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Date of Visit: Chief Complaint:
Patient Name: Age: Date of Birth:
Address: City: State: Zip Code:
Home Phone: Social Security Number: Sex (M/F):
Employer Name: Work Phone:
Student: Full-time Part-Time Name of School:
Marital Status: Married Single Widowed Divorced Other E-mail address:
May we communicate with you via email Y N What time of day and phone number is best to reach you
Name of Spouse/Partner OR Parent:
Emergency Contact Name and Phone Number:
How did you find out about our office: Friend (name)Yellow Pages Web Ad Other
PAYMENT AGREEMENT:
My insurance company is to be billed by Golden Sun Chiropractic Clinic for my office visits. I understand that Golden Sun Chiropractic Clinic will bill my primary insurance first. I authorize my insurance company to send the payment for services rendered directly to Dr. Una Y. Forde. Whatever is not covered will then be billed to my secondary insurance. If I do not have secondary insurance OR my secondary insurance does not cover the remainder of the bill, I will pay for the remainder of the bill either in full or according to a payment plan established with Golden Sun Chiropractic Clinic. I do not have insurance and will be paying at the time of each visit . I will receive a 1.5% discount when I pay at the time of the visit. I will pay for my visit(s) by credit card. Visa MasterCard #Exp. Date I will pay my balance due at the time of the visit. I will then submit the bill to my insurance company. Please give me a receipt.
Note: Minnesota State Law requires a 1.5% tax to be added to all charges.
Signature of agreement by patient/guardian to the above payment agreement:
Dated this day of:
INSURANCE INFORMATION:
HMO PPO Worker’s Comp Auto Group Medicare Medicaid Other
Date of Last x-rays: Medicare: Patient Name (as on card):
Medicare #: Eff. Date:
Primary Insurance Company:
Address/City/State/Zip:
Phone: Contact Person/Claims Adjuster:
Policy Number/Claim Number (Auto/Work Comp): Group Number:
Secondary Insurance Company: Contact Person:
Address/City/State/Zip: Phone:
Secondary Policy Number: Secondary Group Number:
Is your condition due to an accident Yes or No: Auto Home Other Explain
Date of accident: Accident state Do you have an Attorney Yes or No
Attorney’s Name: Company:
Address/City/State/Zip:
Attorney’s phone: Is your condition a work related injury Yes or No Date of Injury:
Are you on disability Yes or No Disabled from date: Disabled to date:
Return to work date: Did you require hospitalization Yes or No Hospital admit date:
Hospital discharge date: Is your condition due to illnessYes or No
Have you had similar difficulties beforeYes or No If yes, date: Explain:
Have you ever had a traumatic injury or accident other than your present condition Yes or No: _____ If yes, explain:
Who is your Primary Care Doctor: Address:
Phone: Number of years with this doctor:
List names of any other doctors you have seen for present condition: (MD, DC, DO other)
Results:
Is this your first visit to a chiropractor Yes or No If no, when was your last visit
List the approximate dates of any surgical operations you have had
Have you ever suffered any broken bones Yes or No: Explain:
History of antibiotic or cortisone/steroid therapies:
Current medications:
List any known allergies:
List any recent lab work you have had done(e.g. stool, blood, urine, hair analysis)
What other types of therapy have you tried for this problem(s): homeopathy herbs diet modification vitamin/mineral
massage acupuncture physical therapy other
What do you hope to receive from your treatment: symptomatic/pain relief correct the cause of my symptoms
improve my overall health and well being other
RELEASE OF INFORMATION AND AUTHORIZATION OF THIRD PARTY PAYMENT
I understand that I am responsible for any services incurred on my behalf and agree to pay in full at time of visit unless prior arrangements are made with GOLDEN SUN CHIROPRACTIC CLINIC. I authorize the release of any information necessary to allow for payment of this claim. I authorize direct payment to the doctor for services billed to my insurance company.
PATIENT/LEGAL GUARDIAN SIGNATURE DATE
PERMISSION TO TREAT A MINOR
I authorize Dr. Una Forde of Golden Sun Chiropractic Clinic to administer treatment to:
NAME OF MINOR SIGNATURE OF PARENT/GUARDIAN DATE
FAMILY HISTORY (Father, Mother, Brother, Sister)
| Presently Has | Previously Had | |
| Allergies | ||
| Alzheimers | ||
| Arthritis | ||
| Asthma | ||
| Cancer | ||
| Diabetes | ||
| Emphysema | ||
| Heart Disease | ||
| High Blood Pressure | ||
| Hypoglycemia | ||
| Kidney Disease | ||
| Learning Disabilites | ||
| Mental Illness | ||
| Polio or MS | ||
| Stroke | ||
| Tuberculosis |
PAST HISTORY(Check mark if you have had in the past or presently have any of the following disorders)
| AIDS/HIV | Hepatitis | ||
| Alcoholism | Hernia | ||
| Allergies | Kidney Problems | ||
| Arthritis | Learning Disabilities | ||
| Asthma | Liver Problems | ||
| Cancer | Meningitis | ||
| Chicken Pox | Mental Illness | ||
| Chronic Fatigue Syndrome | Mumps | ||
| Colitis | Pneumonia | ||
| Diabetes | Polio or MS | ||
| Diverticulitis | Rheumatic Fever | ||
| Drug Abuse | Syphilis | ||
| Emphysema | Other STD(s)_________ | ||
| Epilepsy | Thyroid Imbalance | ||
| Fibromyalgia | Tuberculosis | ||
| Gall Bladder Problems | Ulcers | ||
| Gonorrhea | Other | ||
| Heart Disease |
(Read carefully through the following lists. Check those items which presently apply to you)
GENERAL INFORMATION
| Anemia | Irritable | ||
| Bad Breath | Nervous/Depressed | ||
| Body Odor Problems | Night Sweats | ||
| Convulsions | Skin Disorders | ||
| Dental Problems | Slow Healing Cuts/Bruises | ||
| Dizziness/Loss of Balance | Tumors, Cysts, Lumps, or Odd Swellings | ||
| Fainting | Tremors | ||
| Fatigue/Run Down | Twitches or Tics | ||
| Fevers | Weight Gain/Loss | ||
| Insomnia | Migraines | ||
| Other _______________________________ |
EYE, EAR, NOSE, THROAT
| Vision Impairment | Cataracts | Cough | |||
| Night Blindness | Deafness | Frequent Headaches | |||
| Color Blindness | Earache | Grinding Teeth | |||
| Spots In Front Of Eyes | Hearing Aid | Nose Bleeds | |||
| Eye Pain | Ringing In Ears | Frequent Sore Throats | |||
| Contact Lenses/Glasses | Frequent Colds | Sinusitis | |||
| Other |
HEART/LUNGS
| Chest Pain | Bloody Sputum | Pain Over Heart | |||
| Cough Up Phlegm | High/Low Blood Pressure | Rapid Heartbeat | |||
| Difficult Breathing | Pacemaker | Varicose Veins |
GASTROINTESTINAL
| Poor/Excessive Appetite | Gas, Bloating | Vomiting | Nervous Stomach | ||||
| Excessive Thirst | Diarrhea/Constipation | Abnormal Stools | Stomach Cramps | ||||
| Indigestion | Nausea | Abdominal Pains | Hemorrhoids |
FEMALE REPRODUCTIVE
| Irregular or Profuse Flow | Clots | Date Last Complete Gynecological Exam | |||
| Cessation of Flow | Vaginal Sores | # Of Pregnancies | |||
| Cramping | Breast Lumps | # Of Births | |||
| Breast Soreness | Changes In Body/Psyche Prior To Menstruation | # Of Premature Births | |||
| Vaginal Discharge/Pain | Date Last Menses | # Of Miscarriages | |||
| Menopausal Problems | Age of First Menses | # Of Abortions | |||
| Period Between Menses | Date Last Pap Tes |
Have you taken or do you take birth control pills? Yes or No If yes, what kind and how long?
