DC - Patient Form 1 (Hammond) 0% Complete1 of 3 Patient's information Name * Name First First Last Last Date of Birth * Gender * MaleFemaleN/A Phone Number * SSN * Email Address * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Insurance Insurance Company * None21st CenturyAAAAARPACNAdministrator Golden RuleAESSIAetnaAetna SelectAetna SignatureAetnaStudent HealthAll StateAllied Benefit Systems, IncAllsaversAllstateAmerican LifecareAmerican Specialty Health NetworksAmerihealthANPAC ClaimsAnthem BCBSAPWUAssurant HealthAvizentBankers Life & Casualty CompanyBCBS LouisianaBCBS OOSBCBSLA - OGBBCBSLA MCR HMOBenefit Management ServicesBLUE ADVANTAGEBollinger-schoolBrentwoodBristol WestBroadspireCCMSIcentral states team careCerner HealthPlan ServicesChamp VAChristian Brothers Employee Benefit TrustCIGNACignaCigna InternationalCigna Masters, Mates & PilotsCigna MCR Supplement Total ChoiceCigna New Orleans Electrical Welfare FundCigna Payor 62308CMICNACNIC Health SolutionsColonial Penn Life Insurance CompanyConsociate HealthCoreSourceCorvel CorpCoventry Medicare AdvantageCoventry of LADefinity HealthDelta Health SystemsDmerc C CGSDMERC Jurisdiction DEmployers InsuranceEntergyEsuranceFARAFARA BenefitsFARA ORMFarm BureauFore ThoughtForemost InsuranceFox everrettFreedom Life (cignappo)GEHA (UHC)GeicoGenerally Bad InsGILSBARGo AutoGo Auto InsuranceGolden RuleGuardianGulf Guaranty Employee Benefit Services, IncGWH CIGNAHealth Scope BenefitsHealthSmart Benefit SolutionsHome Builders SIF Claims OfficeHUMANAhumanaHumanaHumana Gold PlusHUMANA GOLD PLUS (thru 2/28/17)Humana MCare Employer PPOHumana OneHumana Regional MCare PPOIMA Inc.John Hopkins Employer Health ProgramsKemperKey SelectLiberty Bankers LifeLiberty Mutual InsuranceLouisiana Horsemen's Benevolent & Protective AssocLouisiana Medicare Part BLSU FirstLUBALWCCManhattan Life Assurance Company of AmericaMasters Mates & Pilots Health PlanMed PlusMedishareMEGA Life & HealthMeritain HealthMHBPMOAA MediplusMutual of OmahaNALC Health BenefitNationwideNew Orleans Electrical Welfare FundNOE-ILA Field Office BNoridian JD DMENovitas Solutions, Inc.Ochsner Health Plan FreedomOffice of Group BenefitsOffice of Risk MGMTOffice of Workers' Comp ProgramsOmni InsuranceOptum HealthOptum VAOxford HealthPCHS Health Plans INCPeoples Health ChoicePGBA South Region ClaimsPHCS GuardianPHCS Tower Life InsPHCS/Amerihealth AdminstratorsPhysicians MutualPPOPlus, LLCProgressive InsuranceRepublic Fire and Casualty Insurance CompanyRISCOM Claims ManagementRisk Management Services, LLCRoyal Neighbors of AmericaS. USA Life Insurancy CompanySafeway InsuranceSedgwickSelman & CompanyShelter Insurance CompanySolidarity HealthcareSt. John's Claims AdministrationStandard Life and AccidentState Farm ClaimsState Farm InsuranceState Farm Insurance Team 8State Farm Team 1Stone TrustSuperior Risk MAnagementSurestThe HartfordTivity HealthTrans America Life Insurance CompanyTraveler's Insurance CoTravelers Insurance Co.TriCareTricare for LifeTrinity Insurance ServicesTriWest - VAUCareUHC Compass Rose Health PlanUHC OxfordUMRUnicareUnited HealthcareUnited Healthcare Claim DivisionUnited Healthcare Medicare SolutionsUnited Healthcare ONEUnited Medical ResourcesUnited of Omaha LifeUnited Teacher AssociatesUnitedHealthcare Student ResourcesUnitrin SpecialtyUS AgencyUSAAUSAA Life Insurance CoUSAA Medical Mail DeptVANTAGE HEALTH PLANVeterans AdministrationWEB TPAWellCare Name of primary insured * Name of primary insured First First Last Last Insurance company and address Contact/ID number Group number Are you covered by Medicare Yes No Medicare # Emergency Contact Emergency Contact Name * Emergency Contact Name First First Last Last Relationship to Patient * MotherFatherGuardianSister/BrotherSpouse Emergency Contact Number * Pain Assessment Are you currently in pain? * YES NO Pain Scale 1 2 3 4 5 6 7 8 9 10 Rate your pain Medical History Check the issues that you have/are experiencing: * Sinus trouble Hay fever Allergies Asthma Emphysema Tuberculosis Cancer Diabetes Epilepsy Thyroid trouble High blood pressure Low blood pressure Heart trouble Pacemaker Stroke Aortic aneurysm Anemia Rheumatic fever Pneumonia Urinary problems Polio Multiple sclerosis Ulcer Liver trouble Kidney trouble Prostate trouble Arthritis Scoliosis Dislocated joint Spinal disc disease Bone fracture Mental/emotional difficulty STD HIV AIDS/ARC Measles Mumps Chickenpox Pneumonia Glaucoma None OtherOther Are you currently taking any medications? * No YesYes Do you have any known medical allergies? * No YesYes Are you currently under medical treatment? * No YesYes Have you been admitted to hospital or had surgery within the last 2 years? * No YesYes Do you use any kind of tobacco * No YesYes Do you use any kind of illegal drugs or have you ever used them? * No YesYes How often do you consume alcohol? * NeverOccasionallyDailyWeeklyMonthly Do you have a family physician? * No YesYes Date of last exam * Name * Name First First Last Last Phone * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Do you have any other complaints or health concerns that are not listed above? Family History Check the conditions that apply to you or any member of your immediate family: * Asthma Cancer Cardiac Disease Diabetes Epilepsy Hypertension Lung Problems Psychiatric Disorder Seizure Disorder Stroke None OtherOther Indicate which of the below you have experienced in the last 1-2 months Check the conditions that apply to you * Anxiety General Fatigue Dizziness Depression Fainting Loss of Sleep Weight Change Nose/Sinus Pain Hearing trouble Vision trouble Chronic Nasal Infection Chronic Cough Skin Rash Chronic Wheezing Difficulty Breathing Abdominal Pain Skin itching/dryness Excess Gas Eczema Varicosities Vomiting (excessive) Diarrhea (excessive) Chest Pain Constipation (excessive) Bruise easy Heartburn/Indigestion Inability to hold urine Irregular Menstruation Painful Menstruation Impotence None OtherOther If you are human, leave this field blank. Next
