Danske Technical Update

Welcome to IMC
Please fill out this form as completely as you can. If you have any questions we'll be glad to assist you.
We look forward to working with you in maintaining your health.
Patient
Information
Name
_
(First Name)
(Last Name)
Address
City/State/Zip
Home Phone
Sex:
0- M
Cell #
~ F Age
_
Work #
.DOB
_
,~ Single ~ Married ~ Divorced ~ Widowed
Patient Employed By
Occupation.
Email Address
_
Referred By
NOTIFY IN CASE OF EMERGENCYIRELEASE
OF LIABILITY:
_
(Nanle and phone # of 2 people)
1.
Phone#
_
2.
Phone#
_
Reason For Visit
Your reason for this visit:
_
Have you ever seen a physician for this problem? If yes, when?
_
Physician's Name
_
Describe your pain and location:
Date symptoms began:
_
Have you had similar conditions in the past?
Activities that are difficult/painful to perform: ~ Sitting
Type of pain:
~ Sharp
~ Tingling
L1 Dull
~ Throbbing
~ Cramping
~ Walking
~ Aching
~ Stiffness
~
Bending
~ Burning
~ Swelling Other:
~--
~ Lifting
~ Numbness
_
Please list any serious injuries or surgeries you have had in the last 10 years:
Description
Falls
_
Broken Bones
_
Dislocations
_
Surgeries
_
Other injuries:
Date
_
Medical Conditions
t:,.Heart Attack/Stroke
t:,.Congenital Heart Defect
t:,.Alcohol/Drug Abuse
t:,.Fainting/Seizures/Epilepsy
t:,.Shingles
t:,.Psychiatric Problems
t:,.Difficulty Breathing
t:,.Anemia
t:,.Arthritis
t:,.Frequent Neck Pain
t:,.Jaw Pain
t:,.Wrist Pain
t:,.Shoulder Pain
t:,.Arm Pain
t:,.Leg Pain
t:,.Low Back Problems
t:,.Ringing in ears
t:,.Frequent Headaches
t:,.Diabetes/Tuberculosis
t:,.Dizziness
t:,.Emphysema/Glaucoma
t:,.Kidney Problems
t:,.Artificial Bones/Joints
t:,.Severe/Frequent Earaches
t:,.Ulcer/Colitis
t:,.Gout
t:,.Numbness
t:,.Tingling
t:,.Muscle Spasms
t:,.Hepatitis
t:,.Cancer
t:,.HIV/AIDS
Personal Habits
HEAVY
MODERATE
LIGHT
NONE
Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Authorization
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I
understand that this information will be used by the Healthcare Provider to help determine appropriate
and healthful treatment. If there is any change in medical status, I will inform the Healthcare Provider.
Initial.
-'I have read the Privacy Practices Notice. IMC will call and remind me of my appointments.
NOT like a reminder call, I will inform you in writing.
Initial
-'-
I understand that [Me has a 24-hour cancellation
and I may be billed for any missed appointment.
Signed:
Date:
Payment is due in full at time of treatment.
If I would
policy
_
IMC, LLC
315 Magnolia Avenue
Fairhope, AL 36532
INFORMED CONSENT
As a patient of IMC, I give the physicians and staff the authority to treat me in accordance
with tests, diagnosis and analysis. The clinical procedures listed below are, in most cases,
beneficial and rarely cause problems or injury. In these rare cases, problem or injury may
be due to underlying physical defects, deformities, illnesses and/or pathologies. As a
patient, I understand it is my responsibility to make such conditions, which would not
otherwise be discovered or obvious, known to the physicians prior to treatment. I
understand that by being accepted as a patient, I am authorizing IMC to proceed with any
treatment that may be deemed necessary. I also understand that I have the right to have
any questions about treatments or procedures fully explained to me.
Modalities that may be used in your treatment include:
Acupuncture
Electric Stimulation
Therapeutic MassagelExercise
Chiropractic
Cold Laser Therapy
Hot/Cold Packs
LET US KNOW WHAT YOUR PAIN LEVEL IS
What is your current level of pain on a scale of 0 (no pain) to 10 (extreme pain)?
When is pain worst? !J.. Morning
!J.. Afternoon
!J.. Evening
_
!J.. Bedtime
Do any medications help your pain?
_
Other treatments you've had for pain?
_
I have read and understand the Informed
Consent for my healthcare needs.
Print Patient Name
Patient Signature
Date
IMe MED LIST
Please list all medications/vitamins·
Name of Medication
Date Informed
.
Name of Medication
Date Informed
`