Tackett New Patient Form Date______

Name (First, Middle, Last)

Address (Street, City, State, Zip)

Cell (____) - _____ - _____ Home (____) - _____ - ______Work (____) - _____ - ______

E-mail ______Sex M _ _ F

Birth Date ______/______/______Age ______S.S. # ______-______-______

Marital Status ______Smoking Status ______

Occupation______

Employer/School______

Address/Phone ______

Primary Care Provider______

Address/Phone ______

Spouse’s Name/Phone______

IN CASE OF AN EMERGENCY, CONTACT: Name Number______

Electronic Health Records Intake Form (IN COMPLIANCE WITH REQ. FOR THE GOV. EHR INCENTIVE PROGRAM)

Preferred method of contact: Text / E- mail/ Phone

Preferred Language ______

Race ______

Ethnicity: Hispanic or Latino / Not Hispanic or Latino / Decline to Ans.

Height ______Weight ______Blood Pressure ______/______

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Patient Condition

Please (X) to indicate if you have had any of the following: Chief Complaint: ▢ Pain ▢Mid Back Pain ▢Low Back Pain ▢Arm Pain R / L Shoulder ▢Leg Pain L / R ▢Other______

Mode of Onset: ▢Overexertion ▢Strenuous Position ▢Fall ▢Slip ▢Gradual ▢Stress ▢W/C ▢Woke up with it ▢Accident: Auto - Motorcycle - Bicycle ▢Other ______

Date of Onset: ______Previous Care: ______

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) ______

Duration: ▢Intermittent (25%) ▢Occasional (25-50%) ▢Frequent (50-75%) ▢Constant (75-100%)

Relation to other body systems: ▢Bowel ▢Bladder ▢Muscle weakness ▢No relation ▢Other______

Relieving Factors: ▢Rest ▢Lying ▢Sitting ▢Standing ▢Hot or Cold Packs ▢Exercise ▢Taping ▢Nothing Helps ▢Adjustments

Aggravating Factors: ▢Working ▢Lifting ▢Bending ▢Pushing ▢Pulling ▢Coughing ▢Sneezing ▢Driving ▢ Riding ▢Sitting ▢Walking ▢Running ▢Standing ▢Laying down ▢Walking ▢Other______

Type of pain / Where on the body? ▢ Tingling ▢ Numbness ▢ Cramps ▢ Dull ▢ Stiffness ▢ Aching ▢ Shooting ▢ Burning ▢ Throbbing ▢ Swelling ▢ Sharp ▢ Other______

FOR DOCTORS USE ONLY S13.4XXD - sprain of ligaments of c-spine , S23.3XXD - sprain of ligaments of thoracic S33.5XXD - sprain of ligaments of lumbar M51.26 - other invert. disc displacement, lumbar region M50.30 - cervical disc degeneration, unspecified M51.36 - disc degeneration, lumbar region M53.0 - cervicocranial M53.1 - cervicobrachial syndrome M54.08 - panniculitis aff. regions of neck and back sacral and sacrococcygeal region M54.12 - radiculopathy, cervical region M48.00 - , site unspecified M60.9 - myositis, unspecified M99.01 - segmental & somatic dysfunction of cervical M99.02 - segmental & somatic dysfunction of thoracic M99.03 - segmental & somatic dysfunction of lumbar M53.3 - Sciatica Front Back

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Are you pregnant? No ______Yes ______Due Date ______

Current medications? (Amount / Frequency )

Any allergies? ▢ yes ▢ no (If yes, please explain)

Any diagnostic testing? ▢ X-Ray ▢ CT ▢ MRI ▢ Other ______

Please (X) to indicate if you have had any of the following: ▢ Arthritis ▢ Upper Back Probs ▢ Muscle Tightness ▢ Sciatica ▢ Diabetes ▢ AIDS/HIV ▢ Dizziness ▢ Asthma ▢ Trouble Sleeping ▢ Migraines ▢ Back Curvature ▢ Heart Attack ▢ Allergies ▢ Heart ▢ Epilepsy ▢ Bruise Easily ▢ Low Blood Pressure ▢ Cancer ▢ STD ▢Tuberculosis ▢ Alcoholism ▢ Stroke ▢ Depression ▢ ▢ ADD/ADHD ▢ Kidney Probs ▢ Anemia ▢ Pinched Nerve ▢ Anxiety ▢ Shoulder Pain ▢ Thyroid Prob ▢ Hepatitis ▢ Mid Back pain ▢ Other ______

Any major / ? ▢ yes ▢ no (If yes, what body part and when?)

Were you referred here? ▢ yes ▢no (If yes, who may we thank?)

Patient Signature: Date: ______

3 Tackett Chiropractic Center 19 Homer Ave Queensbury, NY 12804

ABN Period Covering; January 1, 2020 to December 31, 2020

I understand that I may be financially responsible for any charges incurred at this office, including co-pays, deductibles, and charges denied or not covered by my insurance company. I realize my care may be subject to pre-certification by the insurance company, and I accept any responsibility for charges which may not be approved. The insurance company will review any/all documentation submitted by Tackett Chiropractic for review for medical necessity and base their approval/denial upon this documentation. I understand that this office agrees to notify me as soon as possible if service is not covered and will notify me if my care is not covered by my insurance company. If a treatment plan is approved, this office will make me aware of the number of office visits allowed at the time frame of the certification. Initial visits may be denied, and this may be beyond the offices ability to notify the patient prior to rendering acute care, while waiting for insurance coverage approval. These charges will be the patient’s responsibility if denied by the insurance company. This office may seek payment from you for any services your health insurance plan determines to be not medically necessary. I have read and understand my obligations for payment for care in the absence of insurance coverage.

Patient Name______Date______

Patient Signature______Staff Signature______

Relationship to patient if other than self______

4 Tackett Chiropractic Center 19 Homer Ave Queensbury, NY 12804

Patient Consent Form (H.I.P.A.A)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (H.I.P.A.A). I understand that by signing this consent; I authorize Tackett Chiropractic Center to use and disclose my protected health information to carry out;

• Treatment (including direct or indirect by others healthcare providers involved in my treatment)

• Obtaining payment from third party payers (e.g.) we will check your insurance policy regarding benefits, claims, and authorizations online or by telephone.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under H.I.P.A.A. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Tackett Chiropractic Center at any time to obtain the most recent copy of this notice. I understand that i have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and obtaining insurance information online or my telephone from the insurance companies and health care operations. I understand that Tackett Chiropractic Center is not required to agree to these requested restrictions. However if you do agree, you are then bound to comply with the restrictions.

Patient Name______Date______

Patient Signature______Staff Signature______

Relationship to patient if other than self______

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