We are now offering the knee on trac decompression therapy!

Child Health History Form

Caruso Chiropractic Clinic

We are pleased to welcome you to our practice. To save time and allow us to better serve you, please complete all the information required. If you have any questions, we'll be happy to help. 
Quality of Sleep

Health History

Check any of the following conditions which you had within the last year: 

Musculo-Skeletal
Nervous
C-V-R
Gastro-Intestinal
Genito-Urinary
EENT
Skin
General
Check any of the following diseases which you have had in your life.

Family History


Check the following family members that had any of the diseases mentioned above. 

Your Current Condition

Is today's problems caused by:
Mark your Pain Point
How often do you experience your symptoms?
How would you describe the type of pain?
Using a scale from 0-10(10 being the worst) how would your rate your problem?
How much has the problem interfered with your work?
Who else have you seen for your problem?
Do you consider your problem to be severe?
How would you rate your overall health?
What type of exercise do you do?
What activities do you do at work? Sit:
What activities do you do at work? Stand:
What activities do you do at work? On the phone:
What activities do you do at work? Computer Work:
Have you ever been hospitalized?

I certify that I have read, understood, and answered the above information to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. 

Primary Insured's Gender

Authorization for treatment and billing


I hereby authorize Dr.Sam Caruso & Dr.Bradley Sabo or whichever Dr/Chiropractic assistant they may designate to administer treatment to me or my dependents they deem necessary.

I authorize Caruso Chiropractic Clinic to release any information concerning my condition to any insurance company, attorney, or health practitioners. I authorize direct payment to Caruso Chiropractic Clinic for any sum that I owe now or in the future, from any insurance company that is obligated to reimburse me for charges incurred in your office, or my attorney out of the proceeds of my settlement. A photocopy of this form is acceptable for any payment. I hereby assign and give to Caruso Chiropractic Clinic the right to take action against any insurance company this is obligated by contract to make payment to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for the payment of all services rendered on my behalf or my dependents, and pay it within a 90 day period. I understand that in the event my account is past due, I will be charged and I will be responsible for any additional $20.00 fee.

Consent for Release of Information


I understand under the HIPAA guidelines, my personal account and medical information may not be released to anyone without my consent. I am allowing any/all of my account and medical information to be given to the persons named below when requested by the named persons below. 

Acknowledgement of Receipt of Notice of Privacy Practices


I acknowledge that I am aware of the Caruso Chiropractic Clinic, P.C. Notice of Privacy Practices and if i choose to obtain a written copy I can do so by logging on to www.carusochiropractic.com

Thank you for taking the time to fill out this form.

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Our Location

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Office Hours

BY APPOINTMENT ONLY

Caruso Chiro Office Hours

Monday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Tuesday:

2:00 pm to 6:00 pm

Wednesday:

9:00 am-1:00 pm

2:00 pm-6:00 pm

Thursday:

Closed

Friday:

9:00 am to 1:00 pm

2:00 pm to 6:00 pm

Saturday:

9:00 am-1:00 pm

Sunday:

Closed