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"Getting People BACK in Action" | Translate | ||||
| 1324 E. Garrison Blvd. Gastonia, NC 28054 704.861.1886 |
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| Created by: Innotech Solutions | ||||||
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"Getting People BACK in Action" | Translate | ||||
| 1324 E. Garrison Blvd. Gastonia, NC 28054 704.861.1886 |
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| HOME :: | ||||||
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| Created by: Innotech Solutions | ||||||
DATE:________________ Email Address:____________________________
Name: (Last)_____________________________ (First)_____________________ (M)____
What you preferred to be called: _________________________ Male: Female:
Address:_________________________________________________________
City, State, Zip_________________________________________________________
Home#:______________ CeIl#: ______________ Pager:__________________
Social Security #__________________________ Date Of Birth:__________________ Age:_________
Employer: _______________________________ Work#______________________________
Work Address: ______________________________ Occupation____________________________
Status (circle one): Minor: Single: Married: Other:
Spouse: ____________________________ Spouse Date of birth: ____________________________
Attorney/Adjuster: ___________________ Claim# _______________ Phone: ___________________
Insurance information * Primary card holder name: ____________________________________ Please present your insurance card at the front desk. Please inform the front desk if you have a second insurance. Co-pays are expected at the time of service.
This visit is due to: ________Auto Accident _______Work Related _______Other_____
Please describe the pain and its location: __________________________________________
When did the condition begin? ____________________ Date of accident: _______________
Is condition getting worse? Yes, No, Constant, Comes and Goes
Is this condition interfering with: _____Work ____Sleep ____Daily Routine_____
Have you had a similar condition in the past? _______Yes _____No
Have you been treated by a Medical Doctor for this condition?
lf.so, whom? ___________________Results:_____________________
Have you been treated by a chiropractor before? Yes No
Have you lost any days for work due to this condition? If so how many__ ? Have you returned to work?
*Mark x on the picture where you continue to have pain.
Health History
Are you taking any of the following medications?
Nerve Pills Pain Killers (including aspirin) Muscle Relaxers Stimulants Blood Thinners Tranquilizers Insulin Others Vitamins
Name of Medications:_______________________________________________________________________ _______________________________________________________
Primary Care Physician:_____________________________________________________
Please Circle Yes or No
Y N Heart Attack I Stroke Y N Congenital Heart Defect Y N Alcohol/drug Abuse Y N HIV/AIDS
Y N Frequent Back Pain Y N High/Low Blood Pressure Y N Severe/Frequent Headaches
Y N Fainting I Seizure I Epilepsy Y N Diabetes/Tuberculosis Y N Low Back Problems
Y N Heart Surg I Pacemaker Y N MitralValve Prolapse Y N Venereal Disease Y N Shingles
Y N Emphysema I Glaucoma Y N Psychiatric Problems Y N Kidney Problems
Y N Sinus Problems Y N Difficulty Breathing Y N Artificial Bones I Joints
Y N Heart Murmur Y N Artificial Valves Y N Hepititis Y N Cancer Y N Anemia
Y N Rheumatic Fever Y N Ulcer I Colitis Y N Asthma Y N Chemotherapy Y N Arthriti
Please list any other serious medical conditions you have or have ever had:
List medical and or seasonal allergies:________________________________________________
_________________________________________________
List all surgeries or treatments with dates:_____________________________________________
_____________________________________________
Immediate Family Health History:______________________________________________________
_____________________________________________________________________________________
WOMEN: Are You Pregnant? Yes____ No___ How many weeks? ____
Nursing? ______Medical Authorization and Assignment of Payment
I hereby authorize the staff of The Bradley Chiropractic Clinic to release any information regarding services rendered by them and allow a photocopy of any signature to be used to file insurance. I also assign payment for benefits due me for the services rendered to be made directly to The Bradley Chiropractic Clinic regardless of my insurance benefits. I understand that I am financially responsible for the fees or services rendered. I understand that if I am accepted as a patient by the physicians of The Bradley Clinic, I authorize them to proceed with any treatment that may be necessary. Furthermore, any risk regarding chiropractic treatment will be explained to me upon treatment.
Patient’s or Guardian’s Signature:_________________________________________________________________
Adult Patient______ Spouse______ Parent/Guardian_______
PATIENT NAME: __________________________________ DATE_______________
The rating scales below are designed to measure the degree to which several aspect of your life is presently disrupted by chronic pain. In other words, we would like to know how much your pain is preventing you from doing what you would normally do, or from doing it as well as you normally would. Respond to each category by indicating the overall impact of pain in your life, not just when the pain is at its worst. For each of the six categories of daily living listed, please circles the number which best describes your typical level of activities. A score of 0 means no disruption in functioning at all, and a score of 10 signifies that all of the activities in which you would normally be involved have been totally disrupted or prevented by your pain.
PLEASE CIRCLE THE NUMBER WHICH BEST DESCRIBES YOUR TYPICAL LIMIT OF ACTIVITIES.
FAMILY / HOME RESPONSIBILITIES: this category refers to activities related to the home or family. It includes chores and duties performed around the house (e.g., driving the children to school).
0 1 2 3 4 5 6 7 8 9 10
Completely able to function totally unable to function
RECREATION: This category includes hobbies, sports, and other similar leisure time activities.
0 1 2 3 4 5 6 7 8 9 10
Completely able to function totally unable to function
SOCIAL ACTIVITY: This category refers to activities, which involve participation with friends and acquaintances other, that family members, it includes parties, theater, concerts, dining out, and other social functions.
0 1 2 3 4 5 6 7 8 9 10
Completely able to function totally unable to function
OCCUPATION: This category refers to activities that are part of our directly related to one’s job. This includes non-paying jobs as well, such as that of a homemaker or volunteer worker.
0 1 2 3 4 5 6 7 8 9 10
Completely able to function totally unable to function
SELF CARE: This category includes activities, which involve personal maintenance and independent daily living (e.g., taking a shower, driving, getting dressed, etc.)
0 1 2 3 4 5 6 7 8 9 10
Completely able to function totally unable to function
LIFE-SUPPORT ACTIVITY: This category refers to basic life-supporting behaviors such as eating, sleeping, and breathing.
0 1 2 3 4 5 6 7 8 9 10
Completely able to function totally unable to function
SIGNATURE:_____________________________________ DATE:____________