New Patient Paperwork

Please complete the following information. When you arrive at the office you will be asked to sign a printed version of this information.

Step 1 of 8

12%

Current Date

MM slash DD slash YYYY

Full Name

Sex

Birthday

MM slash DD slash YYYY

SSN

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email Address

Employer

Occupation

Martial Status

Number of Children

Spouse Name

Spouse Work Phone

Emergency Contact

Emergency Contact Phone Number

Who were you referred to our office by?

Insurance

Name of Primary Insurance

Birthdate

MM slash DD slash YYYY

Insurance Company & Address

Contract / ID Number

Group Number:

Are you covered by Medicare?

Yes

Medicare #:

Health Complaints:

Neurological and Vascular Questionnaire:

Do you suffer from Neck Pain? (Select all that apply)

Yes

My neck pain affects my SHOULDERS

My neck pain affects my ARMS

My neck pain affects my HANDS

Do you suffer from Weakness, Numbness, or burning in the shoulder, arms or hands (Select all that apply)

Yes

My neck pain affects my SHOULDERS

My neck pain affects my ARMS

My neck pain affects my HANDS

Do your hands or arms fall asleep regularly?

Yes

My hands fall asleep regularly

My arms fall asleep regularly

Do you have reduced feeling (sensation) or swelling in the hands or arms? (Select all that apply)

Yes

My hands have reduced feeling or swelling

My arms have reduced feeling or swelling

Do you suffer from a loss of handgrip strength? (Select all that apply)

Yes

Do you suffer from back pain with pain in the buttocks, legs, or feet?? (Select all that apply)

Yes

My back pain affects my buttocks

My back pain affects my legs

My back pain affects my feet

Do you have weakness, numbness or burning in the buttocks, legs, or feet? (Select all that apply)

Yes

My weakness, numbness, or burning affects my buttocks

My weakness, numbness, or burning affects my legs

My weakness, numbness, or burning affects my feet

Do your legs or feet fall asleep regularly?(Select all that apply)

Yes

My legs fall asleep regularly

My feet fall asleep regularly

Do you have reduced feeling (sensation) or swelling in the legs or feet? (Select all that apply)

Yes

Do you suffer from cold hands or feet? (Select all that apply)

Yes

My hands get cold

My feet get cold

Do you suffer from headaches, dizziness, or memory loss? (Select all that apply)

Yes

I suffer from headaches

I suffer from dizziness

I suffer from memory loss

Do you have difficulty maintaing your balance?(Select all that apply)

Yes

Do you suffer from vertigo or blurred vision? (Select all that apply)

Yes

I suffer from vertigo

I suffer from blurred vision

Do you suffer from a reduced hearing capacity? (Select all that apply)

Yes

Do you suffer from ringing in your ears? (Select all that apply)

Yes

Do you have bladder or bowel control problems on a regular basis? (Select all that apply)

Yes

I suffer from bladder control problems

I suffer from bowel control problems

Musculoskeletal

Please indicate if you suffer from any of the following, and since when you have started having symptoms.

Headaches

Yes

When did your headaches start?

Neck Pain

Yes

When did your neck pain start?

Upper Back Pain

Yes

When did your upper back pain start?

Mid Back Pain

Yes

When did your mid back pain start?

Lower Back Pain

Yes

When did your lower back pain start?

Shoulder Pain

Yes

When did your shoulder pain start?

Elbow Pain

Yes

When did your elbow pain start?

Wrist/Hand Pain

Yes

When did your wrist/hand pain start?

Arm Pain

Yes

When did your arm pain start?

Hip Pain

Yes

When did your hip pain start?

Knee Pain

Yes

When did your knee pain start?

Ankle Pain

Yes

When did your ankle pain start?

Leg Pain

Yes

When did your leg pain start?

Foot Pain

Yes

When did your foot pain start?

Other neurological and vascular health concerns

Review of Symptoms

General Fatigue

Anxiety

Dizziness

Depression

Fainting

Loss of Sleep

Memory Loss

Weight change

Nose/Sinus Pain

Hearing Trouble R / L

Vision Trouble R / L

Chronic Nasal Infection

Chronic cough

Skin Rash

Chronic wheezing

Difficulty Breathing

Abdominal Pain

Skin Itching/Dryness

Swollen Extremities

Excess Gas

Eczema

Varicosities

Vomiting (excessive)

Diarrhea (excessive)

Chest Pain

Constipation (excessive)

Bruise easily

Heartburn/indigestion

Inability to hold urine

Frequent urination

Irregular Menstruation

Painful menstruation

Impotence

Please mark any of the symptoms you are currently suffering from.

Please indicate if you now have or have any of the following illnesses:

Leave blank if you have never experienced these illnesses.

Sinus Trouble

Now Have

In Past

Hay Fever

Now Have

In Past

Allergies

Now Have

In Past

Asthma

Now Have

In Past

Emphysema

Now Have

In Past

Tuberculosis

Now Have

In Past

Cancer

Now Have

In Past

Diabetes

Now Have

In Past

Epilepsy

Now Have

In Past

Thyroid Trouble

Now Have

In Past

High Blood Pressure

Now Have

In Past

Low Blood Pressure

Now Have

In Past

Heart Trouble

Now Have

In Past

Pacemaker

Now Have

In Past

Stroke

Now Have

In Past

Aortic Aneurysm

Now Have

In Past

Anemia

Now Have

In Past

Rheumatic Fever

Now Have

In Past

Polio

Now Have

In Past

Multiple Sclerosis

Now Have

In Past

Ulcer

Now Have

In Past

Liver Trouble

Now Have

In Past

Kidney Trouble

Now Have

In Past

Prostate Trouble

Now Have

In Past

Arthritis

Now Have

In Past

Scoliosis

Now Have

In Past

Dislocated Joints

Now Have

In Past

Spinal Disc Disease

Now Have

In Past

Bone Fracture

Now Have

In Past

Mental/Emotional Difficulty

Now Have

In Past

Sex. Trans. Disease

Now Have

In Past

HIV

Now Have

In Past

AIDS/ARC

Now Have

In Past

Do you have any other complaints or health concerns that are not listed on this form?

Habits / Activites

Smoking (packs per day)

Never

1 - 2

2 - 3

3 - 4

5 +

Caffeinated Rinks (glasses per day)

Never

1 - 2

2 - 3

3 - 4

5 +

Alcohol Consumption (glasses per day)

Never

1 - 2

2 - 3

3 - 4

5 +

Drug / Substance Abuse

Yes

Exercise

Never

1 - 2

2 - 3

3 - 4

5 +

Type of exercise:

Walking

Jogging

Cycling

Swimming

Other habits we should know about

Medical History

Do you have a family physician?

Yes

Date of last exam

MM slash DD slash YYYY

Name, phone, address of family physician

Please list all doctors (with phone number and address) and the conditions treated in the last 3 years

Have you been hospitalized in the past?

Yes

Date and reason for hospitalization:

Have you ever had surgery?

Yes

Date, reason and results of surgery:

Have you ever had a serious injury?

Yes

Please Describe:

Please list all medications you are currently taking and the conditions they are treating

Are you allergic to any medications?

Yes

Please list

Please list any vitamins or other supplements you are currently taking

Women Only

To your knowledge, ARE YOU PREGNANT?

Yes

If pregnant in the past, were pregnancies normal?

Yes

Are you seeing an OB-GYN regularly?

Yes

Date of last exam

MM slash DD slash YYYY

Physician's name and address

Family History

Does your father have any of the following conditions?

Cancer

Diabetes

Heart Trouble

High Blood Pressure

Stroke

Kidney Disease

Anemia

Mental Ill

Headaches

Osteoporosis

Arthritis

Joint Problems

Scoliosis

Back Problems

Disc Problems

Congenital Defects

Genetic Disease

Other

Deceased

Does your mother have any of the following conditions?

Cancer

Diabetes

Heart Trouble

High Blood Pressure

Stroke

Kidney Disease

Anemia

Mental Ill

Headaches

Osteoporosis

Arthritis

Joint Problems

Scoliosis

Back Problems

Disc Problems

Congenital Defects

Genetic Disease

Other

Deceased

Does your brothers have any of the following conditions?

Cancer

Diabetes

Heart Trouble

High Blood Pressure

Stroke

Kidney Disease

Anemia

Mental Ill

Headaches

Osteoporosis

Arthritis

Joint Problems

Scoliosis

Back Problems

Disc Problems

Congenital Defects

Genetic Disease

Other

Deceased

Does your sisters have any of the following conditions?

Cancer

Diabetes

Heart Trouble

High Blood Pressure

Stroke

Kidney Disease

Anemia

Mental Ill

Headaches

Osteoporosis

Arthritis

Joint Problems

Scoliosis

Back Problems

Disc Problems

Congenital Defects

Genetic Disease

Other

Deceased

Does your children have any of the following conditions?

Cancer

Diabetes

Heart Trouble

High Blood Pressure

Stroke

Kidney Disease

Anemia

Mental Ill

Headaches

Osteoporosis

Arthritis

Joint Problems

Scoliosis

Back Problems

Disc Problems

Congenital Defects

Genetic Disease

Other

Deceased

Other family history we should know about:

Auto Accidents

Is your condition due to an auto accident?

