Patient Information Form Initial Health Status (Chiropractic) - American Specialty Health Networks

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INITIAL HEALTH STATUS
American Specialty Health Networks (ASH Networks)
(Chiropractic) Fax: 877/427-4777
P.O. Box 509001, San Diego, CA 92150-9001
Patient Name:
Birthdate:
Sex: M / F
Address:
City:
State:
Zip:
Telephone:
Social Security #:
Driver Lic. #:
Occupation:
Employer:
Work Phone:
Address:
City:
State:
Zip:
Subscriber Name:
Health Plan:
Subscriber ID #:
Group #:
Spouse Name:
Spouse Employer:
City:
State:
Zip:
Primary Care Physician Name:
PCP Phone:
MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS.
DESCRIBE YOUR CURRENT PROBLEM AND HOW IT BEGAN:
Is this?
Work Related
Auto Related
N/A
DATE PROBLEM BEGAN:
Current complaint (how you feel today):
0
1
2
3
4
5
6
7
8
9
10
No Pain
Unbearable Pain
How often are your symptoms present?
0 – 25%
26 – 50%
51 – 75%
76 – 100%
Can you perform your daily activities?
Yes
No (Describe)
HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN?
No
Yes Date(s) taken:
WHAT AREAS WERE TAKEN?
Please check all of the following that apply to you:
None Apply
No Yes
Condition
No Yes
Condition
History of Recent Infection
Prostate Problems
Recent Fever
Frequent Urination
HIV/AIDS
Pregnancy, # of births
Diabetes
Abnormal Weight
Gain
Loss
Corticosteroid Use
Epilepsy/Seizures
Birth Control Pills
Visual Disturbances
High Blood Pressure
History of Low/Mid Back Pain
Stroke (date)
History of Neck Pain
Dizziness/Fainting
Arthritis
Numbness in Groin/Buttocks
History of Alcohol Use
Urinary Retention
History of Tobacco Use
Aortic Aneurysm
Surgeries/Medications:
Cancer/Tumor
Osteoporosis
Recent Trauma
Family History:
Cancer
Diabetes
High Blood Pressure
Cardiovascular Problems/Stroke
I certify that the above information is complete and accurate. If the health plan information is not accurate, or if I am
not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for
services rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or
health plan coverage in the future. I understand that my chiropractor or a clinical peer employed by ASH Networks
may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my
chiropractor and/or ASH Networks to contact my physician, if necessary.
Patient Signature:
Date:
ASH Networks Chiropractic Initial Health Status
10/24/2002-rf1

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