New Medical Paperwork Updated Intake Form Step 1 of 18 5% Name(Required) First Middle Last DOB(Required) MM slash DD slash YYYY Age(Required)SS#(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Work Phone Emergency Contact First Last Phone Marital StatusMarriedSingleDivorcedWidowedName First Last Is there a chance you could become pregnant? No Yes Date of your last menstrual period? (LMP) MM slash DD slash YYYY Are you currently breastfeeding? No Yes EmployerOccupationEmployment Status Full Time Part Time Duties Full-Duty Light-Duty Job DutiesHave you missed any work? No Yes If Yes, explain Do you have a primary care provider? (PCP)NoYesName/Location(Required)Do you have a PHARMACY that you use?NoYesName/Location What caused your symptoms?Motor Vehicle AccidentFallSporting InjuryOtherOther:When did your problem(s) start or date of accident? (weeks, months, years, specific date):Were you treated at the emergency room or urgent care?NoYesLocationDate MM slash DD slash YYYY Have you had any of the following tests? EMG MRI CT Scan Bone Scan X-Ray Ultrasound EMG (when/where)MRI (when/where)CT Scan (when/where)Bone Scan (when/where)X-Ray (when/where)Ultrasound (when/where) Have you had any of the following tests? Chiropractic Physical Therapy Joint Injections Epidural Steroid Injections Chiropractic (when/where)Physical Therapy (when/where)Joint Injections (when/where)Epidural Steroid Injections (when/where) Consent(Required) I agree to the privacy policy.I clearly understand that if I am accepted as a patient at Fakhoury Medical and Chiropractic Center, I authorize them to proceed with the treatment as necessary. I understand and agree that all services rendered to me are changed directly to me and I am personally responsible for payment. In the case insurance verification is obtained, insurance claims may be filed. I understand that the filing of insurance is not a guarantee of payment, and I remain responsible for the entire amount due. I also understand that if I terminate my care and treatment, any fees for professional services rendered to me prior to my termination of care will be immediately due and payable. In the extent of default, I promise to pay legal interest on the indebtedness together with suck collection costs and reasonable attorney fees as may be required to effect collection. I hereby attest that the above and all following information is true to the best of my knowledge.Signature(Required) What are your main problems or complaints?How would you describe your pain? Check all that apply Achy Dull Sharp Burning Throbbing Numbness Over the past few days/weeks, is your pain: Improving Worsening Not getting any better The same What worsens or aggravates the pain? Check all that apply Standing Sitting Lying Down Walking Twisting Driving Leaning forward Heat Cold Coughing Sneezing Reaching Other OtherWhat reduces or alleviates the pain? Check all that apply Standing Sitting Lying Down Walking Twisting Driving Leaning forward Heat Cold Coughing Sneezing Reaching Other OtherHas this affected your sleep? No Yes Hours of sleep?Do you feel rested upon waking up? No Yes What medications are you taking including over the counter?Current Medication NameDoseFrequencyThis medication is for? Add RemoveDo you have an allergies?NoYesList allergiesWhat is your past/current medical history? Check all that apply Asthma Bronchitis Emphysema Tuberculosis Lung disease Seizures Heart Disease High blood pressure Stroke Diabetes Bladder disorder Bowel disorder Liver disease Kidney disease Thyroid Ulcers Acid reflux Polio Bipolar disease Depression Rheumatism Mental Illness Cancer Other Cancer DiagnosisOtherWhat is your past surgical history?Surgery (appendix, gallbladder removal, hernia, etc.)Date of surgery Add RemoveDoes your family history include? Genetic disease Heart disease Neurological disease Stroke Muscle disease Diabetes Alcoholism or illegal substances misuse Other Other family history What activities have you had difficulties performing since your injury or accident? Check all that apply. Bathing Dressing Showering Brushing teeth Brushing hair Caring for children Climbing stairs Sweeping/mopping Washing dishes Laundry Sexual activity Shopping Cooking Eating Sleeping Relationships Yard work Driving Homework Getting in/out of bed Walking to the bathroom Exercising Managing funds Engaging with family Working Other WorkingOtherDo you have any children?NoYesDo you have any hobbies or activities that require a moderate level of physical activity?Do you smoke?NoYesPacks per dayDo you drink alcohol?NoYesDrinks per weekDo you use/take drugs?NoYesDetailsDo you drink caffeine?NoYesCups per dayDo you exercise?NoYesTimes per week Have you had any of the following symptoms within the past month? Check all that apply HEENT Cardiopulmonary CNS Constitutional Endocrine Gastrointestinal Genitourinary Mental Health Musculoskeletal Skin HEENT double vision blurred vision recent changes in vision ringing in the ears recent changes in hearing ear drainage dizziness headaches (mild/severe) severe recurrent nosebleed difficulty swallowing Genitourinary burning on urination blood in urine changes in urinary habits difficulty holding urine penile or vaginal discharge penile or vaginal bleeding genital sores Musculoskeletal joint pain joint swelling grinding or joints locking of joints neck pain back pain Cardiopulmonary dull chest pain chest pressure /tightness chest palpitations (fluttering) shortness of breath at rest shortness of breath with exertion shortness of breath when lying flat cough coughing up (blood/mucus) wheezing swelling feet sever night sweats Constitutional fever chills night sweats loss of appetite unintentional weight loss CNS paralysis in arms or legs numbness in arms or legs loss of consciences seizures /new onset seizures jerking poor coordination changes in balance Endocrine increase thirst excessive sweating excessive urination excessive drinking hot/cold intolerance Skin loss of hair discoloration to skin dry sores itchiness rashes bruising wounds Mental Health