Have you or do you use a birth control device? Yes or No If yes, what kind and how long?
MALE GENITOURINARY
| Swollen prostate | Painful urination | Decreased libido |
SKIN AND HAIR
| Rashes | Dandruff | Ulcerations | |||
| Itching | Change In Hair Or Skin Texture | Eczema | |||
| Loss Of Hair | Pimples | Recent Moles | |||
| Hives | Sun Burn - 2nd /3rd Degree | Date: | Any other hair or skin problems |
GENITOURINARY
| Bedwetting | Sores On/Near Genitalia | Loss of Bladder Control | |||
| Blood/Pus In Urine | Excessive Urination | Painful Urination | |||
| Unusual Discharge | Diminished Urination | Kidneys Ache |
CARDIOVASCULAR
| High Blood Pressure | Low Blood Pressure | Chest Pain | |||
| Irregular Heartbeat | Dizziness | Fainting | |||
| Cold Hands Or Feet | Swelling Of Hands | Swelling Of Feet | |||
| Blood Clots | Phlebitis | Difficulty In Breathing | |||
| Any other heart or blood vessel problems | |||||
NEUROPSYCHOLOGICAL
| Seizures | Dizziness | Loss Of Balance | |||
| Eating Disorder | Lack Of Coordination | Poor Memory | |||
| Concussion | Depression | Anxiety | |||
| Bad Temper | Easily Susceptible To Stress | Do you have a history of abuse | |||
| Have you ever been treated for emotional problems | |||||
Chiropractic care often requires touch. Are you uncomfortable being touched? Yes or No
(Please let the doctor know if you are uncomfortable with any therapies)
Have you ever considered or attempted suicide? Yes or No
Any other neurological or psychological problems? Yes or No
NMS
| Eyes Sensitive To Light | Pain Between Shoulder Blades | Swollen/Stiff Joints | |||
| Painful Or Stiff Neck | Muscle Tension | Painful Joints | |||
| Grinding Sounds In Neck | Muscle Cramp or Spasms | Normal Range Of Motion Limited Or Painful | |||
| Painful Or Clicking Jaw | Muscle Weakness | Bursitis | |||
| Feels Like Arthritis | Loss Of Strength/Grip | Pinched Nerve | |||
| Cold Hands Or Feet | Numbness In Limbs | Sciatica | |||
| Pain Shoots Down Leg | Slipped Disc |
Sensation Of Pins And Needles Or Tingling (Check area in which you experience pain): Foot Mid Back Ankle
Neck Knee Hand Leg Wrist Hip Joint Elbow Buttocks Arm Low Back
Shoulder Other
The pain gets worse when I: Sit Cough Bend Lay Down Stand Work Stoop
Lift Walk Other
HABITS
| Antacids | Laxatives | Tranquilizers | Stimulants | ||||
| Aspirin | Narcotics | Barbiturates | Painkiller | ||||
| Patent Medicines | Muscle Relaxants |
Average # of hours sleep per night
Alcohol: # of drinks per week
Tobacco: # of Cigarettes/day
Coffee: # of cups/day
Soft drinks: # of cans/day
Water: # glasses/day
OPTIONAL: Please list any "Recreational: drugs you have taken in the past, I.E., LSD, cocaine, marijuana, etc.
Please list any nutritional supplements you are currently taking
18. Exercise (times per week)
Describe:
Diet (my diet is): Typical American Vegetarian
Restricted intake of (e.g. salt,sugar, dairy):
Zone Diet Atkins Weight Watchers Macrobiotic Other
Eating habits:
Skip breakfast 2 Meals/day One meal/day 3 Meals/day Small frequent meals Food rotation
Eat on the run Eat constantly
Food Frequency: (servings per day)
| Fruits(citrus, melons etc.) | Dark green or yellow/orange vegetables | ||
| Grains(unprocessed) | Beans, peas, legumes | ||
| Dairy,eggs | Meat, poultry,fish | ||
COMMENTS
Please tell us any other information you would like to discuss: