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Welcome to Midway Chiropractic!

New Patient Form Rev

2017

23100 Pacific Hwy S Ste 201 Des Moines WA 98198

206-824-9500 / Fax 206-824-9654

Your path to wellness begins now! Please complete this packet as best as you can. If you have any questions please let the staff know.

Last Name: First: Name you go by: Middle Initial:

Street Address: ZIP: City: State:

Other Phone: Contact Phone: Email:

Sex: SSN: Birthdate:

Today’s Date:_________________

How did you find out about us?

Billing Information

Payment must be made at time of service. We accept cash, debit, credit, and personal checks.

□ I’m a returning patient (Welcome back!) and I’m updating my information

□Doctor:___________________ □Family/Friend:_____________________ □Insurance Directory □Internet □Other:__________________

Marital Status:

□Single □Married □Divorced □Widowed

Please provide the front staff with your insurance card and driver’s license.

It is our clinic policy to retain all private health insurance information regardless of claim type.

Please select one or more options below:

□ I have health insurance. / □ I don’t have health insurance.

□ I was in an auto accident.

□ I was injured at work

Do you have car insurance? □ Yes □ No

Was someone else at fault? □ Yes □ No

Name of other person:_____________________________________

Name of other person’s car insurance:__________________________Claim#:_______________________

Name and number of representative for other company:________________________________________________________________

Do you already have a claim? □ Yes □ No

Phone/Fax: Name of employer / school: I work / go to school: □Full time □Part time

Do you have an attorney? □ Yes □ No

Law office Name:__________________________Phone#:______________________________Fax#:___________________________

My Attorney’s Name:__________________________________________________________

Contact Phone: Relation to you: Emergency Contact Name:

Date of Accident:___/___/_________

Name of your car insurance company:___________________________________

Claim#:______________________Name and number of representative:______________________________________

Date of Injury:___/___/_________

Claim#:_______________Claims Manager Name and number:______________________________________

Attending Physican Name:_____________________________________________________

When a patient seeks chiropractic health care and we accept a patient for such care, it is

essential for both to be working for the same objective. It is important that each patient

understand both the objective and the method that will be used to attain it. This will prevent any

confusion or disappointment. You have the right, as a patient, to be informed about the

condition of your health and the recommended care and treatment to be provided so that you

may make the decision whether or not to undergo chiropractic care after being advised of the

known benefits, risks and alternatives.

Chiropractic is a science and art which concerns itself with the relationship between

structure (primarily the spine) and function (primarily the nervous system) as that relationship

may effect the restoration and preservation of health. Health is a state of optimal physical,

mental and social well-being, not merely the absence of disease or infirmity.

One disturbance to the nervous system is called a vertebral subluxation. This occurs

when one or more of the 24 vertebrae in the spinal column become misaligned and/or do not

move properly. This causes alteration of nerve function and interference to the nervous system.

This may result in pain and dysfunction or may be entirely asymptomatic.

Subluxations are corrected and/or reduced by an adjustment. An adjustment is the

specific application of forces to correct and/or reduce vertebral subluxation. Our chiropractic

method of correction is by specific adjustments of the spine. Adjustments are usually done by

hand but may be performed by handheld instruments. In addition, ancillary procedures such as

physiotherapy and/or rehabilitative procedures may be included.

I understand the massage given here is for the purpose of relief from muscular tensions

or spasm, and for increasing circulation. I understand the massage practitioner does not diagnose

illness, disease, or other physical or mental disorder. As such, the therapist does not prescribe

medical treatment or pharmaceuticals, nor perform spinal manipulations. I understand massage

is not a substitute for medical examinations and diagnosis, and that it is recommended to see a

physician for any physical ailment I may have. Because a massage practitioner must be aware of

existing conditions, I have stated all of my known medical conditions and take it upon myself to

keep the practitioner updated on my physical, mental, and emotional health.