Yes

Date of auto accident

MM slash DD slash YYYY

Have you filed an accident report?

Yes

Workplace Injury

Is your condition due to a job injury?

Yes

Date of job injury

MM slash DD slash YYYY

Have you filed an accident report?

Yes

I understand and agree that health and accident policies are an arrangement between an Insurance Carrier and myself. Furthermore, I understand that this Office will prepare any necessary reports and forms to assist me in making collection from the Insurance Company and that any amount authorized to be paid directly to this Office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered tome are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

Restriction of the Activites of Daily Living (ADL)

HEALTH CARE

Are you experiencing difficulty or pain...

Bathing

Yes

Getting into or out of the bathtub

Yes

Getting on or off the toilet

Yes

Washing or shampooing your hair

Yes

Grooming your hair

Yes

Putting on your pantyhose

Yes

Putting on or taking off your shoes

Yes

Putting on a bra

Yes

Applying body lotion or suntan lotion

Yes

Brushing your teeth

Yes

ACTIVITIES INVOLVIING POSTURE

Are you experiencing difficulty or pain...

With prolonged standing

Yes

With prolonged sitting

Yes

With prolonged walking

Yes

Stair climbing

Yes

Crawling

Yes

Stooping

Yes

Bending

Yes

Laying on your stomach

Yes

Laying on your back

Yes

Kneeling

Yes

Squatting

Yes

TRAVEL/DRIVING ABILITIES

Are you experiencing difficulty or pain...

Turning your head while backing up

Yes

Rotating your body while backing up

Yes

With prolonged sitting as a driver/passenger

Yes

When driving on a bumpy road

Yes

SOCIAL AND RECREATIONAL ABILITIES

Are you experiencing difficulty or pain...

Dancing

Yes

Playing sports

Yes

Participating in aerobic sports

Yes

Weight lifting/body building

Yes

Running/Jogging

Yes

SLEEP HABITS

Are you experiencing:

Increased time to fall asleep

Yes

Sleep interruption due to pain

Yes

Awakening early due to pain

Yes

Inability to fall asleep without medication

Yes

POST-CONCUSSION

Are you experiencing:

Changes in balance and coordination

Yes

Sensitivity to light and/or sound

Yes

Increased sleepiness

Yes

Short-term memory loss

Yes

Long-term memory loss

Yes

Slowed "processing" or "fogginess"

Yes

Changes in ability to focus or concentrate

Yes

Changes in personality or behavior

Yes

Changes in ability to tolerate stress

Yes

Increased irritability or aggression

Yes

HOUSEHOLD RESPONSIBILITES

Are you experiencing Difficulty or Pain...

Scrubbing the tub

Yes

Scrubbing floors

Yes

Vacuuming

Yes

Sweeping

Yes

Taking out the trash

Yes

Standing while washing dishes

Yes

Preparing meals or cooking

Yes

Carrying groceries

Yes

Putting away groceries

Yes

Carrying a laundry basket

Yes

Doing the laundry

Yes

Gardening

Yes

Washing the car

Yes

SEXUAL FUNCTIONS

Are you experiencing difficulty or pain...

Participating in sexual activities

Yes

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient's Name

Previous Name:

Date of Birth

MM slash DD slash YYYY

I request and authorize All American Healthcare to release healthcare information of the patient named above to the following doctors/medical facilities/family member/attorney/other:

#1

Name

Address

City

State

Zip Code

#2

Name

Address

City

State

Zip Code

#3

Name

Address

City

State

Zip

This request and authorization applies to:

Authorization

Healthcare information relating to the following treatment, condition, or dates

Authorization Dates

All Healtchare Option

All healthcare information

Other

Other Input Box

New Patient Paperwork

Insurance

Health Complaints:

Musculoskeletal

Please indicate if you now have or have any of the following illnesses:

Habits / Activites

Medical History

Women Only

Family History

Auto Accidents

Workplace Injury

Restriction of the Activites of Daily Living (ADL)

HEALTH CARE

Are you experiencing difficulty or pain...

ACTIVITIES INVOLVIING POSTURE

Are you experiencing difficulty or pain...

TRAVEL/DRIVING ABILITIES

Are you experiencing difficulty or pain...

SOCIAL AND RECREATIONAL ABILITIES

Are you experiencing difficulty or pain...

SLEEP HABITS

Are you experiencing:

POST-CONCUSSION

Are you experiencing:

HOUSEHOLD RESPONSIBILITES

Are you experiencing Difficulty or Pain...

SEXUAL FUNCTIONS

Are you experiencing difficulty or pain...

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

#1

#2

#3

Covington Location:

Hammond: