible outcome for your case.

Please make it a priority to come to all of your scheduled appointments. Should you

frequently forget, miss or cancel an appointments without a 24 hour notice, you will be

billed a $25.00 missed appointment fee. You may reschedule for a same day

appointment if a scheduling conflict arises. ______ Initial

Pre-payment Policy:

Dr. Strauss offers several payment options to make your chiropractic care more

affordable. If you purchase a package of visits at a discounted price, you receive the

discount only if all the visits are used in the package. Should you request a refund of

your package when you have visits remaining, the used visits will be counted using the

regular office visit fee and subtracted from the total payment price. The remainder will

be returned to you within 14 days. _______ Initial

Financial Responsibility Policy:

I understand that I am responsible for all charges for services provided by this office. If

my insurance denies payment for any service or only pays partially for any service, I

understand that I will be responsible for the remaining charges. ______ Initial

Chiropractic Care Fees: Fees are based on out-of-network insurance and cash rates.

Initial (Physical) Exam $125.00 (price may differ due to agreement).

X-rays $50.00 per x-ray view

Adjustment $65.00

Re-Examination $65.00 – $85.00

Physiotherapy** $40.00 (price may differ for cash patients). **Includes one session of any of the following: Myofascial release, ultrasound, electrical

muscle stimulation, massage (not administered by a massage therapist), etc.

Fees are collected at time of service. Co-payments are accepted for Blue Shield

PPO, United Healthcare PPO/EPO, and some other PPO insurances. Some auto

injury cases and Worker’s Compensation are billed to the insurer. Patients

using “medpay” through auto insurance will be held responsible for unpaid

charges (some medpay companies do not pay in-full or may not cover certain

charges/treatments).

Insurance fees may differ based on complexity of your care. If you prefer to

process your own insurance, you can take advantage of our cash fees and plans.

Please provide a valid credit card number for any outstanding unpaid balances.

We will notify you in advance if any payments are required.

CREDIT CARD# __________________________________________________________________________

EXPIRATION DATE:____________ SECURITY CODE:_________ BILLING ZIP CODE:___________

NAME ON CARD: ___________________________________ TYPE OF CARD: VISA MASTERCARD

' : "..'q

it{otice of Privacy Practices

This notice describes how medicaVprotected health information about you may be usedand disclosed and how you can get rrccess to this information Please review it careflrlly.

Summary:

By law, we are required to provide you with our Notice of Privacy Practices (NPP). ThisNotice describes how your medical information may be used and disclosed by us. It alsotells you can obtain access to this information.

As a patient, you have the following rights:1. The right to inspect and copy your information2. The right to request corrections to your information3. The right to request that your information be restricted4. The right to request confidential communications5. The right to a reporf of disclosue ofyour information5. The right to a paper copy of this notice7. We may share your information with other health-care providers only as it

, pertains to your medical conditions

We want to assure you that yorr medicaUprotected health information is secure with us.

This notice contains information about how we will insure that your information remainsprivate.

If you have any questions about this Notice, the name and thb phone number of ourcontact person is listed on this page.

Effective Date of this Notice: Inrrmediately to the date belowContact Person: Dr. Paula StraussPhone Number: (408) 866-8820

Acknowledgement of Notice of Privacy Practices"I hereby acknowledge ttrat I have received a copy of this practice's NOTICE OF

PRIVACY PRACTICES. I understand that if I have questions or complaints regarding

my privacy rights that I may contact the person listed above. I further understand that the

practice will offer me updatesto this NOTICE OF PRTVACY PRACTICES should it be

amende4 modified, or changed in any way.

Patient or Representative Name (please prin|

Patient or Representative Signatue Date

_ Patient refused to sign _ Patient was unable to sign because