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Forms
Patient forms can be downloaded here for printing. Please use the
Instructions below while filling out the forms and bring the completed
forms to your office visit (or come 20 minutes early to fill out the
forms at the clinic).
Patient Forms in Adobe Acrobat format (pdf)
Patient Forms in Microsoft Word format (doc)
HIPPA Guidelines regarding Privacy Practices
Please read the Federal HIPPA guidelines regarding Privacy
Practices
(you must verify that you read them on the first form) .
HIPPA Guidelines in Adobe Acrobat format (pdf)
HIPPA Guidelines in Microsoft Word format (doc)
Instructions for Patient Forms
Acknowledgement of Receipt of Notice of Privacy Practices:
Please sign that you have received and read the HIPPA guidelines
regarding Privacy Practices.
Cancellation Policy:
Please read carefully and sign.
Intake Information:
Fill in appropriate information. Please note that the “insurance Policy
Number” is most often called the “subscriber ID number”, but not the
group number. In many cases it is the social security number of the
policyholder.
Pain diagram:
Use colored pencils corresponding to the type of pain you have (or
the corresponding letter) and draw it on the outline of the body. The
more detail the better.
Mark on the line at the bottom of the page, the intensity of your pain.
You may think of it like a scale of 0-10, 0 being no pain and 10 being
severe pain. If you have several different pains or the pain varies,
make several marks and note the difference. See Pain Diagram
examples for further explanation.
Pain Diagram Examples in Adobe Acrobat format (pdf)
Pain Diagram Examples in Microsoft Word format (doc)
Patient History:
Please list the reasons you are seeing the doctor.
In the Family History section, please mark whether your relative is
living or deceased, and what age they are or at what age they passed
away. List any illnesses they have or had. Also if they are deceased,
please note the cause if known.
In the General History section please circle any symptom that you are
experiencing or have experienced in the past.
Patient forms can be downloaded here for printing. Please use the
Instructions below while filling out the forms and bring the completed
forms to your office visit (or come 20 minutes early to fill out the
forms at the clinic).
Patient Forms in Adobe Acrobat format (pdf)
Patient Forms in Microsoft Word format (doc)
HIPPA Guidelines regarding Privacy Practices
Please read the Federal HIPPA guidelines regarding Privacy
Practices
(you must verify that you read them on the first form) .
HIPPA Guidelines in Adobe Acrobat format (pdf)
HIPPA Guidelines in Microsoft Word format (doc)
Instructions for Patient Forms
Acknowledgement of Receipt of Notice of Privacy Practices:
Please sign that you have received and read the HIPPA guidelines
regarding Privacy Practices.
Cancellation Policy:
Please read carefully and sign.
Intake Information:
Fill in appropriate information. Please note that the “insurance Policy
Number” is most often called the “subscriber ID number”, but not the
group number. In many cases it is the social security number of the
policyholder.
Pain diagram:
Use colored pencils corresponding to the type of pain you have (or
the corresponding letter) and draw it on the outline of the body. The
more detail the better.
Mark on the line at the bottom of the page, the intensity of your pain.
You may think of it like a scale of 0-10, 0 being no pain and 10 being
severe pain. If you have several different pains or the pain varies,
make several marks and note the difference. See Pain Diagram
examples for further explanation.
Pain Diagram Examples in Adobe Acrobat format (pdf)
Pain Diagram Examples in Microsoft Word format (doc)
Patient History:
Please list the reasons you are seeing the doctor.
In the Family History section, please mark whether your relative is
living or deceased, and what age they are or at what age they passed
away. List any illnesses they have or had. Also if they are deceased,
please note the cause if known.
In the General History section please circle any symptom that you are
experiencing or have experienced in the past.
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