Denver Biofeedhuck Clinic, fnc.
Patient Registration
Name:
Apt #:
Street Address:
Zip code:
State:
Cify:
Social Securitv #:
Home phone #:
Cell phone #: (--
)-
Date of Birth:
Gender: Male
Marital Status: Manied
Single
Employment status: Full time
_
Domrnant Hand:
Female
Divorced
# of Children:
Full time with restrictions
_
Part
time
R
L
Ages:
Student
Not working
In case of emergency please notify:
Address:
Phone:
Work irgury:
Autornobile accident:
Major Medical:
If no: Name of insured:
Are you the insured?:
SS # of insured:
If Major Medical: Group #:
Date
of
ID#:
iryury:
lnsurance Claim #:
Insurance company covering this clarm:
Insurance adjuster:
Phone
#:
t__J
-
Insurance address:
Employer's name:
Employer
c
ontacVsupervisor
Fax:
:
(_-)
-
Have you changed employers since your irgury?:
Name of referring physician:
Fax:
(.-)
-
Phvsician address:
Diagnosis:
Patient or Guardian sisnature reouired:
I authorize Denver Biofeedback Clinic, Inc. to perform evaluation
and treatment of myself as needed. I authorize the release of any medical or
other information necessary to my physicians and insurance company to process this claim. I furthermare authorize payment of medical benefits
to Denver Biofeedback Clinic, Inc. I realize that I am fully responsible for any payments not covered by my insurance except where prohibited
by law. "I hereby acknowledge that I have received a copy ofthe Provider's Notice ofPrivacy Rights."
Signed:
Date:
Denver Biofeedhack Clinic, fnc.
Patient Registration Page
2
Describe your rvork and your title or position:
If you have work restrictions, please describe them:
Please describe how you were injured:
Have you had any surgeries related to this iryury?: (dateldescription):
Please date and describe any other major illnesses, accidents or surgeries that you have had:
List all medications and dosages that you are currently taking:
Do you have a history
of
Diabetes
Seizures
Briefly describe activities that are limited due to your current condition:
What are your goals and expectations for biofeedback and this training.
Thyroid dysfunction
Denver Biofeedback Clinic, lnc.
SYMPTOM CHEGKLIST
Name:
Date:
PAIN SCALE: FROM 0 TO 10
- NO PAIN, 10 = SEVERE
BLOOD PRESSURE
_H|GH
-HEADACHES
0
JAW- HEAD NECK- ARMHIP SHOULDER LEG
BACK HAND FEET
tN EARS
_POUNDTNG HEART
_R|NG|NG
_coNSTIPATION
_LOOSE
BOWELSIDTARRHEA
STRESS SCALE: FROM 0 TO 10
_uLcER/TNDTGESTTON
NAUSEAA/OMITING
WORK:
_FATNTNESS/D\ZZTNESS
HOME:_
_ARTHRIT|S
-ALLERGIES
TIGHT KNOT IN STOMACH
_rrcHrNG/RASHES
_EAS
D
I
I LY AN N OYE D/t RRTTATED
FFICULTY CONCENTRATI NG
_OBSESSIVE
SWEATY PALMS
SHORTNESS OF BREATH
COLD HANDS/FEET
THTNK|NG
ANGER
DEPRESSION
I NCREASED WORRYI NG/FEARFUL TH I N KI NG
TENSE/NERVOUS
JUDGEMENT
DTSSATTSFACTTON
_JOB
-IMPAIRED
-FEELING
DIET:
_POOR APPETTTE
_LOWERED
SELF-ESTEEM
_ACC|DENT-PRONE
_TENDENCY FOR ERRORS
_oVER-EAT|NG
SKIP MEALS...HOW OFTEN
CAFFEINE...HOW OFTEN
SUGAR...HOW OFTEN
JAW PAIN:
_JAW TENSTON
_POPPtNG/CLtCKtNG
HOW OFTEN DO YOU:
USE ALCOHOL
USE RECREATIONAL DRUGS
AFTER EATING
_PA|N
-PAIN
ON AWAKENTNG
_cLENCH tNG/c Rt N D
EXERCISE
SMOKE
I
NG..
TMJ SPLINT
JAW LOCKS: OPEN
SLEEP:
NUMBER OF HOURS PER NIGHT
HOW LONG TO FALL ASLEEP
SLEEP PoSlTloN: STOMACH
_
BACK_
SIDE
(RlcHT)_
(LEFT)
_
IF YOU HAVE UNRESTFUL SLEEP, PLEASE ANSWER THE FOLLOWING QUESTIONS:
What time do you get ready to go to bed at night?_
What time do you go to bed?
Do you read or watch TV or work in your bed or bedroom?
Do you wake up during the night?
How many times?
lf you wake up, do you know why? Explain
Are you able to fall back to sleep?_
How long does it take to fall back to sleep?
Do you feel rested in the morning?
What time do you wake up in the morning?
Do you fall back to sleep in the mornings?
What time do you get out of bed?
Do you take naps during the day?
Do you drink coffee, caffeinated sodas, teas or eat chocolate?
How often?
Do you drink alcohol in the evening?
When is the latest you will have caffeine?
How often?
..
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B iofeedhack C nnic, f ur.
Phone 720-855-6680 Fax 303 -433- I 899
RELEASE OF PROTECTED HEALTH INFORMATION AI\T)
VERBAL
C
OMMIJI\ICATIOI{S DISCLO SURE
, hereby authorrze Denver Biofeedback Clinic, Inc. and its agents
to release protected health information related to my evaluation and / or teatment to my insurance company and I or treating physician(s).
I also authorize the rndividuals, professionals, and companies named below to communicate with and / or release information to Denver
Biofeedback Clinic, Inc.
This disclosure is for the purpose of _
Treatment, Payment, Operations, the release of Psychotherapy Notes,
Other. If "the release ofPsychotherapy Notes or Other" is checked, regardless ofwhether additional purposes are also
or _
checked, this form is a HIPAA compliant Authorization. As such, Denver Biofeedback Clinic, Inc. may not condition treatment, payment,
enrollment in a health plan, or eligibility for he'alth plan benefits on your signing this Authorization. Also, if this is an authorization, the
practitioner must provide you a copy.
Insurance name:
Address:
Phone:
_
Fax:
Referring physician:
Address:
Phone:
Fax:
Attorney:
Phone:
Fax:
Other: (Physical Therapists, Psychologists, etc.) *** Please give
a phone number
for each name listed.
THIS DISCLOSURE is intended to cover any and all medical records including but not limited to, those regarding drug and
alcohol abuse, psychological or psychiatric disorders, muscle injuries or disorders, nerve injuries or disorders, bone orjoint injuries and
disorders, and brain injuries and disorders.
Denver Biofeedback Clinic, Inc. and its agents, as well as others named above, are AUTHORIZED to verbally communicate with
my insurance company and physician(s) and each other concerning the information contained in the medial records and regarding my
treatment and evaluation. It is not necessary that I be present during any such conversations. This authorization does not include anyone
other than my biofeedback therapist or their agents, and those named above.
I certiff that this request is made voluntarily and that the information given above is accurate to the best of my knowledge. This,
authorization will expire I year after the date of signature below. I may revoke this authorization with written notice, except to the extent
that the practitioner or Denver Biofeedback Clinic, Inc. has taken action. You may treat a photocopy or fax of this signed authorization as
a duly executed original for all purposes.
DATED
thrs
Signature of Patient
Signature of Therapist
day
2oo-.
of
---,
Location:
Denver Biofeedback Clinic, Inc.
2100 West Littleton Blvd. Suite 245
Littleton, CO 80120
720-855-6680 phone
303-433-1899 fax
[email protected]
Directions:
From the North, take I-25 South to Santa Fe. Go south on Santa Fe to Alamo and turn left onto
Alamo (turning into old town Littleton), follow Alamo a few blocks over the railroad tracks and
take the first right onto Bemis. Park on Bemis or in the back of the building.
From the South, take I-25 to C470 and exit at Santa Fe. Follow Santa Fe North to Alamo and
turn right (turning into old town Littleton), follow Alamo a few blocks over the railroad tracks
and take the first right onto Bemis. Park on Bemis or in the back of the building.