INITIAL HEALTH HISTORY AND REGISTRATION

 

 

Date: __________________

Patient Name: _________________________________        ________________________       ___________

                           Last Name                                                                            First Name                                                               Middle Int.

Address: ___________________________________________________               Apt # ________________

City: ____________________________        State: __________________               Zip Code: ____________

Date of Birth: _____________________                     Sex:     ƒY M     ƒY F                  Age: ______________

                                        (mm/dd/yyyy)

Marital Status:              ƒY Single    ƒY Married     ƒY Separated     ƒY Divorced     ƒY Widowed              

Spouse¡¦s Name: ____________________________________                      # Children: ______________

DL#: __________________________           State: ________           SSN: _________ / _______ / _________

Email Address: ___________________________________

Employer/School: ________________________________    Occupation: _____________________________

Employer/School Address: ______________________________________________           Ste: ________

City: ___________________________          State: _____________________         Zip Code: __________

Work Number: (________) _________________      Fax Number: (________) ______________________

Whom may we thank for referring you? __________________________________________________

 

 

Home Number: (________) ___________________              Cell Number: (________) __________________

Best time and place to reach you ___________________        ___________________________

                                                                                              (time)                                                         (place)

IN CASE OF EMERGENCY, CONTACT

Name: __________________________________     Relationship: _________________________________

Home Phone: (________) _____________________ Work Phone: (________) ____________________

 

                                     * IF NO INSURANCE, SKIP THIS SECTION

 

 

Patient Name: _________________________________        ________________________       ___________

                               Last Name                                                                                 First Name                                                               Middle Int.

Insurance Company: ______________________________________________________________________

Name of Insured: ____________________________________         SSN: _______ / _______ / _________

Address: _______________________________________________________        Ste: _____________

City: ___________________________________      State: ________________       Zip Code: __________

Group/Policy Number: ________________________________________

Medicare:         ƒY Y     ƒY N                 Medicare Number: _________________________________

ASSIGNMENT AND RELEASE

I hereby instruct and direct the ___________________________________________insurance company to pay by check made out to and mailed directly to:

D. L. Davis, D.C.

Westside Chiropractic Center

9911 West Pico Boulevard, Suite 101

Los Angeles, CA 90035

Tel: (310) 203-0500   ¡´   Fax: (310) 203-0508

For the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered.  THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.  This payment will not exceed my indebtedness to the above-mentioned assignee.  I have agreed to pay in a current manner, any balance and/or Co-pay of said professional service charges over and above this insurance payment.

I also authorize the release of medical information pertinent to my claim to any insurance company, claims adjuster, or attorney involved in this claim.

Date: ______________________                  

      (mm/dd/yyyy)

____________________________________________         ___________________________________________

Signature of policyholder                                                                   Witness

_____________________________________

Signature of claimant, if other than policyholder

 

 

 

Is condition due to an accident?            ƒY Yes     ƒY No            Date: ______________________

                                                                                                                          (dd/mm/yyyy)

Type of accident           ƒY Auto     ƒY Work     ƒY Home     ƒY other

To whom have you made a report of your accident?

ƒY Auto Insurance     ƒY Employer     ƒY Workers Comp.     ƒY Other

Attorney Name (if applicable): _________________________________________

 

 

 

Reason for Visit: _________________________________________________________________________

When did your symptoms appear? ___________________________________

Is this condition getting progressively worse?     ƒY Yes     ƒY No     ƒY Unknown

How many days a week do you experience this problem?          ƒY 1     ƒY 2     ƒY 3     ƒY 4     ƒY 5     ƒY 6     ƒY 7

What percentage of time do you experience this problem?         ƒY <25%     ƒY 25%     ƒY 50%     ƒY 75%    ƒY100%

Rate the severity of your pain on a scale of 1 (least pain) to 10 (severe pain): __________________

Does it interfere with your      ƒY Work     ƒY Sleep     ƒY Daily Routine   ƒYRecreation                                                                                                          

Activities or movements that are painful to perform.        

ƒY Sitting    ƒY Standing   ƒYWalking   ƒY Bending    ƒY Lying Down

Type of pain:    ƒY Sharp       ƒY Dull           ƒY Throbbing     ƒY Numbness     ƒY Aching        ƒY Shooting

                        ƒY Burning   ƒY Tingling     ƒY Cramps         ƒY Stiffness        ƒY Swelling     ƒY Other

Mark an X on the diagram where you are having problems.

 

 

 

What treatment have you already received for your condition?   ƒY Medication   ƒY Surgery  ƒY Physical Therapy      

                                                                                                       ƒY Chiropractic      ƒY Other

Name and address of other doctor(s) who have treated you for this condition __________________________

Address: ___________________________________________________    Ste: ________

City: ____________________________________    State: __________________   Zip Code: _____________

Date of Last:   Physical Exam_____________     Blood Test _____________   Urine Test________________

MRI _____________     CT _____________                  Bone Scan _____________    X-ray______________

Please check all that apply:

                        Yes  No                                                    Yes  No                                                    Yes  No                                    Yes  No

Aids/HIV               ƒY   ƒY                      Emphysema           ƒY   ƒY         Miscarriage                        ƒY   ƒY      Scarlet Fever         ƒY   ƒY

Alcoholism            ƒY   ƒY                      Epilepsy                 ƒY   ƒY         Mononucleosis                 ƒY   ƒY      Stroke                     ƒY   ƒY

Allergy Shots       ƒY   ƒY                      Fractures               ƒY   ƒY         Multiple Sclerosis             ƒY   ƒY      Suicide Attempt   ƒY   ƒY

Anemia                  ƒY   ƒY                      Glaucoma               ƒY   ƒY         Mumps                               ƒY   ƒY      Thyroid

Anorexia                ƒY   ƒY                      Goiter                     ƒY   ƒY         Osteoporosis                     ƒY   ƒY         Problems             ƒY   ƒY

Appendicitis         ƒY   ƒY                      Gonorrhea             ƒY   ƒY         Pacemaker                          ƒY   ƒY      Tonsillitis              ƒY   ƒY     

Arthritis                 ƒY   ƒY                      Gout                       ƒY   ƒY         Parkinson¡¦s                                        Tuberculosis         ƒY   ƒY

Asthma                  ƒY   ƒY                      Heart Disease       ƒY   ƒY            Disease                            ƒY   ƒY      Tumors                  ƒY   ƒY

Bleeding                                                Hepatitis                ƒY   ƒY         Pinched Nerve                   ƒY   ƒY      Typhoid

   Disorders            ƒY   ƒY                      Hernia                    ƒY   ƒY         Pneumonia                         ƒY   ƒY         Fever                   ƒY   ƒY

Breast Lump          ƒY   ƒY                      Herniated Disk      ƒY   ƒY         Polio                                    ƒY   ƒY      Ulcers                     ƒY   ƒY

Bronchitis              ƒY   ƒY                      Herpes                   ƒY   ƒY         Prostate                                              Vaginal

Bulimia                   ƒY   ƒY                      High                                             Problems                          ƒY   ƒY         Infections           ƒY   ƒY

Cancer                    ƒY   ƒY                         Cholesterol         ƒY   ƒY         Prosthesis                          ƒY   ƒY      Venereal

Cataracts               ƒY   ƒY                      Hypertension        ƒY   ƒY         Psychiatric Care                ƒY   ƒY         Disease               ƒY   ƒY

Chemical                                                Kidney Disease    ƒY   ƒY         Rheumatoid                                        Whooping

   Dependency      ƒY   ƒY                      Liver Disease        ƒY   ƒY            Arthritis                           ƒY   ƒY         Cough                 ƒY   ƒY

Chicken Pox          ƒY   ƒY                      Measles                 ƒY   ƒY         Rheumatic                         Other_______________________

Diabetes                ƒY   ƒY                      Migraine¡¦s             ƒY   ƒY            Fever                                ƒY   ƒY__________________________

 

                                    

  

      Parent/Sibling                                                                                                    Parent/Sibling       

ƒY Allergies                   ___________________          ƒY Heart Disease                 ___________________         

ƒY Arteriosclerosis         ___________________          ƒY HTN/ Stroke                  ___________________

ƒY Asthma                     ___________________          ƒY Seizures                          ___________________

ƒY Alcoholism               ___________________          ƒY Diabetes                          ___________________

ƒY Cancer                     ___________________          ƒY Other                              ___________________

 

 

 

EXERCISE                WORK ACTIVITY                HABITS

ƒY None                        ƒY Sitting                                   ƒY Smoking           Packs/Day____________________

ƒY Moderate                 ƒY Standing                               ƒY Alcohol             Drinks/Week__________________   

ƒY Daily                        ƒY Light Labor                          ƒY Coffee/Caffeine Drinks      Cups/Day_______________

ƒY Heavy                      ƒY Heavy Labor                        ƒY High Stress Level      Reason_____________________

 

 

 

Injuries/Surgeries you have had:     

                       

Description                                                                                               Date

Falls___________________________________________________      _____________________

Head Injuries___________________________________________________      _____________________

Dislocations ___________________________________________________     _____________________     

Surgeries ___________________________________________________      _____________________

 

MEDICATIONS                                            ALLERGIES                                     VITAMINS

________________________            _________________________          __________________________

________________________            _________________________          __________________________

________________________            _________________________          __________________________

________________________            _________________________          __________________________

________________________            _________________________          __________________________

I certify that the above information is complete and accurate.  If the health plan information is not accurate, or if I am not eligible to receive healthcare benefits through my provider, I understand that I am responsible for all charges for services rendered, and I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future.

Patient Signature: ___________________________________           Date: _______________________

                                                                                                                                    (mm/dd/yyyy)

D. L. Davis, D.C.

Westside Chiropractic Center

9911 West Pico Boulevard, Suite 101

Los Angeles, CA 90035

Tel: (310) 203-0500   ¡´   Fax: (310) 203-0508