INTRODUCTION PATIENT CASE HISTORY
 

 
 Today’s Date: 
 
PATIENT INFORMATION
 
 Name : (First MI Last)
 Preferred Name :
 Address :
City :
State :
Zip :
Date of Birth :
Gender :
                     
Social Security # : 
Home :
Mobile :
Work :
Email :
Preferred Method of Contact :
                 
*Referred By : (Name)

                            


 : 
   
 Race & Ethnicity : (Choose up to 2)






Preferred Language :


 
 
EMERGENCY CONTACT INFORMATION
 
 Name : (First MI Last)  
 Primary Care Physician :  
 Home :  
 Mobile :  
 Doctor’s Phone :  
 Relationship :

                    
 
FINANCIAL INFORMATION
 
 Is today’s visit the result of an accident?

                    
 Will we be working with insurance?
                     (Details)

Primary :        
ID# :               
Secondary :    
ID# :                 
Where would you like statements sent?
                     (Details below)
Name :           
Address :       
Phone :          
Email :           
 I have answered these questions to the best of my knowledge and certify them to be true and correct.

 
 Patient or Guardian Signature :   Date : 


 
It is Usual and Customary to Pay for Services as Rendered Unless Otherwise Arranged


 

 

 

HISTORY OF PRESENT ILLNESS
 

 
 HISTORY OF PRESENT ILLNESS (Please describe)
 
 Major Complaint :
 Secondary Complaints :
When did it start?
What happened?
Which daily activities are being affected by this condition?
 MAJOR COMPLAINT
 
 Grade Intensity/Severity :





 (8-10/10)
 Frequency :

Quality :






 : 
Improves with :




 :    
 :                        
Worsens with :




 :                        
Previous Treatment :

 :           
 :       
 :    
   
              
                       
Previous Diagnostic Testing :


                          

 :                       
*Women: Are you pregnant?
                      Last Menstrual Period: 
    
Present Illness Comments :
 Prescription Medications & Supplements :
 
 Allergies to Medications :

 I have answered these questions to the best of my knowledge and certify them to be true and correct.
 Patient or Guardian Signature :   Date : 
   Print Name: (First MI Last) :     


 

 

 


 PAST, FAMILY, AND SOCIAL HISTORY
 


 
 PAST MEDICAL HISTORY
 
Have you ever had any of the following ?(Please select all that apply and use comments to elaborate.)
 
Illnesses :
 
 
   
 
                                                
 
 
 
 
        
                                                                            
 
 Injuries :
 
 
 
 
 
 
                                                             
 
 
Hospitalizations :  ( Non - surgical with Date ) 
 
 Surgeries : (If yes, provide type & surgery date )
 
                                                         
Shoulder – R / L :              
Elbow / Forearm – R / L :  
Wrist / Hand – R / L :        
Hip – R / L :                       
Knee – R / L :                    
Ankle / Foot – R / L :        
Neck :                                
Back :                                
 
  
 
Medical History Comments :
  
 
FAMILY HISTORY  (Please mark X to all that apply and use comments to elaborate.)
 
                       
 
 
  Mother Father Sibling 1 Sibling 2 Sibling 3 Child 1 Child 2 Child 3 
 Gender F M
Age at death
(If Deceased)
 CVA(Stroke)
 Cancer
 Diabetes
 Heart Disease
 Hypertension
 Other Family History
Aneurysms
Family History Comments:
 
 SOCIAL AND OCCUPATIONAL HISTORY :
 
 
 Marital Status :
                              
Children :
Other :
Student Status :
                           
Highest level of Education :

             .
Employed :

          
Dominant Hand :
                               
Smoking/Tobacco Use : If current smoker, amount  =

  
Alcohol Use :
                 
Caffeine Use :

                                 

                    
Exercise frequency :

                   

                 
Social History Comments :
   
 
 I have answered these questions to the best of my knowledge and certify them to be true and correct.
 Patient or Guardian Signature : 
 Date : 
 Print Name : (First MI Last)
 
 

 



REVIEW OF SYSTEMS
 

 
 REVIEW OF SYSTEMS
 
 Many of the following conditions respond to Chiropractic and Acupuncture treatment.
 Are you currently experiencing any of these symptoms? (Please select all that apply and use comments to elaborate.)
Constitutional : (General)


 :               
Musculoskeletal :


 : 
Neurological :



 :               
Psychiatric :




 :               
Genitourinary :





Gastrointestinal :







Cardiovascular & Heart :



 :               
Respiratory :


 :               
Eyes & Vision :



 :               
Head, Ears, Nose, & Mouth / Throat :






 :               
Endocrine :



 :               
Hematologic & Lymphatic :



 :               
Integumentary  : (Skin, Nails, & Breasts)






Allergic / Immunologic :


 :               
Review of Systems Comments :
 I have answered these questions to the best of my knowledge and certify them to be true and correct.
 Patient or Guardian Signature :  Date : 
Print Name: (First MI Last) :        


 

 



ACCIDENT/INJURY QUESTIONNAIRE

 
 Name : (Last, First MI)
 Today’s Date : 
 
 AUTOMOBILE ACCIDENT – ADDITIONAL INFORMATION
 
 Was anyone else in the vehicle with you?
 
