InMotion Spine Muscle Joint
Dr. Meryl Miller, Dr. Jared Shoemaker
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Is Patient covered by additional Insurance? (required) Yes No
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ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to InMotion SMJ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Responsible Party Signature: Relationship: Date (MM/DD/YYYY):
Is condition due to an accident? (required) Yes No
Date of Accident (MM/DD/YYYY)
Type of Accident Auto Home Work Other
To whom have you made a report of your accident? Auto Insurance Employer Worker Comp Other
Attorney Name
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Reason for visit:
When did your symptoms appear?
What do you think caused the symptoms?
Is this condition progressively getting worse? Yes No Unknown
Has this occurred before? Yes No
When
Areas where you have pain, numbness, or tingling:
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain): 12345678910
Type of pain (Select all that apply):
*If Other, please describe:
What time of day do the symptoms often occur?
Is the pain constant or does it come and go?
Does it interfere with your (Select all that apply): Work Sleep Daily Routine Recreation
Number of days lost from Work or School
Activities you'd like to be able to do again:
Activities or movements that are painful to perform (Select all that apply): Sitting Standing Walking Bending Lying Down Lifting Stretching Other *If Other, please describe:
Pain is reduced by (Select all that apply): Rest Exercise Medicine Adjustments Therapy
What treatment have you already received for your condtion? (Select all that apply): Medications Surgery Physical Therapy Chiropractic Services None Other *If Other, please describe:
Outcomes of these treatments:
Name and Address of other doctor(s) who have treated you for your condtion:
Is there anyone you would like us to keep informed regarding your treatment at the office? Yes No
Please specify name and address:
Date of Last (MM/DD/YYYY): Physical Exam: Spinal X-ray: MRI, CT-Scan, Bone Scan: Chest X-ray:
Any related symptoms/conditions:
Any recent infections? Yes No
Any fever or chills? Yes No
Any dizziness? Yes No
Any change in bowel or bladder habits? Yes No
Have you ever suffered from:
Has a physician treated you for any other condition(s) in the past 12 months? (If yes, please explain): No Yes
*Women Only* Is there any change you may be pregnant? No Uncertain Yes Due date:
None Moderate Daily Vigorous
Activities:
Sitting Standing Light Labor Heavy Labor Other *If Other, please describe:
*1 being lowest, 10 being highest levels of stress
Stress Management Techniques Used:
Please help us to identify your potential health risks by placing a check in any column that applies to you or your blood relatives.