FORMS – Axis Chiropractic

Patient Summary Form PSF-730 (Rev: 7/1/2015)

First Name

Last Name

Gender

Male Female

Patient date of birth

Patient address

State

City

Zip code

Patient Insurance ID#

Health plan

Group number

Referring physician (if applicable)

Date referral issued (if applicable)

Referral number (if applicable)

Provider Completes This Section:

Date referral issued (if applicable)

Patient Type

New to your office Est'd, new episode Est'd, new injury Est'd, continuing care

Date of Surgery

Diagnosis (ICD codes)

1 ⁰

2 ⁰

3 ⁰

4 ⁰

Patient Completes This Section:

Symptoms began on:

Indicate where you have pain or other symptoms:

Mark Carefully On Image

1. Briefly describe your symptoms:

2. How did your symptoms start?

Average Pain Intensity

4. How often do you experience your symptoms?

Constantly (76%-100% of the time) Intermittently (0%-25% of the time) Frequently (51%-75% of the time) Occasionally (26% - 50% of the time)

5. How much have your symptoms interfered with your usual daily activities? (Including both work outside the home and housework)

Back Index

Pain Intensity

The pain comes and goes and is very mild. The pain comes and goes and is moderate. The pain is very severe and does not vary much. The pain is mild and does not vary much. The pain comes and goes and is very severe.

Sleeping

I get no pain in bed. I get pain in bed but it does not prevent me from sleeping well. Because of pain my normal sleep is reduced by less than 25%. Because of pain my normal sleep is reduced by less than 50%. Because of pain my normal sleep is reduced by less than 75%. Pain prevents me from sleeping at all.

Sitting

I can sit in my chair as long as I like. Pain prevents me from sitting more than 1 hour. Pain prevents me from sitting more than 10 minutes. I can only sit in my favorite chair as long as I like. Pain prevents me from sitting more than 1/2 hour. I avoid sitting because it increases pain immediately.

Standing

I can stand as long as I want without pain. I have some pain while standing but it does not increase with time. I cannot stand for longer than 1 hour without increasing pain. I cannot stand for longer than 1/2 hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing because it increases pain immediately.

Walking

I have no pain while walking. I have some pain while walking but it doesn't increase with distance. I cannot walk more than 1 mile without increasing pain. I cannot walk more than 1/2 mile without increasing pain. I cannot walk more than 1/4 mile without increasing pain. I cannot walk at all without increasing pain.

Personal Care

I do not have to change my way of washing or dressing in order to avoid pain. I do not normally change my way of washing or dressing, even though it causes some pain. Washing and dressing increases the pain and I find it necessary to change my way of doing it. Because of the pain, I am unable to do some washing and dressing without help. Because of the pain, I am unable to do any washing and dressing without help.

Lifting

I can lift heavy weights without extra pain. I can lift heavy weights but it causes extra pain. Pain prevents me from lifting heavy weights off the floor. Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., ona table). Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned I can only lift very light weights.

Traveling

I get no pain while traveling. I get some pain while traveling but none of my usual forms of travel make it worse. I get extra pain while traveling but it does not cause me to seek alternate forms of travel. I get extra pain while traveling which causes me to seek alternate forms of travel. Pain restricts all forms of travel except that done while lying down. Pain restricts all forms of travel.

Social Life

My social life is normal and gives me no extra pain. My social life is normal but increases the degree of pain. Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, etc). Pain has restricted my social life and I do not go out very often. Pain has restricted my social life to my home. I have hardly any social life because of the pain.

Changing Degree of Pain

My pain is rapidly getting better. My pain seems to be getting better, but improvement is slow. My pain is gradually worsening. My pain fluctuates, but overall is definitely getting better. My pain is neither getting better nor worse. My pain is rapidly worsening.

Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100

The Keele STarT Back Screening Tool

Thinking about the last 2 weeks tick your response to the following questions:

1. Has your back pain spread down your leg(s) at some time in the last 2 weeks?

No-0 Yes-1

2. Have you had pain in the shoulder or neck at some time in the last 2 weeks?

No-0 Yes-1

3. Have you only walked short distances because of your back pain?

No-0 Yes-1

4. In the last 2 weeks, have you dressed more slowly than usual because of back pain?

No-0 Yes-1

5. Do you think it's not really safe for a person with a condition like yours to be physically active?

No-0 Yes-1

6. Have worrying thoughts been going through your mind a lot of the time?

No-0 Yes-1

7. Do you feel that your back pain is terrible and it's never going to get any better?

No-0 Yes-1

8. In general have you stopped enjoying all the things you usually enjoy?

No-0 Yes-1

9.Overall, how bothersome has your back pain been in the last 2 weeks?

Sub Score (Q5-9)

Welcome to Axis Chiropractic!

Please fill out the following information as completely and accurately as possible. Thank you!

About You

First Name

Last Name

Cell Phone

Birthday

Marital Status

Minor Single Married Other

Gender

Male Female Other

Type of Work

Street Address

City

Zip Code

State

Emergency Contact Information

First Name

Last Name

Home Phone

Work Phone

Relationship

About the Insured

(leave blank if self insured)

First Name

Last Name

Date of Birth

What Brings You To Our Office

Primary Complaint(s) and please explain:

When did this condition begin?

Has this condition

Gotten worse Comes and goes Stayed Constant

Has this condition occurred before?

Yes No

Overall frequency of complaint ( choose one)

Constant—100% of the time Frequent - 75% Intermittent - 50% Occasional - 25%

Describe the Pain or Sensation:

Minimal (An annoyance but has no effect on activity) Slight (Tolerable with some impairment to activity) Moderate (Tolerable with marked impairment of activity) Severe (Intolerable and cannot perform any activities)

What aggravates the problem?

What relieves the problem?

Have you seen other Health Care Providers for this condition?

DC MD PT Other

Type of Treatment and Did It Help?

If this problem went without being taken addressed, how do you think it would affect you?

Place an X where you notice symptoms and rate it 1-10

Mark Carefully On Image

Health Habits & Systems Review

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Do you drink coffee?

Yes No

What Type of Care Are You Looking For?

Just Address My Symptoms Correct the Underlying Issue

Please list any vitamin supplements you are currently taking

ACKNOWLEDGEMENTS

By Signing and Dating below, you are acknowledging the following:

1. I instruct the doctor to deliver the care that, in his professional opinion, can best help me in the restoration of my health. I also understand that the chiropractic care offered in this practice is based on the best available evidence and is designed to reduce or correct a subluxation/neurostructural obstruction. Chiropractic is a separate and distinct profession from medicine and does not claim to cure or treat any named disease or entity.
2. I may request a copy of the PRIVACY POLICY and understand it describes how my personal health information protected and released on my behalf for seeking reimbursement from third parties.
3. I grant permission to be called to confirm or reschedule an appointment and to be sent occasional cards, letters, emails, texts, or health information.
4. I realize that an X-Ray examination may be hazardous to an unborn child and I certify (by signing below) to the best of my knowledge that I am not pregnant
5. I acknowledge that any insurance I have is an agreement between the carrier and me and that I am responsible for the payment of any covered or non-covered services at Axis Chiropractic.
6. It is the practice of this office to provide chiropractic care in an "open adjusting" environment. "Open adjusting" involves multiple office visits at one time in a semi-open adjusting format. Patients are within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. Personal health information will not be discussed. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations or presenting a report of findings--these procedures are completed in a private, confidential setting. Your signature below acknowledges approval of this activity.
7. To the best of my ability, the information I have supplied is complete and truthful. I have not misrepresented the presence, severity or cause of my health concern, and I understand that this office reserves the right to dismiss me as a patient for misrepresentation, lack of payment, or failure to follow the recommended care plan.

**Parents and/or Guardians: Sign Your Name in the "Signature Box" and put the Minor's Name In the "Print Name" Box

Name Signature

Signature Date

Printed Name

Let us get started filling out this form.

I understand this is a legal agreement and intend to sign,
I also agree to sign this agreement electronically. Terms of consent

Forms for Axis Chiropractic

Patient Summary Form PSF-730 (Rev: 7/1/2015)

Provider Completes This Section:

Patient Completes This Section:

Mark Carefully On Image

Average Pain Intensity

Back Index

The Keele STarT Back Screening Tool

Welcome to Axis Chiropractic!

What Brings You To Our Office

Mark Carefully On Image

Health Habits & Systems Review

ACKNOWLEDGEMENTS

**Parents and/or Guardians: Sign Your Name in the "Signature Box" and put the Minor's Name In the "Print Name" Box

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