What is your major complaint? ___________________________________________________________
When did the symptoms begin? ___________________________________________________________
If this is an injury, describe what happened: _________________________________________________
Rate the severity of your symptoms on a scale of 0-10, with 0 representing no pain and 10 representing the most severe pain. My pain is currently on a scale of 0-10: _______________ What is the least intense the symptoms has been on a scale of 0-10: ________________ What is the most intense the symptom has been on a scale of 0-10: _________.
Have you experienced these symptoms before? ___________________ If so, when? ________________
What aggravates the symptoms? __________________________________________________________
What improves the symptoms? ___________________________________________________________
Have you seen a doctor for this condition? ________________ If so, name of doctor: ________________
Does this condition interfere with your sleep? _______________________________________________
In what position do you sleep? ____________________________________________________________
I authorize Bahr Chiropractic Wellness Center, LTD, to release any information deemed appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred to me.
I authorize the direct payment to you of any sum I now or hereafter owe your by my attorney out of the proceeds of any settlement of my case, and by any insurance company obligated to make payment to me or you based in whole or in part upon the charges made for you services.
I understand that whatever amounts you do not collect from insurance proceeds (whether it be in all or part of what is due) I personally owe.
I, the undersigned do hereby appoint Bahr Chiropractic Wellness Center, LTD, authority necessary to endorse and cash my checks, drafts or money orders which are made payable to the undersigned or as co-payee with this clinic when said payments are due to services rendered on behalf of the undersigned clinic.
I understand and agree that health and accident insurance policies are an agreement between and insurance carrier and me. I clearly understand and agree that all services rendered me are charge 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. I will be responsible for any costs, collections, attorney's fee or court cost required to collect my bill.