2902 w main St Ste 4 Rapid City, sd 57702 Patient Information



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c:\users\server\desktop\logo1.jpg 2902 W Main St Ste 4 Rapid City, SD 57702

Patient Information

Name: ______________________________________________ Date: ___________________________

Address: _____________________________________________________________________________

Date of Birth: _______________ Sex: M/F Home Phone: _________________ Cell: ___________

Work Phone: ____________________________ Occupation: ___________________________________

Name or spouse or nearest relative: ___________________________ Phone: ______________________

Referred to this office by: __________________ Payment for services will be by: ___________________

Email address for appointment reminders: __________________________________________________

Would you like your email included on our wellness newsletter list? _____________________________

Emergency Contact: _______________________ Marital Status: ________________________________

Major Complaint Information


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? ____________________________________________________________


Secondary Complaint Information


1. ___________________________________________________________________________________

2. ___________________________________________________________________________________

3. ___________________________________________________________________________________


History


Have you been treated by a health care professional in the last year for a health condition? __________

If so, please describe the condition: ________________________________________________________

Date of last physical exam: _______________________________________________________________

Height: _________________________ Weight: ______________ High or low blood pressure: ________

Surgical History:

1. ___________________________________________ Date: ___________________________________

2. ___________________________________________ Date: ___________________________________

3. ___________________________________________ Date: ___________________________________


Accident History:
1. ___________________________________________ Date: ___________________________________

2. ___________________________________________ Date: ___________________________________

3. ___________________________________________ Date: ___________________________________
Are allergic to any medications? ____________________________________________________________

Do you take any medications? _____________________________________________________________

______________________________________________________________________________________

Female: Are you pregnant? ________________________________________________________________


Have you been seen by a chiropractor before? __________ Name: _______________________________

Additional Complaints/Family History


Please circle all additional complaints that you have at this time. If a family member has or has had any of the following please describe:



Loss of Concentration



Eyes Sensitive to Light

Memory Loss

Heavy Feeling of Head

Headaches

Dizziness

Ringing in Ears

Loss of Balance

Loss of Smell

Loss of Taste

Pain Behind Eyes

Fainting

Palpitation

Neck Stiffness

Neck Motion Restricted

Upper Back Pain / Stiffness

Mid Back Pain / Stiffness

Right / Left Shoulder Pain

Right / Left Arm Pain

Pins & Needles Arms / Legs

Right / Left Leg Pain

Low Back Pain/Stiffness

Sinus Trouble

Nervousness

Chest Pain

Shortness of Breath

Irritable

Anxiety

Depression

Insomnia

Fatigue

Excess Perspiration

Digestive Trouble

Nausea

Vomiting

Diarrhea

Constipation

Cold Hands

Cold Feet

Jaw pain

Hypertension

Diabetes

Convulsions

Allergies: Please List_________________________________________________________________________

Vision Problems

Anemia

Heart Disease

Arthritis

HIV (Aids)

Other (Please List)

_____________________________________________________________________________________________

_____________________________________________________________________________________________
Please Specify Location:

Numbness _______________

Swelling ________________

Cuts ___________________

Bruising ________________


Areas on Interest - please circle if you would like more information


Nutritional Supplements Acupuncture Biofeedback

BrainCore Neurofeedback (helps to alleviate the symptoms of neurological conditions such as ADD/ADHD, Autism, Depression, Anxiety, Insomnia, PTSD, and many more).

Chiropractic for children and/or pregnancy Massage Reiki

Lymphatic Drainage Therapy Hair Mineral Analysis Orthotics

Advanced Allergy Therapeutics (helps to alleviate the symptoms related to numerous allergies).

Authorization & Assignment


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.

Date: _____________________________ Patient Signature: __________________________________




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