WIXLIB

Hill Family Chiropractic Patient ApplicationWELCOME TO OUR OFFICE. WE THANK YOU FOR YOUR TRUST!(Please print using blackor blue ink. If there is something that does not apply to you please put N/A on the line.)Section 1: Patient InformationReferred By:Appt. Date:Name (first, middle, last):Preferred Name:MaleFemaleAddress:Date of Birth: / / Age:City:State:Zip:Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )Social Security Number: Marital Status:MarriedSingleDivorcedWidowEmployer: Occupation: Email:Name of Spouse/Significant Other: Name & Ages of Children:Emergency Contact: Relationship Phone # ( )Section 2: History of ComplaintPrimary Complaint(s):Secondary Complaint(s):Are your complaints due to an Accident?YESNO If yes, what type?WorkAutoPersonalDate of Accident If Work or Auto accident, have you reported this accident to anyone?Who was it reported To? Have you seen any doctors for this condition:YESYesNoNOPlease list the doctor specialty, & for how long you were seen.List any medications you currently take. (Prescription and non-prescription)Section 3: Family History:Does anyone in your family suffer with the same condition(s) or other chronic illnesses? No YesIf yes whom & what condition(s):Section 4: Chiropractic HistoryHave you ever seen a Chiropractor before?YesNoWhen / /For what reason were you seen? Were you helped?YESNOPatient/Guardian’s Signature: Date: / /Doctor’s Signature Date Form Reviewed: / /

Patient NameDOB:Section 5: Past Trauma History: Starting from birth, we all experience thousands of physical, mental, & chemical stresses.These stresses can cause Postural Distortions (misalignments of the spine) and lead to our current health problems.Please write down some of the falls, injuries, & traumas that you’ve experienced. (Please put NA if it doesn’t apply to you)A. Car Accidents (List even minor ones. A 5mph crash from a 3000lb vehicle can cause damage to your spine even if you didn’t feel injured!)Example: 12-1-2007Type of Collision: Front end10 mphInjuries: Neck Whiplash/Neck on Rt. sideDate: / / Type of Collision:FrontSideRear Speed Injuries:Rear Speed Injuries:LtLtRtRtDate: / / Type of Collision:FrontSideB. Sports Injuries (if there are too many to list please write the name of the sport and “MANY” next to it.)Example: 1-1-2008Type of Sport: BasketballType of Injury: Sprained Right KneeDate: / /Type of Sport Type of Injury:Date: / /Type of Sport Type of Injury:LtLtRtRtC. Slips, falls, & Bike Accidents (We understand there may have been a lot of slips & falls since birth, so please list the major ones.)Example: 2-1-2008Type of Injury: Slipped on ice & bruised Left ElbowDate: / /Type of Injury:Lt RtExamDate: / /Type of Injury:Lt RtD. Repetitive Injuries (Please list all repetitive injuries you’ve had in the past.)Example: 3-1-2008Type of Injury: Lifting boxes injured lower backDate: / /Type of Injury:Date: / /Type of Injury:LtLtRtRt*PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms:R Radiating B Burning D Dull A Aching N Numbness S Sharp/ Stabbing T TinglingPatient/Guardian’s Signature: Date: / /Doctor’s Signature Date Form Reviewed: / /

Patient NameDOB:Section 6: Present and Past ConditionsUsing the codes listed below, please fill in EVERY blank with the applicable letter.Check to indicate if you have Pain or Stiffness and on which side of your body.If both sides apply, please check R & L .P Past Health IssueExample: C oulderElbowPainPainPainStiffStiffStiffC Current Health IssuePainStiffRLLocationRespiratoryRL AsthmaRL Chest PainWristPainStiffJaw PainClickPopSwollen or Painful JointsSpineHead / Shoulders Feel Heavy / TiredNeckPainStiffUpper BackPainStiffMid BackPainStiffLow BackPainStiffRRRLLLRRLLRRRRLLLLPain with cough, sneeze, or strain with bowelmovement LOCATION of Pain:Other:Numbness / Tingling or Pain In:N Never had this Health ConditionOther ConditionsHeadaches / MigrainesTrouble SleepingMaleImpotenceProstate ProblemsDifficulty BreathingLung ProblemsCOPDDigestionHeartburnDigestion ProblemsGallbladder ProblemsColon TroubleDiarrhea / ConstipationHemorrhoidsImmune SystemSkin ProblemsSinus Problems/AllergiesFrequent Colds / FluAnemiaOther:Excessive SweatingCancer & Type:Emotional / Mental DisordersLearning DisabilityNervous / IrritableLoss of MemoryDizziness / Loss of BalanceArthritisEpilepsy / ConvulsionsKnocked UnconsciousFrequent Ear InfectionsRinging in Ear R / LHearing Loss R / LFemaleMenopausal ProblemMenstrual CycleProblemsTrouble ConcentratingAIDS / HIVFracture / Dislocation of Bones:Recreational DrugsWhat UsedHow OftenOrgan Problems orDysfunctionDiabetesOther:Urinary TractArmHand /FingersRRLLLiver TroubleHepatitisKidney TroubleFrequent UrinationLegsRLBedwettingFoot / ToesRLHigh/Low BloodPressureHeartSocial HistorySmokingHow muchHow OftenAlcoholic BeverageConsumptionOccursExerciseTypeHow OftenOther:Patient/Guardian’s Signature: Date: / /Doctor’s Signature Date Form Reviewed: / /

Patient NameDOB:Section 7: Functional Assessment: Check any activities of life that your current conditions are affecting: Sitting Sit to Stand Standing Walking Driving Sleep/Rolling Reading Computer Use Yard work/Gardening Running Climbing Pushing/Pulling Dressing/Shaving Dishes/Laundry Bending Lifting Exercising/SportsDoctors Notes:Section 8: Past Health ConditionsTransfer conditions from page 3 marked with a “P” for past health issue.Please list: when, how long it lasted, description of symptoms (ex. Sharp, pain, burning), how often (ex. Weekly, daily),severity (0 no pain; 10 worst pain) .Past Health Issue:Past Health Issue:Past Health Issue:Are any of these past conditions due to an accident?Date of AccidentYESNO If yes, what type?Have you seen any doctors for this condition:WorkYESAutoPersonalNOPlease list the doctor specialty, & for how long you were seen.List any past hospitalizations and/or surgeries:Surgeries:List Hospitalizations Other Than Surgeries:Patient/Guardian’s Signature: Date: / /Doctor’s Signature Date Form Reviewed: / /Revised 1110812

NEW PATIENT CONSULTATIONPatient Name DOB / / Exam Date / /Using Black or Blue ink, list ALL the CURRENT conditions you marked on Page 3 of your New Patient Paperwork; in order of severity.Region of Present Complaint(s): List inorder of Severity(Indicate if on Right side, Left Side, or Both)EXAMPLE:SHOULDER PAIN; RIGHT SIDEOnset-Whendid you firstnotice thiscomplaint?(Use Weeks,Months, orYears.)3 WEEKS AGOTime-Have youexperienced thispreviously? When?How long?Yes; 5 yrs ago; 1monthQuality-Describeyour symptoms?(examples: sharp,dull, burning,crushing)sharpProvocation-What makes yoursymptoms better or worse?(Specific examples: Lifting, Twisting,Bending, Sitting, Standing, Running,Walking.)LIFTING; RUNNINGHow often doyoursymptomsbother you?C ConstantlyW WeeklyM MonthlyCSeverity ofpain:0 No Pain5 ModeratePain10 Worst Pain7Doctors Notes:Doctor’s Signature Date Form Reviewed: / / 2012 Elevation Health All rights reservedRevised 11142012

Hill Family Chiropractic HIPAA Privacy Authorization FormAuthorization for Use or Disclosure of Protected Health Information(Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)This authorization affects your rights regarding the privacy of your personal healthcare information. Pleaseread it carefully before signing.I understand that my treatment, payment, enrollment or eligibility for benefits will not be affected by my signing or notsigning this release.PLEASE SELECT OPTION A (or) B:A. I hereby authorize Hill Family Chiropractic, to use and/or disclose the protected health information describedbelow for the purpose(s) of treatment and care. (Select one of the options below)I hereby authorize the release of my complete health record (including records relating to mental healthcare, communicable disease, HIV or AIDS, and treatment of alcohol/drug abuse).I hereby authorize the release of my complete health record with EXCEPTION of the followinginformation: Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Other (pleasespecify):Complete this Section if you checked either of the options above:I authorize Hill Family Chiropractic or its Business Associates to release all information to the following familymembers or friendsName RelationshipName RelationshipB. Do not discuss/release my medical records or private information to anyone (including family members) or anyentity. This option is not available for our minor patients; we must have written documentation indicating theadult caregiver(s) with whom we may discuss the child’s care.This authorization shall be in force until properly revoked by me at which time this authorization expires. Torevoke my authorization, I must submit a Revocation of Authorization Notice to Hill Family Chiropractic, Attn:Medical Records Manager.This medical information may be used by the person I authorize to receive this information for medicaltreatment or consultation, billing or claims payment, or other purposes as I may direct or as permitted by law.Hill Family Chiropractic and its employees, officers and physicians are hereby released from any legalresponsibility or liability for disclosure of the above information to the extent indicated and authorized herein.I understand that I have the right to revoke this authorization, in writing, at any time. I understand that arevocation is not effective to the extent that any person or entity has already acted in reliance on myauthorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurerhas a legal right to contest a claim.I understand that information used or disclosed according to this authorization may be disclosed by therecipient and may no longer be protected by HIPAA, federal or state law.Signature of Patient or Personal RepresentativeDatePrint Name of Patient or Personal Representative Relationship to PatientYou have the right to receive a copy of this HIPAA privacy authorizationRev11142012