Where Chicago's Athletes Get Adjusted
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>> NOTE:  You can either fill in the form below and submit directly online, or click  > HERE <  and print the form (.pdf file), fill it in, and bring to the office.

 

__________________________

 

 

Confidential Patient Health Record

Date

PERSONAL HISTORY

Your Name
Address
Your Email
City
State
Zip
Home Phone
Birthdate
Age
Sex
Cellphone
Marital Status
Cellphone Provider
Emergency Contact
Social Security #
Phone #
Business Employer
Relationship
Type of Work
Health Insurance Carrier
Business Phone
ID #
How Did You Hear About Us?
Group

CURRENT HEALTH CONDITION

Chief Complaint
When Did This Condition Begin?
Has This Condition Occurred Before?
Is This Condition:
Other Condition Details:
Have you Made A Report Of Your Accident To Your Employer?
Any Other Doctors Seen For This Condition?
Who?
Type Of Treatment:
Medications Currently Being Taken:
Vitamins/Supplements Currently Being Taken:
Do You Wear Foot Orthotics?
Do You Have A Pacemaker?
Any Other Conditions That You Wish To Discuss With The Doctor

PAST HEALTH HISTORY

Major Surgeries/Operations
Major Accidents/Falls
Hospitalizations (other than above)
Have You Had Previous Chiropractic Care?
Date Of Last Visit
Treating Doctor And/Or Facility
Results

Below are a list of diseases which may seem unrelated to the purpose of your appointment. However these questions must be answered carefully as these problems can affect your overall course of care.

CHECK ANY OF THE FOLLOWING DISEASES THAT YOU HAVE HAD:

PneumoniaMumpsInfluenzaRheumatic FeverSmall Pox
PleurisyPolioChicken PoxArthritisTuberculosis
DiabetesEpilepsyWhooping CoughCancerMental Disorders
AnemiaHeart DiseaseMeaslesThyroidEczema
Have You Tested HIV Positive?

CHECK ANY OF THE FOLLOWING YOU HAVE HAD:

MUSCULO-SKELETAL Low Back PainPain Between ShouldersNeck PainArm PainJoint Pain/StiffnessWalking ProblemsDifficult Chewing/Clicking JawGeneral Stiffness
NERVOUS SYSTEM NervousnessNumbnessParalysisDizzinessForgetfulnessConfusion/DepressionFaintingConvulsionsCold/Tingling ExtremitiesStress
EENT Vision ProblemsDental ProblemsSore ThroatEar AchesHearing DifficultyStuffy Nose
GASTRO-INTESTINALPoor/Excessive AppetiteFrequent NauseaVomitingDiarrheaConstipationHemorrhoidsLiver ProblemsGall Bladder ProblemsWeight IssuesAbdominal CrampsGas/BloatingHeartburnBlack/Bloody StoolColitis
GENERAL FatigueAllergiesLoss Of SleepFeverHeadaches
MALE/FEMALE Menstrual IrregularityMenstrual CrampsVaginal Pain/InfectionBreast Pain/LumpsProstate/Sexual Dysfunction
FEMALES ONLY When Was Your Last Period? Are You Pregnant?
CONSUMPTION CoffeeTeaAlcoholCaffeinated BeveragesCigarettesWhite Sugar
Water consumption per day:

FAMILY HISTORY MotherFatherBrotherSisterChildSpouse


CONSENT FOR TREATMENT AND CONSULTATION/HIPAA POLICIES

I hereby consent and request to the performance of Chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic Radiographs, on myself(or on the patient named below, for whom I am legally responsible) by Dr. Jason W. Ingham and/or other licensed doctors of chiropractic who now or in the future treat the undersigned while employed by, working or associated with or serving as vacation relief for Dr. Jason W. Ingham whether signatories to this form or not.
Chiropractic only has one goal. It is important that each patient understand both the objective and the method used to obtain this goal. This will prevent any confusion or disappointment. We do not offer to diagnose or treat any condition other that vertebral subluxation. However, if during the course of chiropractic spinal examination, we encounter any non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings , we will recommend that you seek the services of a healthcare provider that specializes in that area.
I understand and I am informed that, as in the practice of medicine, the practice of chiropractic involves some risk to treatment, including but not limited to, fractures, disc-injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all the risks and complications, and I wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I also understand that the practice of chiropractic is limited in its diagnostic abilities and Dr. Jason W. Ingham cannot, will not, and is not expected to diagnose medical conditions.
My "Protected Health Information" means health information, including my demographic information, collected from me and created or received by my physician. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I consent to the use or disclosure of my protected health information by Advanced Spine & Sports Care for the purpose of diagnosing or providing treatment to me , obtaining payment for my health care bills or to conduct health care operations of Advanced Spine & Sports Care. I understand that Dr. Ingham may refuse to diagnose or treat me, if I don't consent to the use or disclosure of my protected health information for the above states of purpose. (My signature on this document is evidence of this consent.)
I understand that I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of this practice. Advanced Spine & Sports Care is not required to agree to the restrictions that I may request , the restriction is binding on Advanced Spine & Sports Care and Dr. Ingham.
I understand I have the right to review Advanced Spine & Sports Care's Notice Of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the type of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of care operations of Advanced Spine & Sports Care. The Notice Of Privacy Practices of Advanced Spine & Sports Care is also provided on request at the main administrative desk of this practice. Notice Of Privacy Practices also describes my rights and Advanced Spine & Sports Care's duties with respect to my protected health information.
Advanced Spine & Sports Care reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised Notice of Privacy Practices by calling Advanced Spine & Sports Care's office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
I have the right to revoke this consent, in writing, at any time, except that Advanced Spine & Sports Care or Dr. Ingham has taken action in reliance on this consent.
I have read, or have read to me, the above consent. I have also had the opportunity to ask questions about its content, and by signing below, i agree to the above procedures and conditions. I intend this consent form to cover the entire course of treatment for my present and any future condition(s) for which I seek treatment.
PATIENT SIGNATURE
DATE
GUARDIAN SIGNATURE
DATE

INSURANCE INFORMATION:
PRIMARY
SECONDARY
INSURANCE NAME:
INS. ADDRESS:
INS. CITY/STATE/ZIP:
POLICY OR CLAIM NUMBER:
GROUP PHONE:
ADJUSTOR:
INSURED IF DIFF. FROM PT :
ADDRESS:
INSURED SOC SEC NUM: