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ACOALLEN CHIROPRACTIC ORTHOPEDICSPATIENT INFORMATIONOakmont Business Center 825 N. Cass Ave. Suite 104, Westmont IL 60559 Tel (630) 522-4060Patient’s Last NameFirstMiddleHome PhoneWork PhoneCell mployer AddressCityPatient Date of BirthMarital Status (Circle One)SingleMarriedDivorcedE-Mail AddressStateZIP CodeInsurance ProviderEmployer Phone No.StateCityStateZIP Code()ExtAre YouWorking (Circle)ZIPCurrentlyCodeYESPrimary Care Physician (PCP)PCP Street AddressPCP Phone No.(Have you ever been to a Chiropractor before?If yes, what for:Please indicate referring physician / sourceNOYESNO Friend)Have you ever been to physical therapy before?If yes, what for: Family OtherYESNOName of referring physician / sourceWORK OR AUTO ACCIDENT INFORMATIONIs Injury Work or Auto related?for today’s visit? YesHave you or do you plan to file a worker’s compensation or auto claim regarding the reasonDate of Injury No YesAUTHORIZATION TO TREAT A MINOR NoPLEASE FILL OUT THE FOLLOWING INFORMATION REQUESTED IF APPLICABLEI hereby request and authorize Allen Chiropractic Orthopedics physicians to perform diagnostic tests and render chiropractic adjustments1.and other treatment to MY MINOR SON/DAUGHTER This authorization also extends to all other providers and office staff members.NAME OF MINOR PATIENTDATE OF BIRTHCARD HOLDER’S SSN #As of the date, I have the legal right to select and authorize health care services for the minor child named above.(If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse / formerspouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I willimmediately notify this office.DATESIGNATURE PARENT / GUARDIANRELATIONSHIP TO PATIENTPRINTED NAME PARENT / GUARDIANWITNESS1minor son/ward or other
ACOALLEN CHIROPRACTIC ORTHOPEDICSHEALTH HISTORYPATIENT NAME: TODAY’S DATE:What is the reason for your visit?What do you think caused this problem?When did your symptoms appear?Please circle the best description of your symptoms: Constant / On & Off – usually lasting: Minutes Days WeeksIs the condition getting progressively worse?Do symptoms interfere with your:WorkYesSleepNoRecreationUnknownDaily RoutineList all activities or situations that worsen your pain(include duration of tolerance; example “sitting 15minutes”)List all factors that offer pain relief (examples “moist heat,ice, medications”)VISUAL PAIN SCALEPlease list your PRIMARY symptom (i.e. neck pain)Instructions: Please circle the number that best describes the question being asked for the primary symptom listed above1. What is your pain RIGHT NOW?No Pain worst possible pain0123456789102. What is your TYPICAL or AVERAGE pain?No Pain worst possible pain0123456789103. What is your pain level AT ITS BEST (how close to “0” does your pain get at its best)?No Pain worst possible pain0123456789104. What is your pain level AT ITS WORST (how close to “10” does your pain get at its worst)?No Pain worst possible pain012345678910
PAIN DIAGRAMPlease mark the areas on the picture below that correspond to the areas of your body where you feel the described sensations.Use appropriate symbols. Mark areas of radiation. Include all affected areasPLEASE DO NOT SIMPLY CIRCLE THE AREA OF INVOLVEMENTNumbness - - - -Pins & Needles ooooBurning xxxxAching ****Stabbing / / / /Please list any current medical conditions or symptoms you are currently experiencing, or have experienced during the pastyear:In your lifetime have you had any hospitalizations, serious illnesses or surgeries? (feel free to write on the back of this page)YearReasonHospitalOutcomePlease list any major traumas / accidents (ie. Falls, car accidents)List ANY & ALL bones you have fractured:Any significant scars anywhere on your body (surgery or otherwise)? Please list general area:Do you have a scar on your chin from a fall or accident, possibly in childhood?YesNo
Ever been in a cast (immobilized) for your ankle, leg, and/or knee (for a sprain, fracture, or post-surgically)?YesNoIf YES, which side?LeftRightHave you had Cancer, Chemotherapy, radiation therapy or burns?Have you ever had a metal implant?YesNo If yes explain:YesDo you or have you worked in a machine shop/metal fabrication?Do you use, or have you used, a heel lift in your shoes?Do you use orthotics?YesNoNoYesYesNoIf YES do you wear them:Do you walk a dog (or other animal) on a leash?YesNoall the time orjust in athletic shoes?NoDo you carry a (please circle) purse / hand bag / laptop bag / OR small child frequently? If YES, which side?Do you use a computer daily?YesLeftRightNo Is the monitor (please circle) directly in front of you or a little to one side?How many hours do you sit at the computer daily? hoursDo you use a mouse or touch pad on your computer? (circle one)Is your primary automobile a manual or automatic transmission (circle one)Are you right or left hand dominant?Do you need glasses?YesRightLeftNo If YES do you wear them all the timeDo you have a hearing deficit?Do you know how to ride a bike?YesNo If YES, which earYesLeftYesRightNoBoth Do you use hearing aids?YesNoNoIn your hobbies, do you prop an arm or leg on a support (ie. Step, ledge, counter)?YesNoWhat are your hobbies or chosen sports? Please list major ones:List your prescribed medications, over-the counter medications, herbs, vitamins and inhalersNameDosageFrequency UsedPlease provide details of any known allergies (i.e. latex, medications, foods)AllergenReactionFEMALE ONLY QUESTIONSHave you had any “procedures” for female related issues (ie. Endometriosis, cysts, etc.)?Have you had a hysterectomy, laproscopic surgery, etc?Do you have children?YesNoYesYesNoNoIf YES please indicate how manyWere the births Normal Delivery or Cesarean? (please circle)Are you pregnant?YesNoIf YES please indicate anticipated due date:
HEALTH HABITSEXERCISE: Sedentary (No exercise) Mild Exercise (i.e., climb stairs, walk 3 blocks, golf) Occasional Vigorous Exercise (i.e. work or recreation, lessthan 4x/week for 30 min.) Regular Vigorous Exercise (i.e. work or recreation 4x/weekfor 30 minutes)DIET:Are you dieting? Yes No# of meals you eat in an average day?How much water do you drink on a daily basis?1234567Packs/tin/pouches per day # of YearsHave you in the past? Yes NoIf yes, please indicate the year you quitSLEEP:Does your complaint disrupt your sleep? Yes8910 TerribleCAFFEINE: None Coffee Tea Cola#of Cups/Cans Per Day? NoHow do you rate the quality of your sleep?PerfectPlease rate the quality of your diet:PerfectTOBACCO:Do you use tobacco? Yes No Cigarettes Smokeless tobacco12345678910 TerribleSTRESS:Please rate your stress management strategies:Perfect12345678910 Terrible8910 TerriblePlease rate your daily stress level:ALCOHOL:Do you consume alcoholic beverages? Yes NoIf yes, how many alcohol containing beverages do youconsume? # daily weeklyPerfect1234567FAMILY HEALTH HISTORYPlease help us to identify your potential health risks by placing a check in any column that applies to you or your blood relatives.Condition / Body SystemSelfGrandparentParentSiblingChildAids / HIVArthritisBleeding disordersCancerEndocrine / glandular (diabetes, thyroid)HepatitisImmuneStroke / TIACirculatory Problems (blood vessels, heart)Ear, Nose, ThroatHeart ProblemsHigh blood pressureNeurological (brain, nerves)Gastrointestinal (stomach, intestines)Muscle / Joint / BoneGenitourinary (urinary, kidney, prostate)PsychologicalRespiratory (lung, breathing)SkinI certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staffresponsible for any errors or omissions that I may have made in completion of this formPatient SignatureDate
ACOALLEN CHIROPRACTIC ORTHOPEDICSINSURANCE INFORMATIONPlease check the box that applies to your case and provide the requested informationSelf Pay – our office accepts cash, checks, Visa and MastercardPrivate Insurance orMedicareSecondary Insurance (if applicable)Insurance Company Name Insurance Company NameAddressAddressCity, State, ZipCity, State, ZipPolicy Holder / InsuredPolicy Holder / InsuredSSN and Date of BirthSSN and Date of BirthPolicy or ID. NumberPolicy or ID. NumberGroup NumberGroup NumberInsurance Company Phone ( ) Insurance Company Phone ( )Workers CompensationDate of InjuryEmployer at time of InjuryClaim NumberAddressWC Insurance Co. NameCity, State, ZipAddressContact personCity, State, ZipTelephone NumberContact PersonFax NumberTelephone Number( )( )( )Auto Accident Insurance (Ins. of vehicle that you were not in)Med-Pay Insurance (Insurance of vehicle you were in)Please separately download and complete the ACO AUTO ACCIDENT QUESTIONNAIREDate of AccidentDate of Accident/ / Driver PassengerName of Liable Ins. Co.Name of driver &/or passenger auto Ins. Co.AddressAddressCity, State, ZipCity, State, ZipTelephone Number( )Telephone NumberFax Number( )Fax Number( )Claim NumberClaim NumberPolicy HolderPolicy HolderContact PersonContact Person( )INSURANCE WAIVERI, the undersigned certify that I (or my dependant) have insurance coverage with andassign directly to Dr. Allen or his corporation (Allen Chiropractic Orthopedics) all insurance benefits, if any, otherwise payable to me forservices rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the useof his/her signature on all insurance submissionsPLEASE PRINT NAMERESPONSIBLE PARTY SIGNATURE POLICY HOLDER’S D.O.B. RELATIONSHIPTODAY’S DATE
PAGE 1 of 2ACOALLEN CHIROPRACTIC ORTHOPEDICSFINANCIAL / INSURANCE POLICYWelcome to our office. We are committed to providing you with the best possible services and would like to make youcomfortable in your association with us. The following is a statement of our Financial Policy, which we require you toread and sign. Your cooperation in abiding by this policy will help to control the costs of your health care.PAYMENT POLICYWe will bill your insurance company for treatment rendered. However, all medical supplies or supplements must bepaid for at the time of delivery; we will not bill your insurance company but will provide you with the necessarypaperwork in order that you may file a claim with your own insurance company for the reimbursement of supplies thatwere provided.This medical supply policy applies to all patients regardless of Health Insurance (Indemnity, PPO, HMO, POS),Workers Compensation, Personal Injury or Auto Accident.INSURANCE PLANSIt is necessary that you disclose if the reason for your visit is either work related or pertaining to personal injury (iemotor vehicle accident) prior to the initiation of or at any point during care. This will determine our billing practicesspecific to your case. Please refer to Workers Compensation and Personal Injury policies for further details.As a courtesy our office will inquire about your insurance benefits for treatments specific to our practice. Pleaseunderstand that your insurance carrier has advised us that payment of benefits will not be determined until yourclaim is received and reviewed according to the specifics of your plan. Understand that you are financiallyresponsible to meet any deductible and for the remaining balance not covered by your plan.NETWORKSWe are “in-network” with Blue Cross Blue Shield and “out-of-network” with all other insurance plans. Therefore outof network benefits will apply to your care. As the insured, it is your responsibility to know and understand the benefitsof your health insurance plan including differences between in and out of network coverage such as deductible and copay amounts, percent of coverage and any referrals that may be required (in the event of an HMO plan or to specificallysee our physical therapist)CO-PAYMENTSCo-payments as required by your plan are due at the time of your visit.HMO/POS INSURANCEHMO and POS Plans require a written referral from your Primary Care Physician for any office visit, procedure, orother service provided to you from this office. You must confirm with your insurance company if you can be treated atour clinic and bring your written referral along with your insurance card at the time of your appointment, otherwise wewill have to reschedule the appointment.WORKERS COMPENSATION & PERSONAL / AUTO INJURYWorkers Compensation and Personal Injury cases will be self (cash) pay. We do not submit for reimbursement forthese cases (it can take us years to get paid on some cases) but we will furnish you the information you may need tobill for reimbursement.INITIAL HERE
PAGE 2 of 2FINANCIAL / INSURANCE POLICYCOLLECTION POLICYIn the event that you do not meet your financial obligation for services provided in our office, we will have no choice butto send your account to collections. We will make every attempt to work with you in the event of financial hardship.However, if collections become necessary, any fees incurred (usually your balance plus 35%) will be yourrdresponsibility. You will be sent a courtesy notice with your 2 statement before you are sent to collections.Balances will accrue interest. Once your account goes to collections the process cannot be reversed.CANCELLATION POLICYPatients canceling appointments less than 24 hours prior to their scheduled date and time may be charged a 45 feefor that appointment. You will be responsible for payment of this charge and your insurance company will not likelyreimburse you for this fee. Thank you for your understanding and compliance with our Financial Policy. Our officeaccepts cash, checks, Visa and Mastercard.NOTICE OF PRIVACY PRACTICESAs required by the privacy regulations created as a result of the Health Insurance Portability and AccountabilityAct of 1996 (HIPPA) this notice describes how health information about you (as a patient of this practice) may be used anddisclosed and how you can get access to this information. It is available for you to download from our websitewww.doctorallen.com or you may request a copy from your health care provider.REQUIRED SIGNATUREI (signed below) have read the above Financial Policy and I understand and agree to the Financial Policy. My signatureauthorizes an Assignment of Benefits with Allen Chiropractic Orthopedics and my insurance carrier. I hereby giveauthorization to Allen Chiropractic Orthopedics for my evaluation and treatment as deemed clinically necessary./ /Signature (Patient or Responsible Party)Today’s DateName (Print)
CHIROPRACTIC ORTHOPEDICS PATIENT INFORMATION Oakmont Business Center 825 N. Cass Ave. Suite 104, Westmont IL 60559 Tel (630) 522-4060 Single Married Divorced Home Phone Work Phone Cell Phone E-Mail Address .