anxiety depression frequent crying recent memory changes / loss aggression recent memory changes / loss restlessness at night Gastrointestinal abdominal pain nausea / vomiting vomiting blood black and tarry stool bloody stool clay-colored stools difficulty holding bowel movements dramatic change in bowel habits jaundice (yellowing of skin, eyes) diarrhea constipation Medical Records Release/Request Form(Required) I agree to the medical release request formBy signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information to the physician/person/facility/entity of Fakhoury Medical and Chiropractic CenterSignature(Required)Signature for medical release formThe information you may release subject to this signed release form is as follows:(Required) Complete Records Care Plan History & Physical Lab Reports Progress Notes Radiology Reports Other Other(Required) Health Insurance – Assignment of Benefits(Required) I agree to the assignment of benefitsThe insured assigns all of the rights and benefits of any applicable medical payments or other coverage provided by any insurance policy issued to Fakhoury Medical and Chiropractic Center or services and supplies provided. I understand that I’m responsible for my copayments or deductibles got clobbered by my Health Insurance coverage. This assignment includes but is not limited to all rights to collect benefits directly from any insurance carrier obligated to provide benefits or services and supplies I have received. All rights to take legal or other action against any insurance carrier obligated to provide benefits if for any reason the insurance carrier fails to pay any benefits due; and alll attorneys’ fees, legal assistant fees, costs, and any interest on fees and costs for any legal or other action taken by Fakhoury Medical and Chiropractic Center as my assignee. This is an assignment of rights only, and is not a delegation of any of my duties under the subjects insurance policy. I agree that Fakhoury Medical and Chiropractic Center May yet retain any attorney it chooses to bring the legal action against any insurance carrier obligated to provide benefits for services and supplies I have received, and that the attorney chosen needs a different than any attorney I may have handling any claim. I may be given a copy of this assignment to retain if the requested; I have read this assignment and I’m satisfied that I fully understand the purpose and implications of executing this assignment and do sell freely and voluntarily Signature(Required)Health Insurance Assignment of Benefits HIPAA Right of Access Form for Family Memeber/Friend(Required) I agree to the privacy policy.I direct my Health Care &Medical Services providers and payers to disclose and release my protected health information described below to: Name:RelationshipContact InformationHealth information to be disclosed upon the request Of the person named above Disclose my complete health record (including but not limited two diagnoses, lab tests, prognosis, treatment, and billing for all conditions) Disclose my health record, as above, but do not disclose the following choses below HIPAA Choices mental health records Communicable diseases (including HIV & AIDS) Alcohol/drug abuse treatment Other (please specify) HIPAA OtherForm of Disclosure (unless another format is mutually agreed upon between my provider and designee): An electronic record or access through an online portal Hard copy This authorization shall be effective until (check one) All past, present, and future period, OR Date or event unless I revoke It. (Note: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.) HIPAA Date or Event Consent to use or disclose information for treatment, payment or health care operations(Required) I agree to the policy.The patient here by consents to the use or disclosure of his or her individually identifiable health information ” protected health information” by Fakhoury Medical and Chiropractic Center 1009 SW 16th Lane Ocala FL 34471, in order to carry out treatment, payment, healthcare operations. The patient should review FMCC’s notice of privacy practices for protected health information ” attached” for a more complete description of the potential uses and disclosures of such information, and the patient has the right to review such notice prior to signing this consent form. FMCC reserves for itself, the right to change the terms of its notice of privacy practices or protected health information at anytime. If the FMCC does not change the terms or kits notice of privacy practices, the patient may obtain a copy of the revised notice by written request. Patient retains the right to request that FMCC further restricts how his or her protecting health information is used or disclosed to carry out treatment, payment, or healthcare operations. FMCC is not require to agree to such requested restrictions; however, if FMCC does agree to that patience for questing restrictions, such restrictions are then binding on the FMCC. At all times, patient retains the right to revoke this consent. Such revocation must be submitted to the FMCC in writing. The revocation shall be affected except to the extent that the FMCC as already taken action in reliance on the consent. FMCC May refuse to treat the patient if he or she (or an authorized representative) does not sign this consent form (except to extend that the FMCC is required by law to treat individuals). If the patient has the right to refuse to provide further treatment to patient as of the time of revocation (except to the extent that the FMCC is required by law to treat individuals). I wish to have the following restrictions to the use or disclosure of my Health Care information: I have read, accepted and understand this information. I have received a copy of this form and I’m the patient, or am authorized to act on behalf of the patient to signed this document, verifying consent to the above stated terms. Restrictions to the use or disclosure of my health information:Signatureconsent to use or disclose information policy
