Patient InformationToday's DatePrimary Care PhysicianFirst NameMiddle NameLast NameMarital StatusSingleMarriedDivorcedSeperatedWidowSignificant OtherIs this your legal name?YesNoIf not, what is your legal name?Former NameBirth DateAgeSexMaleFemaleStreet AddressCityState/ProvinceZIP / Postal CodeHome Phone #Social Security #Driver's License #Phone #OccupationEmployerEmployer Phone #Chose Clinic because | Referred to clinic by (chose one)FacebookTelevisionDinner SeminarEvent at your Work PlaceHealth FairNewspaperFormer PatientWebsiteWebinarReferralOtherIf you chose OtherIf you choose Referral, whom may we thank for referring you?EmailSpouse's NameEmergency ContactSpouse's EmployerResponsible Party (If different from Patient)NameSocial Security #Date of BirthAddressEmployerEmployer AddressPhone #Relationship to PatientEmployer Phone #InsuranceName of InsuredRelationship to PatientBirth DateSSNPolicy #Group #Insurance CompanyName of EmployerEmployer AddressEmployer Phone #Past Medical HistoryCheck all conditions that apply to youMeaslesMumpsChickenpoxWhooping CoughScarlet FeverDiphtheriaSmall PoxPneumoniaRheumatic FeverArthritisVeneral DiseaseAnemiaBladder InfectionEpilepsyMigraine HeadachesTuberclosisDiabetesCancerPolioGlaucomaHerniaBlood or Plasma TransfusionBack TroubleHigh Blood PressureLow Blood PressureHemorrhoidsAsthmaHives or EczemaAIDS or HIVInfectious MonoBronchitisMitral Valve ProlapseStrokeHepatitisUlcerKidney DiseaseThyroid DiseaseBleeding TendencyAny Other DiseaseAny other disease?Date of last Chest X-RayGynecologic HistoryAre you currently pregnant?YesNoPregnancies #Menstrual OnsetDurationLast Menstrual PeriodNatural Delivery or C-SectionDatesAre they regular?YNPain Associated?YNPlease list all the medications you are takingMedication Name 1DosageMedication Name 2DosageMedication Name 3DosageIf you are taking additional medications, please list them here.Signature of Patient, Parent or GuardianDateClinician ReviewedDateActivity LevelSelect one of the followingInactive : no regular physical activity with a sit down jobModerate Activity : Occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cyclingVigorous Activity : Participation in extensive physical exercise for at least 60 minutes per session, 4 or more times per weekLight Activity : no organized physical activity during leisureHeavy Activity : consisten lifting, stair climbing, heavy construction, etc or regular participation in jogging, swimming or cycling or active sports at least three times per weekChief ComplaintWhat problem are you seeing the doctor for? Specific Complaint: describe the pain at its worst, how often do you have the problem?Is it on the right or left side?RightLeftHow long have you had this problem, first time experienced the problem at any level?What treatment have you tried in the past?What activities have you given up due to the problem? How bad is it?How severe is the problem?12345678910Are you on any medications for the problem?Family HistoryPrevious Hospitalizations or SurgeriesDo you have a Sulfa Allergy?YesNoAllergies / Medication AllergiesFamily Medical HistoryMother AgeDiseaseIf Deceased, Cause of DeathFather AgeDiseaseIf Deceased, Cause of DeathSiblings AgeDiseaseIf Deceased, Cause of DeathSiblings AgeDiseaseIf Deceased, Cause of DeathChildren AgeDiseaseIf Deceased, Cause of DeathUse ofAlcoholNeverRareModerateDailyTobaccoNeverRareModerateDailyDrugsNeverRareModerateDailyExposure toFumesDustSolventsNoiseHobbies and ActivitiesExerciseFamilyGolfBoatingHikingReadingSportsChurch GroupsOtherOther HobbiesIndicate which of the following you have experienced in the last 1-2 months1 = Never, 2 = Rare, 3 = Occasionally, 4 = Frequency, 5 = ConsistentMuscle Aches12345Headaches12345Fatigue12345Fibromyalgia12345Migraines12345Weakness/Tiredness12345Arthritis12345Dizziness12345Lightheadedness12345Joint Pain12345Fogginess / Forgetful12345Constipation12345Diarrhea12345Medical HistoryAre you diabeticYesNoWhich TypeType 1Type 2Diagnosis DateLast HA1CHA1C dateLast Fasting Blood Sugar LevelBlood Sugar Test DateDo you have any implantable device?YesNoIf yes, Please listDo you have history of seizures?YesNoIf yes, Please listHistory of CellulitusYesNoAny current wounds, rashes or skin infection?YesNoIf yes, Please listSymptom surveyFoot PainLeftRightWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingHand PainLeftRightWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingKnee PainLeftRightWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingHip PainLeftRightWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingShoulder PainLeftRightWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingElbow PainLeftRightWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingWrist PainLeftRightWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingNeck PainYesNoWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingLow Back PainYesNoWhen did this pain start?Description (Please check the term(s) that relates to your symptomConstantDailyOn and offDullAcheBurningPressureSharpStabbingTightCrampingTinglingNumbRadiatingDeepSoreThrobbingHave you had any previous testing, workup, or imaging for the above selected conditions?YesNoLoss of Function or Paralysis?YesNoBowel/Bladder incontinence?YesNoSleep issues?YesNoMotor Weakness?YesNoIf Yes, then who did you see and what was done?Have you tried TENS therapy?YesNoDo you Stumble?YesNoFallen?YesNoDo you have to hold on to walls/furniture?YesNoFailed treatments:ASSIGNMENT OF BENEFITSAssignment of Benefits & Payment Responsibility to (Provider 1, Title), (Provider 2, Title), (Provider 3, Title), (Provider 4, Title) and Integrity Advanced Medical (referred to as "Providers")Legal Assignment of Insurance Benefits:In exchange for and in connection with any and all of the service(s) provided to me (“Services”) by Providers, I hereby irrevocably assign to Providers all of my rights, benefits, privileges, protections, claims, and any interests of any kind whatsoever, without limitation, including, but without limitation, direct payment to Providers for Services, appealing rights, rights to fiduciary duties, rights to sue, rights to payment, rights to pursue or interplead claims, rights to submit claims, and rights to information requests, and/or disclosures from any source, (collectively “Rights”) that I had, have or may have in the future pursuant to or in connection with any plan insurance plan, health benefit plan, trust, fund, or any other source of payment, insurance, indemnity or health/ or medical coverage of any kind (collectively “Health Care Arrangement”), such that in no event shall I have less Rights than those of the Rights under any Health Coverage to which I am or may become entitled. I hereby instruct any applicable insurance plan, health benefit plan, trust, fund, or any other source of payment, insurance, indemnity or health/medical coverage of any kind to please advise and disclose to Providers information regarding my benefits and all pertinent information and documentation related to my claims. I acknowledge that I am responsible for any deductibles, co-payments, and any and all non-covered service(s) as determined by my insurance company. I also acknowledge that it is my responsibility to know and understand my insurance benefits. I will be responsible for payment for any services or amounts not covered or paid by my insurance. I understand that I may be billed and held responsible by Providers for any such balances, including, but not limited to, any deductible, co-insurance, co-payments, or non-covered service(s). I further authorize Providers to file any claim on my behalf for Services rendered and assign to Providers all Rights to collect payments for Services. I understand that Providers may release my medical records to my insurance carrier(s) as necessary for the processing of claims. This Assignment of Benefits shall remain in effect until revoked by me in writing.Signature of Beneficiary/Participant/Parent/Legal Guardian:Printed Name of Beneficiary/Participant/Parent/Legal Guardian:DatePatient Consent for CommunicationWe have the ability to call or text you, reminding you of your appointments. If you would like to receive this feature in the future, please read the consent below and sign. Patients in our practice may be contacted via phone/text message to be reminded of an appointment, to obtain feedback on an experience within our office, and to provide general health reminders/information.I consent to receiving appointment reminders and other healthcare communications via telephone from Integrity Advanced MedicalI consent to receive text messages from Integrity Advanced Medical at my cell phone and any number forwarded or transferred to that number. The cell phone number that I authorize to receive text messages for appointment reminders, feedback and general health reminders/information is:CarrierI consent to emails, to receive communications as stated above. The email that I authorize to receive email messages for general health reminders/feedback/information is:I understand that this request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing.SignatureDatePatient Consent to TreatI hereby authorize the Doctor/Nurse Practitioner/Physician Assistant of Integrity Advanced Medical to treat my case as they deem appropriate through the use of lab testing, traction, durable medical equipment, rehabilitation, manual therapy, chiropractic manipulation of the spine, nutritional support, and diagnostic testing. I realize the goal of holistic health care is to strengthen the patient’s body in order to heal themselves. It is understood and agreed the amount paid to the clinic for X-rays is for interpretation and only the X-ray negatives will remain the property of this office, being on file. The patient also agrees that he/she is responsible for all bills incurred at this office.SignatureDateIntegrity Advanced MedicalHIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Our Notice of Privacy Practices provides information about how Integrity Advanced Medical may use and disclose your protected health information and when we need your written authorization to do so. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards. Name of PatientDate of Birth My AuthorizationI authorize:To use or disclose the following health informationAll of my health informationMy health information relating to the following treatment/conditionMy health information for the period of healthcare fromStart DateEnd DateOtherThe above party may disclose this health information to the following recipient:Email AddressPhoneFaxThe purpose of this authorization is (check all that apply):At my requestTo authorize the using or disclosing party to communicate with me for marketing purposes when they receive payment from a third party to do so.To authorize the using or disclosing party to sell my health information .I understand that the seller will receive compensation for my health. Integrity Advanced Medical information and will stop any future sales if I revoke this authorization.OtherThis authorization endsOn (Date):DateWhen I am no longer a patient of the practiceWhen the following event occurs:2. My Rights I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.Signature of Patient:DateIf the patient is a minor or unable to sign please complete the following:If the patient is a minor or unable to sign please complete the following:Patient is a minorPatient is unable to sign because:Authorized Representative SignatureDatePrint Name of RepresentativeAuthority of representative to sign on behalf of patientParentLegal GuardianCourt OrderOtherOther representativeII. Additional Consent for Certain Conditions This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.I consentI do not consentSignature of Patient or Authorized Representative:DateTimeIV. Additional Consent for HIV/AIDS This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.I consentI do not consentSignature of Patient or Authorized Representative:DateTimeV. Notice of Privacy Practices The signature below indicates that I have been provided with a copy of the Notice of Privacy Practices for the authorized party listed above and have read and understood its content.Signature of Patient or Authorized Representative:DateTime INTEGRITY ADVANCED MEDICAL Provider Statement of Patient/Client Rights and Responsibilities Rights: Patients/Clients have the right to be treated with dignity and respect. Patients/Clients have the right to fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment for care. Patients/Clients have the right to have their treatment and other patient information kept private. Only by law may records be released without patient permission. Patients/Clients have the right to access care easily and in a timely fashion. Patients/Clients have the right to a candid discussion about all their treatment choices, regardless of cost or coverage by their benefit plan. Patients/Clients have the right to share in developing their plan of care. Patients/Clients have the right to the delivery of services in a culturally competent manner. Patients/Clients have the right to information about the organization, its providers, services, and role in the treatment process. Patients/Clients have the right to information about provider work history and training. Patients/Clients have the right to information about clinical guidelines used in providing and managing their care. Patients/Clients have a right to know about advocacy and community groups and prevention services. Patients/Clients have a right to freely file a complaint, grievance, or appeal, and to learn how to do so. Patients/Clients have the right to know about laws that relate to their rights and responsibilities. Patients/Clients have the right to know of their rights and responsibilities in the treatment process, and to make recommendations regarding the organization’s rights and responsibilities policy. Responsibilities: Patients/Clients have the responsibility to treat those giving them care with dignity and respect. Patients/Clients have the responsibility to give providers the information they need, in order to provide the best possible care. Patients/Clients have the responsibility to ask their providers questions about their care. Patients/Clients have the responsibility to help develop and follow the agreed-upon treatment plans for their care, including the agreed-upon medication plan. Patients/Clients have the responsibility to let their provider know when the treatment plan no longer works for them. Patients/Clients have the responsibility to tell their provider about medication changes, including medications given to them by others. Patients/Clients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits. Patients/Clients have the responsibility to let their provider know about their insurance coverage, and any changes to it. Patients/Clients have the responsibility to let their provider know about problems with paying fees. Patients/Clients have the responsibility not to take actions that could harm others. Patients/Clients have the responsibility to report fraud and abuse. Patients/Clients have the responsibility to openly report concerns about quality of care. Patients/Clients have the responsibility to let their provider know about any changes to their contact information (name, address, phone, etc). Patients/Clients have the right and the responsibility to understand and help develop plans and goals to improve their health. I have read and understood my rights and responsibilities.Patient Signature:DateSubmit
