Fillable Health Questionnaire (Palmer College of Chiropractic)

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Health Questionnaire (Palmer College of Chiropractic)

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File # ________
Date: ___/___/___
1
Health Questionnaire
3/13/2013 Patient Initials _______________
Health Questionnaire
Patient Information
Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev.
First Name Middle Name_______________ Nick Name
Last Name Suffix __________Previous Name_____________________
Address 1
City State Zip Code
Primary Phone Secondary/Mobile Phone
Home Email Work Email
By providing my email address, I authorize my doctor to contact me via the email address(es) provided.
Referred by: Patient/Friend Physician Advertisement Student Community Event Sports Event
Community Event Palmer’s Reputation Name of person or event:_________________________________
Which email address would you like us to use to communicate with you? (check one) Home Work
Contact Method (check one) Primary Phone Secondary Phone Mobile Phone Home Email Work Email
Date of Birth Age Gender (check one) Male Female Unspecified
Marital Status (check one) Single Married Other Spouse’s Name: _____________________________
Employment Status (check one)
Employed FT Student PT Student Other Retired Self Employed
Race (check one)
White Black/African American Hispanic American Indian/Alaskan Native
Asian Asian Indian Chinese Filipino
Japanese Korean Vietnamese Native Hawaiian or other Pacific Island
Samoan Guamanian or Chamorro Other I choose not to specify
Multi-Racial (check one) Yes No Unknown
Ethnicity (check one) Hispanic or Latino Not Hispanic or Latino I choose not to specify
Preferred Language (check one)
English Spanish American Sign Language Chinese French German
Tagalog Vietnamese Italian Korean Russian Polish
Arabic Portuguese Japanese French Creole Greek Hindi
Persian Urdu Gujarati Armenian I choose not to specify
Verification Question (choose only one question by circling the question, then give the answer to that question)
What is the name of your favorite pet? In what city were you born? What high school did you attend?
What is your favorite movie? What is your mother’s maiden name? On what street did you grow up?
What was the make of your first car? When is your anniversary?
Verification Answer to the Chosen question:
Answers must be at least 6 characters. This allows Palmer to email encrypted health information securely to the provided email address.
Emergency Contact Information: Full Name _____________________________ Relationship:_______________
Address: ____________________________________________________Phone Number: ____________________
City State Zip Code
/ /
File # ________
Date: ___/___/___
2
Health Questionnaire
3/13/2013 Patient Initials _______________
Have you previously been a patient in any of our Clinics? No Yes; if yes: date and location of last visit:
___________________________________________________________________________________________
Patient Condition
Reason(s) for visit:__________________________________________________________________________
Is this condition due to an accident? Yes No Auto Work Home Other Date____________
What was the mechanism of accident/injury? _____________________________________________________
When did your symptoms appear?______________________ Is it constant or does it come and go?_________
How often do you have this problem? ___________________ How long does the pain last?________________
Does the pain radiate? Yes No If yes, Explain: ______________________________________________
Does it interfere with your: Work Sleep Daily Routine Recreation
Activities or movements that are difficult / painful to perform:
Sitting Standing Walking Bending Lying Down
Mark an “X” on the picture where you continue to have pain, numbness or tingling.
Circle your pain on the below scale of 0 to 10:
(at rest) No Pain 0 1 2 3 4 5 6 7 8 9 10 Extreme Pain
(with activity) No Pain 0 1 2 3 4 5 6 7 8 9 10 Extreme Pain
What time of day is your current pain/problem worse?
Morning Late in the day Middle of night As day progresses N/A
My current pain/problem seems to be:
Getting better Staying the same Getting worse N/A Explain:____________________________________
My current pain/problem can be described as (check all that apply):
Electric Sharp Stabbing Knife-like Piercing Shooting Achy Griping Heavy Cramp-like
Burning Deep Superficial Stiffness (am >1-2 hours or PM or Both) Spasm Tearing N/A
What treatment have you already received for your condition?
Medications Surgery None Physical Therapy Chiropractic Care
Name of other doctor(s) who have treated you for this condition and how __________________________________
Were you satisfied with the results of your treatment? Yes No Explain_________________
Smoking History
Do you currently smoke tobacco of any kind?
Yes Former smoke Never been a smoker
If yes, how often do you smoke:
Current every day smoke
Current sometimes smoker
If yes, what is your level of interest in quitting smoking?
0 1 2 3 4 5 6 7 8 9 10
No interest Very Interested
Allergies
Are you allergic to any medication(s)? 
 Yes No If yes, which medications?
____________________________________
Are you allergic to any of the following?
Bee Sting Latex Peanuts Shellfish
Dairy Mold Pollen Wheat
Eggs Nuts Other____________
Describe the reaction:___________________
File # ________
Date: ___/___/___
3
Health Questionnaire
3/13/2013 Patient Initials _______________
Medications
Current medications, including frequency and dosage if known. If there are no current medications, check here:
Medication Name
Quantity / Dosage (ie.
1 tablet / 5 mg)
Frequency (ie. 2 times / day)
Start Date
Do you currently use any recreational drugs? Yes No
Social History
WORK ACTIVITY: What is your job description: ___________________________________
What do you do most of the day at work? Sitting Standing Light Labor Heavy Labor Other:________
What job did you do during most of your life?
How would you describe the physical stress level at work? Low Medium High
EDUCATION : Mark the highest level of education completed: Elementary school Middle school High School
Vocational School GED Associates Degree Bachelors Degree Graduate Degree Doctorate other
DIET/NUTRITION:
Are you on any special diet? Yes No If yes, for what reason?_________________________
Is your weight a concern for you emotionally or physically? Yes No
Have you gained or lost over 10 pounds in the past 6 months without wanting to? Yes No
My dietary intake consists mainly of the following: (Mark all that apply)
Fruits Vegetables Whole Grains High Fiber Low Fiber
High Salt Low Salt High Sugar Low Sugar Low Carbohydrate
High Fat Low Saturated Fats High Protein Low Calorie
Rate your appetite on the below scale of 1 to 10:
Normal Appetite 1 2 3 4 5 6 7 8 9 10 Eat Nothing
How many 8 ounce glasses of water do you drink a day? _____
Alcohol Use: Now? Yes No Amount/Weekly____ How long? _____ Years/Months
In the past?  Yes No Amount/Weekly____ How long? _____ Years/Months
How many coffee caffeine drinks do you drink a day? Cups ____ None ____
How many soda caffeine drinks do you drink a day? Cans ____ None ____
Current Vitamins, Minerals, Herbs, etc. List ANY/ALL non-prescription items you are CURRENTLY taking.
Vitamin, Mineral, Herbs
Quantity / Dosage (ie.
1 tablet / 5 mg)
Frequency (ie. 2 times / day)
Start Date
File # ________
Date: ___/___/___
4
Health Questionnaire
3/13/2013 Patient Initials _______________
Health Review:
How many hours of sleep are you getting per night? Less than 5 6-8 8-10 10 or more hours
How would you rate your sleep on the following scale? Wake-up Fully Rested 0 1 2 3 4 5 6 7 8 9 10 No/Poor Sleep
How many days a week do you exercise for 30 minutes or more? 0 1-2 3-4 5-6 7
How would you rate the intensity of your exercise? High Intensity 0 1 2 3 4 5 6 7 8 9 10 No Exercise
How would you rate your physical stress level? No stress 0 1 2 3 4 5 6 7 8 9 10 Very stressed
How would you rate your emotional stress level? No stress 0 1 2 3 4 5 6 7 8 9 10 Very stressed
List your major Stressors: __________________________________________________________________________
What are you health goals? _________________________________________________________________________
In addition, talk to your doctor about other areas which may be affecting your health-such as worries about finances,
social support, and alcohol, tobacco and/or drug use.
Personal Health History
Are your currently under the care of a Healthcare Provider or any other doctor? Yes No
If yes, for what condition(s)_________________________________________________________________________
_________________________________________________________________________________________________
Provider’s Name ________________________________________ Phone Number_______________________________
Has any doctor diagnosed you with Hypertension recently? Yes No
If yes, describe: _________________________________________________________________________________
Has any doctor diagnosed you with Diabetes recently? Yes No
If yes, was your blood lab-work test for hemoglobin A1c >9.0% Yes No Not Sure
If yes, other comments regarding Diabetes: ___________________________________________________________
Have you had an X-ray or CT scan or MRI of your low back spine in the past 28 days? Yes No
Do you wear any of the following? Heel Lifts Innersoles Arch Supports Orthotics Other____________
For how long? ________________________________________ Were they prescribed by a doctor? Yes No
Have you seen a chiropractor in the past? Yes No Date of last visit______________
If yes, name and location of previous Chiropractor___________________________ Phone Number_________________
Were you satisfied with your care? Yes No Why? ________________________________________________
Date of last:
Chiropractic Exam
Prostate/PSA
Cholesterol
Mammogram
MRI
Pap Smear
CT-Scan
Colon
Spinal X-ray
Stool check for blood
Bone Density Scan
Childhood Illnesses:
ADD depression Psoriasis
atopic dermatitis diabetes Rash
allergies/hayfever ear infections scoliosis
anemia fetal drug exposure seizures
asthma headaches sickle cell
bedwetting hepatitis spina bifida
cerebral palsy HIV other:
chicken pox measles
crohn’s/colitis mumps
Immunization:
All recommended vaccines Not vaccinated
adenovirus DTaP(diphtheria,tetanus,pertussis)
haemophilus B hepatitis B
Influenza IPV(polio)
MMR(measles,mumps, rubella)
pneumococcal rotavirus
tetanus varivax(chicken pox)
other:_________
File # ________
Date: ___/___/___
5
Health Questionnaire
3/13/2013 Patient Initials _______________
Adult Illnesses:
ADD CVA(stroke) heart disease Parkinson Disease suicide
Alzheimer’s chicken pox hepatitis Unspecified pleural effusion attempt(s)
arthritis cystic kidney disease HIV pneumonia thyroid
asthma depression high blood pressure psoriasis problems
cancer diabetes influenza pneumonia psychiatric condition vertigo
cerebral palsy eczema liver disease scoliosis Other:______
chicken pox emphysema lung disease seizures ___________
colitis eye problems lupus erythema shingles
CRPS(RSD) fibromyalgia multiple sclerosis STD’s (unspecified)
Injuries: (List date next to injury)
back injury fracture laceration (severe)
broken bones head injury motor vehicle accident
disability (ies) industrial accident soft tissue injury
fall (severe) joint injury Other:______________
Surgeries:
Date
Procedure (ie knee repair)
Description
1
In Patient/Out Patient
2
In Patient/Out Patient
3
In Patient/Out Patient
4
In Patient/Out Patient
5
In Patient/Out Patient
Review of systems
Please indicate if you have any of the following by checking the box.
Constitutional
None daytime drowsiness fever night sweats
chills fatigue loss of appetite weight gain / loss
Eyes/Vision
None cataracts itching wears contacts/glasses
blindness double vision photophobia
blind spots eye problems tearing
Ears, Nose &
Throat
None fainting history of head injury runny nose
dizziness frequent sore throats loss of sense of smell sinus infection
ear discharge headaches nosebleeds
ear pain hearing loss nasal congestion
Respiration
None cough shortness of breath wheezing
asthma coughing up blood sputum production
Cardiovascular
None high blood pressure paroxysmal nocturnal varicose veins
claudication low blood pressure dyspnea
(leg pain and ache) orthopnea (difficulty shortness of breath
heart problem breathing lying down) with exertion
heart murmur palpitations ulcers
Gastrointestinal
None belching difficulty swallowing jaundice
abdominal pain black/tarry stool heartburn ulcers
abnormal stool constipation hemorrhoids rectal bleeding
(Color/consistency) diarrhea indigestion loss of bowel control
Female
None/N/A birth control frequent urination vaginal discharge
abnormal vaginal breast lump/pain hormone therapy urine retention/incontinence
Bleeding burning urination irregular menstruation cramps
File # ________
Date: ___/___/___
6
Health Questionnaire
3/13/2013 Patient Initials _______________
I … am currently pregnant am NOT currently pregnant
I … currently have menses currently DO NOT have menses
My menses… are regular are NOT regular
______age of first menses ______age when menopause began
Date of last menstrual period ____/____/____
If you have been pregnant in the past, please fill in the appropriate information below.
______Number of complicated pregnancies ______Number of uncomplicated pregnancies
______Number of C-sections ______Number of vaginal deliveries
______Number of miscarriages ______Number of terminated pregnancies
Male
None/N/A burning urination frequent urination prostate problems
erectile dysfunction hesitancy/dribbling urine retention/incontinence
Sexual Health
Do you have any concerns about your sexual health? Yes No
Are you or have you ever been a victim of domestic or sexual abuse? Yes No
Skin
None change in skin color history of skin disorders rash
change in nail hair loss itching skin lesions/ulcers
texture hives numbness varicosities
Nervous
System
None limb weakness seizures stroke
dizziness loss of consciousness sleeps disturbance unsteadiness of gait/loss
facial weakness loss of memory slurred speech of balance
headache numbness stress
Psychological
None bi-polar disorder depression memory loss
anxiety confusion insomnia mood change
behavioral change convulsions loss or change of appetite
Hematologic
None bleeding blood transfusion fatigue
anemia blood clotting bruising easily lymph node swelling
Please check the appropriate response. If you are not sure, check the “?” box.
No Yes ?






Do you have a past history of cancer?
Have you had any unexplained weight loss?
Your pain does not improve with rest?
Are you over 50 years old?
Failure to respond to a course of conservative care (4-6 weeks)?
Have you had spinal pain greater than 4 weeks?
No Yes ?





Prolonged use of corticosteroids (such as organ transplant Rx)?
Intravenous drug use?
Current or recent urinary tract, respiratory tract or other infection?
Immunosuppression medication and/or conditions?
Are you currently or have you used blood thinners?
No Yes ?





History of significant trauma?
Minor trauma in person >50 years old?
Do you have osteoporosis (weak bones)?
Are you over 70 years old?
Any history of prolonged use of corticosteroids?
No Yes ?




Acute onset urinary tract retention or overflow incontinence (wet underwear)?
Loss of anal sphincter tone or fecal incontinence (bowel accidents)?
Saddle anesthesia (numbness in the groin region)?
Global or progressive muscle weakness in the legs (legs give out)?
File # ________
Date: ___/___/___
7
Health Questionnaire
3/13/2013 Patient Initials _______________
All the answers I have given are correct to the best of my knowledge, and I agree to continue with my Chiropractic
evaluation at the Palmer Clinics at this time.
Patient Signature Date
Signature of Parent or Legal Guardian Relationship
Family History
Relation
Age (now
or at death)
Serious illness/cause of death
Father
alive deceased
no significant disease
has/had__________________
Paternal grandfather
alive deceased
no significant disease
has/had__________________
Paternal grandmother
alive deceased
no significant disease
has/had__________________
Mother
alive deceased
no significant disease
has/had__________________
Maternal grandfather
alive deceased
no significant disease
has/had__________________
Maternal
grandmother
alive deceased
no significant disease
has/had__________________
Brother(s)
alive deceased
no significant disease
has/had__________________
Sister(s)
alive deceased
no significant disease
has/had__________________
Son(s)
alive deceased
no significant disease
has/had__________________
Daughter(s)
alive deceased
no significant disease
has/had__________________
File # ________
Date: ___/___/___
8
Health Questionnaire
3/13/2013 Patient Initials _______________
While we will work closely with you to resolve your chief complaint, as health professionals we are also concerned about
your overall wellness. On future visits we will discuss issues with you that may impact your overall health.
Name of your health insurance company: ____________________________________________
Insurance policy number: _______________________________Social Security Number___________________________
Group number: _________________________________________________________________
Complete if applicable to your current health condition:
Personal Injury Auto Accident Worker Compensation
If you have consulted an attorney, please provide attorney’s name and address:
Name: ________________________________________ Phone: __________________________
Address: ______________________________________________________________________
Dear Patient:
For our records and for your convenience, please check the appropriate box for the following questions.
Thank you and welcome to the Palmer Clinics.
1. Are you a Medicare Patient? YES NO
If so, please state your secondary insurance carrier:
2. Are you a Medicaid Patient? YES NO
3. Are you filing for a Worker’s Compensation case? YES NO
4. Are you filing for a Personal Injury case? YES NO
5. Are you a minor (under the age of 18)? YES NO
Please state the Parent/Legal Guardian’s name
* Questions 6-12 to be completed ONLY if patient is associated with Palmer College:
6. Employee of Palmer College Employee Spouse Employee Dependant Child
If so, please state which department
Please state student’s name
7. Palmer Alumni Alumni Spouse Alumni Dependant Child
Please state the alumni’s name
File # ________
Date: ___/___/___
9
Health Questionnaire
3/13/2013 Patient Initials _______________
8. Employed by one of Palmer’s contractors: (i.e. ARAMARK, PerMar, etc.)
Please state which company
9. Prospective Student Prospective Student Spouse Prospective Student Dependant Child
If so, please present your prospective student card to the front desk.
Please state student’s name
10. Graduate/Undergraduate Student at Palmer Student Spouse Dependant Child
If so, please state your starting date
As well as your anticipated graduation date
Please state student’s name
11. Palmer DC Student Student Spouse Student Dependant Child Student Parent
If so, please state your starting date
As well as your anticipated graduation date
Please state student’s name
12. Palmer CT Student Student Spouse Student Dependant Child
If so, please state your starting date
As well as your anticipated graduation date
Please state student’s name
All the answers I have given are correct to the best of my knowledge, and I agree to continue with my Chiropractic
evaluation at the Palmer Clinics at this time.
Patient Signature Date
Signature of Parent or Legal Guardian Relationship
Palmer Chiropractic Clinics
Consent for Purposes of Treatment, Payment and Healthcare Operations
I, _______________________________________ [Name of Individual] consent to Palmer Chiropractic
Clinics’ (“the Practice’s”) use and disclosure of my Protected Health Information for the purpose of
providing treatment to me, for purposes relating to the payment of services rendered to me, and for the
Practice’s general healthcare operations purposes. Healthcare operations purposes shall include, but not be
limited to, clinical education, quality assessment activities, credentialing, business management and other
general operation activities. I understand that the Practice’s diagnosis or treatment of me may be conditioned
upon my consent as evidenced by my signature on this document.
For purposes of this Consent, "Protected Health Information" means any information, including my
demographic information, created or received by the Practice, that relates to my past, present, or future
physical or mental health or condition; the provision of health care to me; or the past, present, or future
payment for the provision of healthcare services to me; and that either identifies me or from which there is a
reasonable basis to believe the information can be used to identify me.
I understand I have the right to request a restriction on the use and disclosure of my Protected Health
Information for the purposes of treatment, payment or healthcare operations of the Practice, but the Practice
is not required to agree to these restrictions. However, if the Practice agrees to a restriction that I request, the
restriction is binding on the Practice.
I understand I have a right to review the Practice’s Notice of Privacy Practices prior to signing this
document. The Notice of Privacy Practices describes my rights and the Practice’s duties regarding the types
of uses and disclosures of my Protected Health Information.
I have the right to revoke this consent, in writing, at any time, except to the extent that the Chiropractor or
the Practice has acted in reliance on this consent.
____________________________________________________
Signature of Patient or Personal Representative
____________________________________________________
Name of Patient or Personal Representative
____________________________________________________
Date
____________________________________________________
Description of Personal Representative’s Authority
July 25, 2007
Palmer Chiropractic Clinics
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
I, , [patient’s name] acknowledge that I have received,
reviewed, understand and agree to the Notice of Privacy Practices of Palmer Chiropractic Clinics, which
describes the Practice’s policies and procedures regarding the use and disclosure of any of my Protected
Health Information created, received or maintained by the Practice.
Date Signature
Print Name
FOR OFFICE USE ONLY IF NOTICE NOT PROVIDED TO PATIENT
The Practice has made a good-faith effort to obtain an acknowledgement of
[patient’s name] receipt of our Notice of Privacy Practices. In spite of
these efforts, the Practice has been unable to obtain a signed acknowledgement of receipt for the following
reasons (check all that apply):
Patient Unavailable
Patient Physically Unable
Patient Unwilling
In an effort to obtain the patient’s acknowledgement, the Practice has attempted to provide the patient with a
Notice of Privacy Practices in the following manner (check all that applies):
Personally Mail Phone Follow Up
Other:
Date Signature
Print Name of Chiropractor
Palmer Chiropractic Clinics
Name of Practice
July 25, 2007
Acceptance Agreement — Palmer Clinics
The Teaching Clinics:
The Palmer Clinics are the foremost chiropractic teaching clinics in the world. Student interns, in their last
year-and-a-half of clinical education, study under some of the finest professional doctors of chiropractic in order to
further develop and enhance their skills. As a patient in the Palmer Clinics, you will be assigned to a licensed and
experienced Doctor of Chiropractic (D.C.) who will directly oversee your care. Your D.C., also called a “faculty
clinician,” will assign a student intern to work with your case under his/her direct supervision.
In each of these clinic settings it is probable that your chiropractic care will be observed by students in
training. Information about your case may be shared with students learning about the care process and with licensed
chiropractors overseeing your care. In some situations, your care will occur in an open environment where others can
share in this learning experience. Conversations between your faculty clinician and you regarding your health care may
be overheard by others in the vicinity of the conversation.
Statement of Understanding:
I, _____________________________________, was informed about the setting in which my care is to be performed
and, as indicated by my signature below, acknowledge my understanding that:
The Palmer Chiropractic Clinics are teaching clinics.
My personal healthcare information may be overheard by others in the clinic setting and my health care
information may be shared with others as an educational tool for learning.
The chiropractic assessment and chiropractic care provided in the Palmer Clinics may occur in an open
environment where others may observe in this learning experience.
Patient Records:
Patient records, including X-rays, are the property of Palmer Clinics. These records are only released with your written
permission or as required legally. As a teaching institution, data is occasionally gathered for research purposes. Patient
confidentiality is always maintained.
Financial Matters:
Payment is due at the time services are provided unless prior arrangements have been made. All charges will be
explained to you prior to any service being performed.
Insurance: The Clinics accept assignment for most insurance coverage and will be happy to pre-verify your
insurance coverage. You will need to provide your insurance card for this process.
Medicare/Medicaid: Palmer Chiropractic Clinics will accept assignment for Medicare/Medicaid. Patients are
Responsible for their co-payment and payment for any services not covered by Medicare/Medicaid.
Personal Injury: In most cases, Palmer Chiropractic Clinics will accept assignment for payment. If Palmer
Chiropractic Clinics accepts assignment for payment the patient is still legally responsible for their account
balance. Patients will be required to sign a lien in the case of personal injuries. In this situation, you are asked
to authorize direct payment to the clinic through your attorney or the insurance company, and permit the
endorsement of co-issued checks.
Workers’ Compensation: Work-related injury cases are accepted on assignment with permission of the
employer and prior authorization from the employer’s compensation insurance carrier.
I have read the above statements and accept these conditions.
Print Name:
Signature: Date:
July 25, 2007
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Health Questionnaire (Palmer College of Chiropractic)

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