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Neighborhood Chiropractic and Acupuncture LLCRegistration and HistoryPATIENT INFORMATIONLast Name:Date:First NameMiddle Initial:Address:City:State:Zip:Cell Phone Number:Home Phone Number:Email:May we send you e-mail correspondence? YesSex M F Single Married Divorced Widowed MinorBirthdate:Age:Occupation:Patient Employer and/or School:Work Phone Number:May we call you at work? Yes NoWho is responsible for this account? Self Insurance Company Guardian Name:Who do we thank for referring you? NoIn Case of Emergency, ContactName:Home Phone:Primary Care Physician:Relationship:Work Phone:Phone Number:ACCIDENT INFROMATIONIs this condition due to an accident? Yes No Date of Accident:Type of Accident: Auto Work Home Other:To whom have you made report of your accident? Auto Insurance: Employer Worker Comp. Other:Claim # (if applicable):Attorney Name (if applicable):PATIENT CONDITIONReason for your visitWhen did your symptoms appear?Is this condition getting progressively worse? Yes No Don’t KnowMark an X on the picture where you have pain, numbness, or tingling.Areas of your body that need special attention? Yes No Describe:Rate the severity of pain from 1 (least pain) to 10 (most pain):Type of pain: Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling Other (describe):Location of numbness or tingling:How often do you have these symptoms?Is it constant or does it come and go?Does it interfere with your: Work Sleep Daily Routine RecreationActivities that are painful: Sitting Standing Walking Bending Lying Down LovemakingAre you experiencing any other symptoms in your body? OtherNeighborhood Chiropractic and Acupuncture LLC 6040 SE Belmont Ste. 1230 Portland, OR 97215 (503)-236-8701
HEALTH HISTORYName:What treatment have you already had for your condition?Date: Medications Surgery Physical Therapy Chiropractic Services None Other:Name of other practitioners who have treated you for this condition:Have you ever had chiropractic care? Yes NoMassage? Yes NoAcupuncture?Date of Last: Physical Exam:X-ray (Area):Lab Work:Spinal Exam:MRI, CT-Scan or Bone Scan:Place a mark in the box to indicate if you have had any of the following:o AIDS/HIVo Eating Disorderoo Allergies to oils/o Easy Bruisingofragranceo Emphysemaoo Anemiao Epilepsy/ seizuresoo Arm/ Hand Paino Faintingoo Arthritiso Fibroidsoo Asthmao Fibromyalgiaoo Bleeding Disorderso Glaucomaoo Blood clotso Gonorrheaoo Cancero Headachesoo Cataractso Hearing Difficultyoo Chemical Dependencyo Heart Diseaseoo Chicken Poxo Hepatitisoo Communicable diseaseo Herniated Discoo Contactso Herniaoo Diabeteso High Cholesteroloo Dizzinesso Jaw Problemso Other condition not listed above:Kidney DiseaseLeg/Foot DiseaseLiver DiseaseLow Back ProblemsLow Blood PressureMultiple SclerosisNeck Pain/ StiffnessOpen cuts or soreOsteoporosisPacemakerParkinson’s diseasePinched NervePneumoniaPolioProsthesisPsychiatric CareRespiratory Problemsoooooooooooooo NoRheumatoid ArthritisRheumatic FeverSciaticaShoulder ProblemsSkin DiseaseStrokeThyroid ProblemsTransient IschemicAttack (TIA)TuberculosisTumors/ GrowthsTyphoidUlcersVaricose VeinsVenereal DiseaseExercise: None Moderate Daily Heavy Describe:Work Activity: Sitting Standing Light Labor Heavy LaborHabits: Smoking: # Cigarettes or Packs/day? How many years? Were you ever a smoker? Yes No Alcohol: # Drinks/week? Caffeine Drinks # Cups/Day? High Stress Level Reason:Women: Are you pregnant? Yes No Due Date:Number of children:Injuries/ Surgeries (Include a date and a description):Falls:Head Injuries:Broken Bones:Dislocations:Surgeries:Car Accidents:Family Health HistoryHas anyone in your immediate family had the following conditions? (including grandparents): Heart Disease Stroke Cancer Diabetes Other Describe any selected: Other Family Diseases:Medications: YesFor what condition?Vitamins/Herbs/Supplements:Allergies:Is there anything else you would like to share with your doctor?Neighborhood Chiropractic and Acupuncture LLC 6040 SE Belmont Ste. 1230 Portland, OR 97215 (503)-236-8701
