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1 C O N F I D E N T I A L PAT I E N T I N F O R M AT I O N The following information is needed in order to better serve you. Please complete all questions. If you need help, please ask the receptionist. PLEASE PRINT. Today s Date: Name: Home Phone: Address: City: State: Zip: Age: Birth Date: Marital Status: M S W D No. of Children Referred by: Address: Please Check Type of Payment: Cash Check MasterCard/Visa Your Employer: Occupation: Years on Job: Employer Address: City: State: Zip: Office Phone: Cell Phone: Your SS#: Do You Have Health Insurance? Yes No Insurance Company: Insurance Plan/Group#: Your Work Hours: Do You Have Medicare? Yes No Medicaid? Yes No Name of Spouse or Parent: Birth Date: Spouse s Employer: Occupation: Office Phone: Cell Phone: Spouse s SS#: Describe The Major Complaints That Bring You To Our Office: Is Your Condition Due To An Accident? Yes No Date of Accident: Type of Accident? Auto Work/Job At Home Other: I (we) agree to pay for services rendered to the above mentioned patient as the charge is incurred. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself and that I am personally responsible for payment of any and all services covered or non-covered. 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. Patient s Signature: Date: Guardian s Signature (For Minors): Date: Notice to our new patients: Full payment for services rendered is due at the end of each visit. If for any reason this request cannot be met, arrangements must be made in advance before seeing the doctor.
2 H E A LT H R E V I E W Skin, Hair, Nails ( ) Eczema ( ) Itchy skin ( ) Rough, scaly skin ( ) Dry skin ( ) Oily skin ( ) Yellow skin ( ) Bruise easily ( ) Baldness ( ) Paper thin nails ( ) Nail bitting Eyes ( ) Blurred vision ( ) Double vision ( ) Eye fatigue ( ) Excessive tearing ( ) Lack of tearing ( ) Light bothers eyes ( ) Excessive itching ( ) Pain in eyeball Ears ( ) Loss of hearing ( ) Pain in ears ( ) Discharge from ears ( ) Vertigo ( ) Ringing in ears Nose & Sinuses ( ) Nose bleeds ( ) Pressure over eyes ( ) Nose obstruction ( ) Frequent colds ( ) Sinusitis ( ) Loss of smell ( ) Allergies Mouth & Throat ( ) Pain in throat ( ) Bleeding gums ( ) Abscessed teeth ( ) Dentures ( ) Difficulty swallowing Respiratory ( ) Shortness of breath ( ) Dry cough ( ) Coughing up blood ( ) Wheezing ( ) Productive cough Gastrointestinal ( ) Poor appetite ( ) Constant nibbling ( ) Difficulty swallowing ( ) Indigestion ( ) Nausea & vomiting ( ) Abdominal pain ( ) Change in bowel habits ( ) Diarrhea ( ) Constipation ( ) Hemorrhoids Genitourinary Urination is ( ) Frequent The amount is ( ) High ( ) Low ( ) Frequent urination at night ( ) Intense desire to urinate ( ) Difficulty urinating ( ) Lack of control ( ) Pain with urination ( ) Dribbling ( ) Bloody urine ( ) Cloudy urine Venereal Disease ( ) Syphilis ( ) Gonorrhea ( ) Other Women Only ( ) painful periods ( ) spotting ( ) premenstrual symptoms ( ) irregular periods ( ) lumps in breast ( ) vaginal discharge # of pregnancies # of deliveries Social History ( ) Smoking ( ) Other tobacco use ( ) Alcohol use ( ) Drink coffee or tea Diet is ( ) Balanced ( ) Not balanced Rest is ( ) Sufficient Recreation is ( ) Sufficient Family stress is ( ) Severe ( ) High ( ) Minimal ( ) None My job stress is ( ) Severe ( ) Minimal ( ) None ( ) Nervousness ( ) Irritability ( ) Fatigue ( ) Depression ( ) Panic attacks ( ) Problems sleeping ( ) Generally feel run-down
3 M U S C U L O S K E L E TA L S Y S T E M Head Shoulders ( ) Frequent headaches ( ) Pain in shoulders ( ) Severe headaches ( ) Pain across shoulders ( ) Head feels heavy ( ) Muscle spasms ( ) Vertigo ( ) Can t raise arm ( ) Dizziness ( ) Above shoulder ( ) Light headedness ( ) Above head ( ) Loss of taste ( ) Loss of smell Arms & Hands ( ) Loss of hearing ( ) Pain in upper arm ( ) Loss of balance ( ) Pain in forearm ( ) Pain in hands Neck ( ) Pain in fingers ( ) Pain in neck ( ) Pins & needles ( ) Pain with movement ( ) In arms ( ) Swelling in neck ( ) In fingers ( ) Stiffness in neck ( ) Fingers go to sleep ( ) Pinched nerve in neck ( ) Cold hands ( ) Neck feels out of place ( ) Swollen fingers ( ) Muscle spasms in neck ( ) Loss of grip strength ( ) Grinding sounds in neck ( ) Popping sounds in neck Hips, Legs & Feet ( ) Limited neck movement ( ) Pain in buttocks ( ) Pain in hip Mid-Back ( ) Pain down leg ( ) Mid-back pain ( ) Knee pain ( ) Pain between shoulder blades ( ) Leg cramps ( ) Sharp stabbing pain ( ) Pins & needles in legs ( ) Dull ache ( ) Numbness in legs ( ) Pain from front to back ( ) Numbness in toes ( ) Pain over kidney area ( ) Cold feet ( ) Muscle spasms ( ) Swollen ankles ( ) Swollen feet Lower Back ( ) Lower back pain ( ) Lower back feels out of place ( ) Muscle spasms
4 H E A LT H H I S T O RY Name: Date: List All Current Health Problems: List Any Other Doctors Seen, Treatments And Results Obtained: Your Current Physician(s)/Therapist(s): List All Surgeries And Their Dates: List Any Medications You Are Taking: List Any Traumas And Their Dates: Please Check The Conditions You Have Or Have Had: ( ) AIDS ( ) Diabetes ( ) Polio ( ) Anemia ( ) Epilepsy ( ) Rheumatic fever ( ) Arthritis ( ) Fibromyalgia ( ) Rheumatoid arthritis ( ) Cancer ( ) Hypoglycemia ( ) Tuberculosis ( ) Chronic fatigue ( ) Multiple sclerosis ( ) Venereal disease ( ) Depression ( ) Parkinson s disease CARDIOVASCULAR VERTEBROBASILAR ( ) General swelling ( ) Double vision ( ) Inability to form words ( ) Swelling in legs ( ) Loss of coordination ( ) Burning sensations ( ) Swelling in face ( ) Loss of memory ( ) Blindness ( ) Swelling around eyes ( ) Ringing in ears ( ) Previous head injury ( ) Chest pain ( ) Heart attack ( ) Previous neck injury ( ) Pounding heart beat ( ) High blood pressure ( ) Taking birth control pills ( ) Rapid heart beat ( ) Muscle weakness ( ) Family history of stroke ( ) Irregular heart beat ( ) Dizziness ( ) Blood vessel disease ( ) Blue or purple skin ( ) Blurred vision ( ) Check if you smoke ( ) Blue or purple nail beds ( ) Stroke ( ) Fainting ( ) Cold hand/feet ( ) Hypertension ( ) Area of numbness
5 Coordination of Care Patient: (Print Name Please) In an effort to provide the highest quality of care I would like Upper Cervical Health Centers to coordinate care with the following parties: (Add Name & Check all that apply) Primary Care Physician: Orthopedist: Physical Therapist: Podiatrist: Dentist: Other: I understand that by signing below I am giving Dr. Knecht and Upper Cervical Health Centers- Fort Myers permission to contact and send my notes, records and/or imaging to the above checked health care providers that are part of my health care team. I understand that this is not a guarantee that the above mentioned health care providers will read or respond to said records but is an effort to coordinate care to provide superior care for the patient. Patient: Date: (Signature of Patient/Parent if minor) (Ex: 00/00/0000) McGregor Blvd., Ste 102 Fort Myers, FL (239)
H E A LT H H I S T O RY
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