New Patient Info - Dr. James Huang
Please fill-in the following form and submit it when finished. Completing this form before your visit will save you time, not to mention saves you from all the usual annoying paperwork that you have to endure in most offices. The privacy of your information is important to us and we will never share any identifying information with any third parties without your direct consent. Thanks and we look forward to seeing you soon!
Email address *
Full Name (First and Last name) *
Your answer
Contact Number *
Your answer
Emergency Contact *
Your answer
Emergency Contact Number *
Your answer
Address *
Your answer
DOB *
Your answer
Sex *
Married? Do you have Children? *
Your answer
Do you Have a Primary Doctor? *
DC, MD, ND, etc
Required
If yes, who is it?
Your answer
Do you have insurance?
If yes, what is it? Please put member ID and insurance company name if you would like us to check your benefits.
Your answer
Is your visit due to an injury from a car accident?
If yes, please provide the following information: your current auto insurance provider, claim #, estimated damage to your vehicle, and medical coverage ($1000, $5k, $10k)
Your answer
How did you hear about this office? *
Required
How can we help you today? If you have multiple areas of pain please list them in order of importance. *
Your answer
If you are experiencing pain please rate it on a scale of 1 to 10. (10 being the worse pain you have ever felt.) *
Your answer
Have you been to a chiropractor before? If so, how was the experience?
Your answer
Health History
This section will review your health history and provide Dr. Huang with the necessary information to give you a comprehensive picture of your health. Please understand that this information will be used with the highest considerations for your privacy according to the regulations set out in HIPAA. Your honesty is appreciated.
Family History *
List any known family illnesses (e.g. hypertension) and the side they originate, (e.g. maternal grandmother).
Your answer
Have you ever been hospitalized or had a major illness? Please explain. *
e.g. Hospitalized for mononucleosis at age 17
Your answer
What do you do for work (occupation)? *
Be specific about your workstation, and what you do for the majority of your day e.g. sitting, standing, typing, etc.
Your answer
What do you do to stay active? *
List hobbies, sports, and activities outside of work.
Your answer
Are you currently taking any medications? *
If so, what are you taking, and why are you taking it?
Your answer
Are you currently taking any supplements? *
If so, what are you taking, and why are you taking it?
Your answer
Are you a vegetarian, vegan, or omnivore?
If so, how long and why?
Your answer
Do you have any gastrointestinal problems? *
e.g. indigestion, IBS, heartburn, etc
Your answer
Do you ever have trouble breathing? *
e.g. shortness of breath, asthma, etc.
Your answer
Do you have any known problems with your ears, eyes, nose or throat? Please explain. *
e.g. chronic ear infections, nearsightedness, decreased sense of smell, swollen throat, etc.
Your answer
Do you have any hormonal problems? *
e.g. thyroid issues, menopause, adrenal stress, etc
Your answer
Do you have any known neurological disorders? *
e.g. headaches, Parkinson's, MS, depression, anxiety, etc.
Your answer
If you mentioned Headaches, please explain further
e.g. location, frequency, intensity, triggers, treatments, etc.
Your answer
Do you have any cardiovascular problems? *
e.g. hypertension, history of heart surgery, murmur, etc.
Your answer
Do you have any reproductive problems? *
e.g. endometriosis, history of hysterectomy, severe menstrual cramping, frequent urination, prostate problems, etc.
Your answer
Do you have any problems going to the bathroom? *
e.g. painful urination, incontinence, constipation, frequent urination
Your answer
Do you have any musculoskeletal complaints other than those already mentioned? *
e.g. plantar fasciitis, old shoulder or knee injuries, etc.
Your answer
Do you have any allergies that you're aware of at this time? *
e.g. seasonal, medicinal, food, etc
Your answer
Do you have any skin conditions? *
e.g. eczema, rash, etc.
Your answer
Do you have any other conditions you wish to share? *
e.g. diabetes, metabolic disorder (syndrome X), etc.
Your answer
How are your stress levels on most days? *
I'm free as a bird
I'm ready to burst
What tools do you use to stay healthy? *
e.g. gym membership, fitbit, garmin, zeo sleep, smartphone apps, etc.
Your answer
Have you had any imaging studies completed in the last 3 years (xray, MRI, CT) *
If yes, it is beneficial to have them with you at your visit (don't stress if you can't get them).
Your answer
Is there any chance that you are pregnant?
This question relates specifically to eligibility for imaging studies. You do not have to answer it if you so choose.
Your answer
Informed Consent *
Doctors of Chiropractic who use manual therapy techniques are required to advise patients that there are or may be some risks associated with such treatment. In particular you should note: a) While rare, some patients may experience short term aggravation of symptoms, rib fractures or muscle and ligament strains or sprains as a result of manual therapy techniques; b) There are reported cases of stroke associated with many common neck movements including adjustments of the upper cervical spine. Present medical and scientific evidence does not establish a definite cause and effect relationship between upper cervical spine adjustment and the occurrence of stroke. Furthermore, the apparent association is noted very infrequently. However, you are being warned of this possible association because stroke sometimes causes serious neurological impairment and may on rare occasion result in injuries including paralysis. The possibly of such injuries resulting from upper cervical spinal adjustment is extremely remote; c) There is rare reported cases of disc injuries following cervical and lumbar spinal adjustments or chiropractic treatment. Chiropractic treatment, including spinal adjustments, has been the subject of government reports and multi­disciplinary studies conducted over many years and has demonstrated to be effective treatment for many neck and back conditions involving pain, numbness, muscle spam, loss of mobility, headaches and other similar symptoms. Chiropractic care contributes to your overall well being. Dr. Huang may record your progress via video. I consent to have Dr. Huang to use any video footage for educational purposes. The risk of injuries or complications from chiropractic treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same treatments. I acknowledge I have discussed, or have had the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general and my treatment in particular (including spinal adjustment) as well as the contents of this Consent. I consent to the chiropractic treatments offered or recommended to me by my chiropractor, including spinal adjustment. I intend this consent to apply to all my present and future chiropractic care.
Required
By clicking the box below, you are agreeing to the terms of your visit. *
This means you understand that we collect for services at the time they are received. As a courtesy to our patients, we can provide you with the necessary information to be reimbursed by your insurance. Most PPOs will reimburse upwards of 80% of the cost of a visit. If your insurance does not reimburse the doctor you are responsible to pay the doctor at the cash rate. Check with your individual policy for specific information. If you are a Medicare patient you agree to zero reimbursement as Dr. Huang is a non-participating provider for Medicare. All fees can be found at www.drjameshuang.com. It is the patients responsibility to pay for all services performed in the clinic. All payment is due once services are rendered. It is the patients responsibility to maintain appointments. The patient must notify the office within 24 hours if there is a schedule change or cancelation, otherwise the patient will be billed in full for that appointment time. This a wellness clinic and there are many patients that can benefit from care in the clinic. Giving proper notice allows for other patients to receive care that may be needed. All appointments are scheduled, there are no walk­-ins. So it is very important that patients respect this responsibility.
Required
End of Section
At this time, you have finished all the necessary paperwork. If time permits, we will send you a brief online questionnaire that will help us gauge your current state of health. The same privacy precautions apply to your personal information. Thanks and we look forward to seeing you.
A copy of your responses will be emailed to the address you provided.
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