Neighborhood Chiropractic and Acupuncture LLCAcupuncture Health HistoryName:(first)(middle)Date: / /(last)Date of Birth: / / Age:Gender: M/FMarital status:SMDWSuccessful health care and preventive medicine are only possible when the practitioner has a completeunderstanding of the patient physically, mentally and emotionally. Please complete this questionnaire asthoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank you.1. When and where did you last receive health care?For what reason?2. Please identify the health concerns that have brought you in order of importance below:ConditionPast Treatmenta.How does this condition affect you?b.How does this condition affect you?c.How does this condition affect you?d.How does this condition affect you?3. If applicable, please list any foods, drugs, or medications you are hypersensitive or allergic to (please include reaction):4. Please list any medications (prescribed and over-the-counter), vitamins, herbs, and supplements you are currently taking:5. Do you have any reason to believe you may be pregnant?6. Do you have any infectious diseases? No Yes, how far along? No Yes, please identify:Name: Date of Birth: Date:pg 1
Neighborhood Chiropractic and Acupuncture LLCAcupuncture Health History7. Family History:Check those applicable:Age (if alth (G Good, P Poor)CancerDiabetesHeart DiseaseHigh Blood PressureStrokeMental IllnessAsthma/Hay fever/HivesKidney DiseaseAge (at death)Cause of Death8. Height:Weight: Currently: Past Maximum:When?9. Blood Pressure: What is your most recent blood pressure reading? / When was this reading taken?10. Childhood Illness (please circle any that you have had):Scarlet Fever DiphtheriaRheumatic FeverMumpsMeaslesGerman MeaslesChicken Pox11. Immunizations (please circle any that you have had, or had reactions to):Polio Hepatitis BOthers:12. Hospitalizations and Surgeries:ReasonWhenReasonWhen13. X-Rays/CAT Scans/MRI’s/NMR’s/Special Studies:ReasonWhenReasonWhen14. Emotional/Mental (please circle any that you experience now and underline any that you have experienced in the past):Mood SwingsNervousnessMental TensionPoor ConcentrationMemory ProblemsSeasonal Depression15. Energy and Immunity (please circle any that you experience now and underline any that you have experienced in the past):FatigueSlow Wound HealingChronic InfectionsChronic Fatigue SyndromeChronic Swollen Glands16. Head, Eye, Ear, Nose, & Throat (Please circle any that you experience now. Underline any that you have experienced in the past):Impaired VisionEye Pain/StrainImpaired HearingNose BleedsEar RingingGlaucomaStuffinessFrequent Sore ThroatsGlasses/ContactsLoss of SmellTeeth MigrainesTMJ/Jaw ProblemsHay FeverSinus ProblemsHead TraumaName: Date of Birth: Date:pg 2
Neighborhood Chiropractic and Acupuncture LLCAcupuncture Health History17. Respiratory (Please circle any that you experience now. Underline any that you have experienced in the past):PneumoniaFrequent Common ColdsBronchitisAsthmaTuberculosisDifficulty BreathingWheezingEmphysemaShortness of BreathPersistent CoughPleurisyOther:18. Cardiovascular (Please circle any that you experience now. Underline any that you have experienced in the past):Heart DiseaseChest PainHeart MurmursSwelling of AnklesRheumatic FeverHigh/Low Blood PressurePalpitations/FlutteringStrokeVaricose Veins19. Gastrointestinal (Please circle any that you experience now. Underline any that you have experienced in the past):UlcersChanges in AppetiteHeartburnBelchingNausea/VomitingGall Bladder DiseaseConstipationLiver DiseaseDiarrheaHepatitis B or CEpigastric PainHemorrhoidsPassing GasAbdominal Pain20. Genito-Urinary Tract (Please circle any that you experience now. Underline any that you have experienced in the ast):Kidney DiseasePainful UrinationFrequent UTIBlood in UrineFrequent Urination at NightFrequent UrinationKidney StonesImpaired Urination22. Female Reproductive/Breasts (Please circle any that you experience now. Underline any that you have experienced in the past):Irregular CyclesBreast Lumps/TendernessPremenstrual ProblemsPainful PeriodsClottingNipple DischargeBleeding Between CyclesHeavy FlowVaginal DischargeMenopausal SymptomsDifficulty ConceivingPain with IntercourseDate of last annual exam Was it normal? Yes No Have you had an abnormal pap? No Yes, when?Have you been diagnosed with Ovarian Cysts, Endometriosis, PCOS, Fibroids, or any STD’s? (please circle any that apply) YesDo you do regular breast exams? No24. Menstrual/Birthing History:a. Age of First/Last Menses:d. Birth Control Type:g. # of Abortions:b. # of Days of Menses:e. # of Pregnancies:h. # of Live Births:c. Length of Cycle:f. # of Miscarriages:25. Male Reproductive (please circle any that you experience now and underline any that you have experienced in the past):Sexual DifficultiesProstrate Problems Testicular Pain/SwellingPenile DischargeHerniasSTD’s26. Musculoskeletal (Please circle any that you experience now. Underline any that you have experienced in the past):Neck/Shoulder PainMuscle Spasms/CrampsLow Back PainLeg PainArthritisArm PainUpper Back PainMid Back PainJoint Pain (if so, where?):27. Neurologic (Please circle any that you experience now. Underline any that you have experienced in the oss of BalanceSeizures/Epilepsy28. Endocrine (Please circle any that you experience now. Underline any that you have experienced in the past):HypothyroidHypoglycemiaHyperthyroidDiabetes MellitusNight SweatsFeeling Hot or ColdFatigue29. Other (Please circle any that you experience now. Underline any that you have experienced in the past):AnemiaCancerRashesEczema/HivesCold Hands/FeetAcneGeneral ItchinessIs there anything else we should know?Name: Date of Birth: Date:pg 3
Neighborhood Chiropractic and Acupuncture LLCAcupuncture Health History30. Lifestyle: What does your typical diet consist of? Yes No, how many?a.Do you typically eat at least three meals per day?b.Exercise routine:c.Spiritual practice:d.How many hours per night do you sleep?Do you wake rested?e.Level of education completed:Bachelorsf.Occupation: Employer:Do you enjoy work? YesHigh School No YesMasters NoDoctorateOtherHours/Week:Why/Why not?g.Nicotine/Alcohol/Caffeine Use:h.Have you experienced any major traumas? No Yes, explain:i.How many glasses of water do you drink per day?j.Do you take vacations?k.Do you eat refined sugar? Do you add salt? Do you eat out often? Do you go on diets often?l.Have you ever been treated for drug or alcohol addiction? Yes NoDo you spend time outdoors?m. Television habits:Reading habits:n.Do you have supportive relationships in your life?o.Interests and hobbies:Name: Date of Birth: Date:pg 4
Neighborhood Chiropracticand Acupuncture LLC6040 SE Belmont Street Suite 1230 Portland, Oregon 97215(P) 503.236.8701 (F) 503.236.8710HIPAA Policy – Acknowledge of Receipt of Notice of Privacy PracticesI, acknowledge that I have received, reviewed, understandand agree to the Notice of Privacy Practice of Neighborhood Chiropractic and Acupuncture which describesthe Practice policies and procedures regarding the use and disclosure of any of my Protected Healthinformation created, received, or maintain by the Practice.Missed/ Cancellation PolicyWhen you make an appointment, you’re paying for the practitioner’s time. Appointments require a 24hour cancellation notice. We are unable to bill insurance companies for missed appointments.Those who repeatedly miss appointments will be asked to pay 25 fee for missed/cancelledappointments without 24-hour notice. Thank you for your understanding of this matter.Communication ConsentHere at Neighbor Chiropractic and Acupuncture LLC, we are adding different options for communicationto allow to have better access to your medical records, billing, and appointments. In order tocommunicate information regarding your care, account, appointments, and the clinic, we needpermission to do so. We will never sell any of your information, nor use it for marketing purposes.I, authorize Neighborhood Chiropractic to contact me and/ornamed authorized person(s) and to convey Personal Health Information by the following methods andassume responsibility to notify Neighborhood Chiropractic whenever this information changes.Text Message Reminders: Yes Text:No, Provider may only leave a name and phone number.Detailed Voicemail:Yes Phone:No, Provider may only leave a name and phone number.Detailed Email:Yes Email:No, provider may not contact me by email.Email Billing:Yes Email:No, I prefer billing statements/ correspondence to be mailed in paper form.Please list names & relationships of other people authorized to receive information about your care:I hereby attest the above information is correct, and that I have read and understood the above policies.Print Name:Date:Signature:HIPAA Policy, Communication Consent, and Cancellation Policy
Neighborhood Chiropractic and Acupuncture LLC 6040 SE Belmont Ste. 1230 Portland, OR 97215 (503)-236-8701 Neighborhood Chiropractic and Acupuncture LLC Registration and History PATIENT INFORMATION Last Name: Date: First Name Middle Initial: Address: City: State: Zip:
