∙112 Southport Drive ∙ Somerset, KY 42501 ∙ Please fill out everything completely and to the best of your knowledge. PATIENT INFORMATION: Legal First Name_____________________ Middle Initial_____ Last Name__________________________ Preferred Name__________________________ Social Security Number ___________________________ Home Phone_____________________________ Cell Phone_____________________________________ Street Address____________________________City___________________State______Zip___________ Sex: Male Female Birthdate___________Age_____ Single Married Widowed
Divorced
E-Mail: _________________________________________ (□ Please email me an appointment reminder) Employed Retired Unemployed Current Student: School:___________________ Grade:______ Employer _____________________________________Occupation_______________________________ Employer City________________________
Phone:____________________
How did you hear about our office?: ________________________________________________________ SPOUSE OR GUARDIAN INFORMATION: First Name_______________________ Middle Initial _____ Last Name___________________________ Birthdate __________________________
Phone___________________________
Street Address ( same as above) ____________________________________________________________ City________________________________________ State____________ Zip______________________ Employer _____________________________________ Occupation______________________________ Employer City__________________________ State_________ Phone_________________________
Emergency Contact ( same as above)
___________________________________________________
Office Use__________ Date__________
Page
1
Phone _____________________________Relationship to Patient __________________________
HIPAA Patient Information Release Form Patient
(Please Print):
Parent /Guardian (if a minor):
In general, the HIPAA privacy rule gives individuals the right to request confidential communications or that a communication of private health information be made by alternative means, such as sending correspondence to the patient’s office instead of the their home. Occasionally our office will send out greeting cards, reminder postcards, call and/or email you regarding an appointment, etc. Please let us know which form(s) of communication you would prefer to be contacted by. By signing this form, I am acknowledging that I have been notified of the Privacy Practices utilized in this office and may request a copy of such document. I may be contacted in the following manner: (check all that apply)
Belcher Chiropractic may speak with who regarding (check all that apply):
Home Telephone: □ O.K to leave message with detailed information □ Leave message with call-back number only □ Please call this as my appointment reminder number Work Telephone: □ O.K to leave message with detailed information □ Leave message with call-back number only □ Please call this as my appointment reminder number Cell Phone: □ O.K to leave message with detailed information □ Leave message with call-back number only □ Please call this as my appointment reminder number □ Please text my appointment reminder Cell phone carrier: _______________ Written Communication: □ O.K to mail to my home address □ Leave message with call-back number only □ O.K. to email □ Please email my appointment reminder
Spouse: ________________________ □ Appointment □Financial □Condition
Parent/Child:____________________ □ Appointment □Financial □Condition
Friend: _________________________ □ Appointment □Financial □Condition
Employer: _______________________ □ Appointment □Financial □Condition
Attorney: _______________________ □ Appointment □Financial □Condition
Ins. Agent: ______________________ □ Appointment □Financial □Condition
I hereby authorize Aaron Belcher, D.C. to disclose any information that may be required by their examination or other means of my physical or mental condition, financial situation or appointment times. If this section is not completed, we will only be able to discuss your case with you and you only.
________________ Relationship to Patient
____________ Date
Office Use__________ Date__________
2
Patient or Guardian Signature
Page
_______________________________
• Medical Doctor’s name: _______________________
None
ACCIDENTS
List any accidents and approximate dates
• Have you had chiropractic care?
_________________________________________________________________________
No Yes: Approximate last adjustment? ____________ For what problem? ____________________ •Do you take: Muscle relaxers
_________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ None
ALLERGIES List any allergies
Pain killers
_________________________________________________________________________
Over-the-counter
_________________________________________________________________________
Other prescription drugs
_________________________________________________________________________ _________________________________________________________________________
• Do you smoke? No
N/A (Cancer & type, stroke, heart conditions, diabetes, etc)
FAMILY MEDICAL HISTORY
Socially
Mother: ____________________________________________________
Regularly
Her mother:__________________________________________________ Her father:_____________________________________________________ Father: _____________________________________________________________ His mother:___________________________________________________ His father:_____________________________________________________ Your Siblings:_____________________________________________________
Regularly • Approximate date of last: Physical exam_________ Spinal x-ray__________
MEDICATIONS
None
List medications you are currently taking
Blood test___________
_________________________________________________________________________
Urine test___________
_________________________________________________________________________
Spinal exam__________
_________________________________________________________________________
Chest x-ray__________ • How many hours of sleep per night? _________
_________________________________________________________________________ _________________________________________________________________________ SURGERIES None List surgeries and approximate dates
• Do you take tablets to go to sleep? Y N
_________________________________________________________________________
• Do you sleep on your Back Side
_________________________________________________________________________
MRI/CT ____________
Stomach
• What kind of pillow? Thick Medium Thin
_________________________________________________________________________
• Age of mattress ____ Is it comfortable? Y N
_________________________________________________________________________
• Do you wear Heel lifts Arch supports Orthotics
_________________________________________________________________________
Patient Signature________________________________
Date___________________ Office Use__________ Date__________
3
Socially
Page
• Do you consume alcohol? No
GENERAL SYMPTOMS
GENERAL Bruise easily Chills Dental problems Depression Difficulty sleeping Dizziness Fainting Fever Forgetfulness Headache Loss of sleep
Nervousness Numbness Sweats Tiredness Weight gain/loss GENITO-URINARY Blood in urine Frequent urination Lack of bladder control Painful urination
Check any symptoms you currently have or have had in the past 3 months. GASTROINTESTINAL
Appetite poor Bloating Bowel changes Constipation Diarrhea Excessive hunger Gas Hemorrhoids Indigestion Nausea Rectal bleeding Stomach pain Vomiting Vomiting blood CARDIOVASCULAR Chest pain Blood pressure Irregular heart beat Poor circulation Rapid heart beat Swelling of ankles Varicose veins
EYE, EAR, NOSE, THROAT Bleeding gums Blurred vision Crossed eyes Difficulty swallowing Double vision Earache Ear discharge Hay fever Hoarseness Loss of hearing Nosebleeds Persistent cough Ringing in ears Sinus problems Vision-flashes SKIN Hives Itching Change in moles Rash
WOMEN ONLY Abnormal pap smear Bleeding between periods Breast lump Extreme menstrual pain Hot flashes Painful intercourse Other Date of last Pap Smear____ Date of last period_______ Have you had a mammogram? Yes; date: ____________ No Are you pregnant? Yes No Maybe Due Date: _____________ Number of children______
CHECK ANY DISEASES YOU CURRENTLY HAVE OR HAVE PREVIOUSLY BEEN DIAGNOSED WITH: AIDS Alcoholism Anemia Anorexia Appendicitis Arthritis Asthma Bleeding disorders Blood Pressure ↑ or ↓ Breast lump Bronchitis Cancer Type: ___________
Cataracts Chemical dependency Chicken pox Diabetes Emphysema Epilepsy Fibromyalgia Fractures Glaucoma Goiter Gonorrhea Gout
Heart disease Hepatitis Hernia Herpes High cholesterol HIV positive Kidney disease Liver disease Measles Migraines Miscarriage Mononucleosis
Multiple sclerosis Mumps Osteoporosis Pacemaker Pneumonia Polio Prostate problem Prosthesis Psychiatric care Rheumatoid arthr. Rheumatic fever Scarlet fever
Stroke Suicide attempt Thyroid problems Tonsillitis Tuberculosis Tumors, growths Typhoid fever Ulcers Vaginal infections Venereal disease Whooping cough Other _______________ _______________ _______________
Date______________________ Office Use__________ Date__________
Page
Patient Signature_______________________________________
4
I certify that the above information is correct to the best of my knowledge. I will not hold Belcher Chiropractic, PLLC responsible for any errors or omissions that I may have made in the completion of this form.
Dr. Aaron Belcher, DC • 112 Southport Drive • Somerset, KY 42501 • • P: 606.676.0022 • F: 606.676.0333 •
Patient Name __________________________________ What area is bothering you the most today?:
When was your most recent flare up? What may have caused the pain? Rate this pain using the scales below:
Today 0 1 2 3 4 5 6 7 8 9 10 0= None
2= Mild Pain
At Its Worst 0 1 2 3 4 5 6 7 8 9 10
4= Moderate Pain
6= Restricts some activity
Effects Daily Activities 0 1 2 3 4 5 6 7 8 9 10 8= Restricts Most Activity
10= Severe
On average, how many hours a day do you have this pain? _____hours What time of day is this pain at its worst? □ Not effected by time
□ Morning
(Check the single best option)
□ Midday
□ Afternoon
□ Evening
□ Nighttime
Does your pain radiate to other areas? No Yes- Describe: Pins & Needles Tingling Tender Throbbing Other __________________ (Circle all that apply)
Climbing Stair Standing Other: ____________
Does anything give you relief from the pain? Ice/Heat Shower Rest Exercise/Stretching Chiropractic Other: __________
Lifting Sleeping No (Circle all that apply)
Medication I haven’t tried anything Nothing relieves my pain
With this complaint, I would like: To become pain free An explanation of my condition To learn how to care for this condition on my own
(Circle all that apply)
To resume normal activity To reduce symptoms
Patient Signature _________________________________________ Date____________ Office Use__________ Date__________
5
Does your pain limit or effect daily activities? Walking Sitting Pushing Pulling Job Activities: ___________
(Circle all that apply)
Numbness Stabbing
Page
Describe the type of pain you are feeling. Aching Sharp Radiating Shooting Dull Burning Other ______________
Patient Name __________________________________ Is there a 2nd area bothering you today?:
When was your most recent flare up? What may have caused the pain? Rate this pain using the scales below:
Today 0 1 2 3 4 5 6 7 8 9 10 0= None
2= Mild Pain
At Its Worst 0 1 2 3 4 5 6 7 8 9 10
4= Moderate Pain
6= Restricts some activity
Effects Daily Activities 0 1 2 3 4 5 6 7 8 9 10 8= Restricts Most Activity
10= Severe
On average, how many hours a day do you have this pain? _________hours What time of day is this pain at its worst? □ Not effected by time
□ Morning
(Check the single best option)
□ Midday
□ Afternoon
□ Evening
□ Nighttime
Does your pain radiate to other areas? No Yes- Describe: Numbness Stabbing
Pins & Needles Tingling Tender Throbbing Other __________________ (Circle all that apply)
Climbing Stair Standing Other: ____________
Does anything give you relief from the pain? Ice/Heat Shower Rest Exercise/Stretching Chiropractic Other: __________
Lifting Sleeping No (Circle all that apply)
Medication I haven’t tried anything Nothing relieves my pain
With this complaint, I would like: To become pain free An explanation of my condition To learn how to care for this condition on my own
(Circle all that apply)
To resume normal activity To reduce symptoms
Patient Signature _________________________________________ Date____________ Office Use__________ Date__________
6
Does your pain limit or effect daily activities? Walking Sitting Pushing Pulling Job Activities: ___________
(Circle all that apply)
Page
Describe the type of pain you are feeling. Aching Sharp Radiating Shooting Dull Burning Other ______________