If during the course of care we encounter non-chiropractic or unusual findings, we will

advise you of those findings and recommend that you seek the services of another health care

provider.

I have read and fully understand the above statements and therefore accept chiropractic

care on this basis. I agree that financial responsibility for my treatment is ultimately my own.

I agree that a fee may be charged if I cancel my appointment less than 24 hours

before it begins.

Informed Consent

Consent to evaluate and adjust a minor child:

I, the above signed, being the parent or legal guardian of ______________________________ have read and fully

understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care.

Patient / Guardian Signature:________________________________________

Printed Name:________________________________________

Date:________________________________________

Health History Please answer the following questions to help us better evaluate your condition for the best healthcare possible.

Have you ever been treated by a chiropractor before? YES NO

If yes how long ago and why?

Do you know what may have caused today’s pain? (Brief Summary, please include estimated dates if possible)

Have you seen any other medical provider for this condition? YES NO

If yes, please list

Did the above listed providers help improve your condition? (Brief Explanation of your experience)

Please list all the medications or supplements, that you are currently taking, as well as any you have taken in the recent past.

Please list any other medical conditions you suffer, or have suffered from in the past.

If you have had any surgeries or major medical treatments, please list them here with approximate dates.

Have you ever had any serious injuries? Please list them with approximate dates.

Are you currently wearing any kind of foot support? (Heel lifts, Arch Supports, etc.) YES / NO

Women - Are you pregnant? YES NO If yes, how long?_________ Nursing? YES NO Are you taking oral contraceptives? YES NO

Do you exercise regularly or participate in any sports? YES NO

Have you ever had a professional massage? YES NO

Have you ever had any of the following medical conditions?

Signature:_______________________________________________ Date:_____________________________

Name:_______________________________________

Pain/Discomfort Rating Scale

Please choose the number which best describes your pain in each of the questions below

What is your pain/discomfort RIGHT NOW? (0= No Pain 10= Unbearable Pain)

What is your pain/discomfort TYPICAL OR AVERAGE?

What is your pain/discomfort AT ITS WORST?

HEADACHE 0 1 2 3 4 5 6 7 8 9 10 NECK 0 1 2 3 4 5 6 7 8 9 10 UPPER BACK 0 1 2 3 4 5 6 7 8 9 10 LOW BACK 0 1 2 3 4 5 6 7 8 9 10

PAIN DISABILITY INDEX QUESTIONNAIRE

PLEASE USE THE LETTERS BELOW TO MARK THE AREAS IN WHICH YOU FEEL THE CORRESPONDING SENSATIONS.

A = ACHE B = BURNING

S = STABBING P = PINS/NEEDLES

O = OTHER N = NUMBNESS

COLOR IN AREAS TO INDICATE BRUISING



Name:_______________________________________

PATIENT SIGNATURE:____________________________________________ DATE:_______________________

DOCTOR SIGNATURE:____________________________________________

PATIENT-SPECIFIC FUNCTIONAL SCALE

NAME:________________________________________________

We want to know what 3 activities in your life you are unable to perform, or are having the most

difficulty performing, as a result of your chief problem.

0 1 2 3 4 5 6 7 8 9 10

In the 3 boxes below marked “Activity”, write down 3 different activities that are being affected by

your problem. You can choose any activity you like, such as running, using the computer, washing the dishes,

lifting your children, or even simply sitting.

ACTIVITY 1 SCORE

ACTIVITY 2 SCORE

ACTIVITY 3 SCORE

After you’ve listed your activities, now it’s time to score them. Look at the number scale below. On

this scale, 0 means that you can’t do your activity at all, for example you can’t sit because of your problem.

10 would mean that you can sit normally, like before your problem started. Using the scale, write a number

to the right of each activity above. After you finish, sign your name at the bottom of this form and you’re

done!

Unable to

Perform Activity

Able to Perform Activity At Same

Level As Before Injury/Problem

IMPORTANT: PLEASE READ THIS FORM CAREFULLY. IT MUST BE COMPLETED

BEFORE YOU CAN BEGIN/CONTINUE TREATMENT.



10 MEANS YOU ARE PERFECTLY FINE AND 0 MEANS YOU CAN’T DO IT!!!

Neck Index

Patient Name:_____________________________________________________

This questionnaire will give your provider information about how your neck condition affects your everyday life. Please

answer every section by marking the one statement that applies to you. If two or more statements in one section apply,

please mark the one statement that most closely describes your problem.

Pain Intensity

Sleeping

Reading

Personal Care

Concentration

Work

Lifting

Driving

Recreation

Headaches

□ I can look after myself normally without causing extra pain. □ I can look after myself normally but it causes extra pain. □ It is painful to look after myself and I am slow and careful. □ I need some help but I manage most of my personal care. □ I need help every day in most aspects of self care. □ I do not get dressed, I wash with difficulty and stay in bed.

□ I have no pain at the moment. □ The pain is very mild at the moment. □ The pain comes and goes and is moderate. □ The pain is fairly severe at the moment. □ The pain is very severe at the moment. □ The pain is the worst imaginable at the moment.

□ I have no trouble sleeping. □ My sleep is slightly disturbed (less than 1 hour sleepless). □ My sleep is mildly disturbed (1-2 hours sleepless). □ My sleep is moderately disturbed (2-3 hours sleepless). □ My sleep is greatly disturbed (3-5 hours sleepless). □ My sleep is completely disturbed (5-7 hours sleepless).

□ 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, but I can manage if they are con-veniently positioned (e.g., on a 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. □ I cannot lift or carry anything at all.

□ I can read as much as I want with no neck pain. □ I can read as much as I want with slight neck pain. □ I can read as much as I want with moderate neck pain. □ I cannot read as much as I want because of moderate neck pain. □ I can hardly read at all because of severe neck pain. □ I cannot read at all because of neck pain.

□ I can concentrate fully when I want with no difficulty. □ I can concentrate fully when I want with slight difficulty. □ I have a fair degree of difficulty concentrating when I want. □ I have a lot of difficulty concentrating when I want. □ I have a great deal of difficulty concentrating when I want. □ I cannot concentrate at all.

□ I can drive my car without any neck pain. □ I can drive my car as long as I want with slight neck pain. □ I can drive my car as long as I want with moderate neck pain. □ I cannot drive my car as long as I want because of moderate neck pain. □ I can hardly drive at all because of severe neck pain. □ I cannot drive my car at all because of neck pain.

□ I am able to engage in all my recreation activities without neck pain. □ I am able to engage in all my usual recreation activities with some neck pain. □ I am able to engage in most but not all my usual recreation activities because of neck pain. □ I am only able to engage in a few of my usual recreation activities because of neck pain. □ I can hardly do any recreation activities because of neck pain. □ I cannot do any recreation activities at all.

□ I can do as much work as I want. □ I can only do my usual work but no more. □ I can only do most of my usual work but no more. □ I cannot do my usual work. □ I can hardly do any work at all. □ I cannot do any work at all.

□ I have no headaches at all. □ I have slight headaches which come infrequently. □ I have moderate headaches which come infrequently. □ I have moderate headaches which come frequently. □ I have severe headaches which come frequently. □ I have headaches almost all the time.



Low Back Index (Oswestry) Patient Name:_____________________________________________________

This questionnaire will give your provider information about how your back condition affects your everyday life. Please

answer every section by marking the one statement that applies to you. If two or more statements in one section apply,

please mark the one statement that most closely describes your problem.



Pain Intensity

Lifting

Standing

Walking

Sitting

Sleeping

Sex life (If applicable)

□ I can stand as long as I want without increased pain. □ I can stand as long as I want but my pain increases with time. □ Pain prevents me from standing more than 1 hour. □ Pain prevents me from standing more than 1/2 hour. □ Pain prevents me from standing more than 10 minutes. □ Pain prevents me from standing at all.

□ I have no pain at the moment. □ The pain is very mild at the moment. □ The pain is moderate at the moment. □ The pain is fairly severe at the moment. □ The pain is very severe at the moment. □ The pain is the worst imaginable at the moment.

Personal Care (Washing, Dressing, ect.) □ I can look after myself normally without causing extra pain. □ I can look after myself normally but it causes extra pain. □ It is painful to look after myself and I am slow and careful. □ I need some help but manage most of my personal care. □ I need help every day in most aspects of personal care. □ I do not get dressed, I wash with difficulty, and I stay in bed.

□ My sleep is not disturbed by pain. □ My sleep is occasionally disturbed by pain. □ Because of my pain, my sleep is only 3/4 of my normal amount. □ Because of my pain, my sleep is only 1/4 of my normal amount. □ Because of my pain, my sleep is only 1/2 of my normal amount. □ Pain prevents me from sleeping at all.

□ I can lift heavy weights without increased pain. □ I can lift heavy weights but it causes increased pain. □ Pain prevents me from lifting heavy weights off of the floor, but I can manage if they are conveniently positioned (e.g. on a table). □ Pain prevents me from lifting heavy weights off of the floor, but I can manage light to medium weights if they are conveniently positioned. □ I can lift only very light weights. □ I cannot lift or carry anything at all.

Social life

□ Pain does not prevent me walking any distance. □ Pain prevents me from walking more than 1 mile. □ Pain prevents me from walking more than 1/2 mile. □ Pain prevents me from walking more than 100 yards. □ I can only walk using a stick or crutches. □ I am in bed most of the time and have to crawl to the toilet.

□ My social life is normal and does not increase my pain. □ My social life is normal, but it increases my level of pain. □ Pain has no significant effect on my social life, but prevents me from participating in more energetic activities (e.g. sports, dancing). □ Pain has restricted my social life and prevents me from going out very often. □ Pain has restricted my social life to my home. □ I have no social life because of pain.

□ I get no increased pain when traveling. □ I get some pain while traveling, but none of my usual forms of travel make it any worse. □ I get increased pain while traveling, but it does not cause me to seek alternative forms of

travel. □ I get increased pain while traveling, which causes me to seek alternative forms of travel. □ My pain restricts all forms of travel except that which is done while I am laying down. □ My pain restricts all forms of travel.

□ I can sit in any chair as long as I like. □ I can sit in my favorite chair as long as I like. □ Pain prevents me from sitting for more than 1 hour. □ Pain prevents me from sitting more than 1/2 hour. □ Pain prevents me from sitting more than 10 minutes. □ Pain prevents me from sitting at all.

□ My sex life is normal and does not increase my pain. □ My sex life is normal, but it increases my level of pain. □ My sex life is nearly normal, but is very painful. □ My sex life is severely restricted by pain. □ My sex life is nearly absent because of pain. □ Pain prevents any sex life at all.

Traveling

Statement of Privacy Practices

Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health in-formation is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights. We are required by federal law to include this notice.

PROTECTING YOUR PERSONAL HEALTHCARE INFORMATION

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our chiropractic care operations. Your personal health information will never be otherwise given to anyone- even family members- without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our office and electronic systems are secure from unau-thorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

COLLECTING PROTECTED HEALTH INFORMATION (PHI)

We will only request personal information needed to provide our standard of quality chi-ropractic care, Implement payment activities, conduct normal chiropractic practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the in-formation will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protect-ed to the full extent of the law.

DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION

PATIENT RIGHTS

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstanc-es. We will not use our information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your ap-pointments including voicemail messages, answering machines, and postcards.

You have a right to request copies of your health care information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies the amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. We thank you for being a patient here. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

MIDWAY CHIROPRACTIC

SIGNATURE:_________________________________________________

DATE:________________________

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