You were?  
Front seat
              
Rear Seat




Name of Driver, if not self
Name of Driver of other vehicle:
Did airbags deploy?
                
Did Police arrive?
                
Using Seatbelt?
                
Did you strike the windshield or object in car?
Were you knocked unconscious?
                 
Where was your vehicle impacted?




  
Where was the other vehicle impacted?




  
Your Auto Ins :
Policy # :
Claim # :
Phone # :
Address :
City :
State :
Zip :
   
Other’s Auto Ins :
Policy # :
Claim # :
Phone # :
Address : 
City :
State :
Zip :
 WORKER’S COMPENSATION INJURY – ADDITIONAL INFORMATION
 
 Employer :
Occupation :
Claim # :
Address :
City :
State :
Zip :
Contact Person :
Phone :
Email :
 
 GENERAL ACCIDENT / INJURY INFORMATION – (PLEASE USE THE REVERSE SIDE OF THIS PAGE IF ADDITIONAL SPACE IS NEEDED)
 
 Date of Accident :  
 Time :   :  
   
Please describe the accident in as much detail as possible?
 
 Before the accident / injury :
 Have you ever had any complaints in the involved area before?
                     
If yes - Were they present at the time of the accident/injury?
                     
If yes - Summarize these complaints prior to the accident : 
Were you capable of performing all of your work activities without restriction?
                     
 
 At the time of the accident / injury :
 Did you feel pain immediately after the accident?
                    
When?
Were you taken anywhere after the accident?
                    
When?
If yes, How?
Where?
If yes, Did you receive treatment?
             
 
 Since the accident / injury :
 Are your symptoms:
                     
Are your work activities restricted as a result of this accident/injury?
                
Have you missed any work since this accident?
- (Dates ?) 
Have you retained an Attorney?
              
Name:
Phone:
Address:
City:
State:
Zip:
 
 
 Signature :
 Date :



 



Runnels Chiropractic, L.L.C.


Authorization and Release
 
 
I authorize payment of insurance benefits directly to Dr. Steven K. Runnels or Runnels Chiropractic, LLC. I authorize Runnels Chiropractic, LLC to release any information pertinent to my case to any insurance company, adjusters, and / or attorney involved in the case, I hereby release Runnels Chiropractic, LLC of any consequence thereof. I agree to be financially responsible for all charges incurred at Runnels Chiropractic, LLC including my insurance deductible, co-payment, and any other services rejected by my insurance company. Any account unpaid after 30 days of the date of service shall bear interest at the rate of 16% per month. Should it become necessary to resort to collections, the patient shall be responsible for all costs of collections including a reasonable attorney’s fee.


 
 Insurance :
                     
 Company :  
 Patient’s Signature :  
 Date :  
 Guardian’s Signature :  
 Date :  
 



 
Clinical Summary Report (CCR)
 
I understand that a clinical summary report is created after each visit for the purpose of EHR and is available for my review. At this time, I am asking Runnels Chiropractic to save these electronically for me and not print them out after each visit. I understand that, upon request, these reports are available to be printed or emailed to me for review.
 
 Patient’s Signature :   Date : 






 






Email Consent
 

 
 Date: 







I    hereby give Runnels Chiropractic permission to send my personal health information via unencrypted email.






 
 Patient/Parent or Guardian Signature  
   
   
   
 Printed Name of Patient/Parent or Guardian  
 
Runnels Chiropractic

Acknowledgement of Receipt of 
Notice of Privacy Practices

This form will be retained in your medical record.

NOTICE TO PATIENT

We are required to provide you with a copy of our Notice of Privacy Practices, Which state how we may use and/or discolse your information. Please sign this form to acknowledge receipt of the Notice.
 
Patient Name: 
Date of Birth: 

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of Runnels Chiropractic.

I understand that the Notice describes the uses and disclosures of my protected health information by Runnels Chiropractic and informs me of my rights with respect to my protected health information.
 
 Patient's Signature or that of Legal Representative
 Printed Name of Patient or that of Legal Representative
 
Today's Date
 
 If Legal Representative, Indicate Relationship