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Dr. Kris Dearborn

Dr. Michael Ahn

Dr. Joseph Hamlin

5035 NE Elam Young Pkwy, Ste 300 Hillsboro, OR 97124

Tel: 503.626.3700 | Fax: 503.643.6667

Work or Auto Injury Patient Forms

1 PATIENT INFORMATION FORM

If your injury is NOT due to a Work Injury or Automobile accident, STOP HERE and click this link to go to Cash or Insurance Patient Forms

CURRENT ADDRESS

If you are under 18 years of age, who are your legal parents or guardian?









Please indicate any other healthcare providers who you've seen for THIS injury or condition, and when you last saw them.

What operations have you had?

Serious illnesses or conditions?





What medications or drugs are you taking?


















I have read, understood and agree to the foregoing. The information which I have provided is true and complete to the best of my knowledge


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

2 Authorization to Disclose Medical Records

(Please Only Sign the Highlighted Box Below)

Information to be released from:

Information to be sent to:

Oregon Spine and Disc

5035 NE Elam Young Pkwy. Suite 300 Hillsboro, OR 97124

P.503-626-3700 F.503-643-6667

Purpose of disclosure:

Information to be released:





*Must be initialed to be included in other documents.








Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

3 Automobile Accident Description

File #

Claim #

Date of Injury

Circle Vehicle Damage


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

4 NECK DISABILITY INDEX QUESTIONNAIRE

File #

Claim #

Date of Injury

Read carefully: This questionnaire has been designed to enable us to understand how your NECK pain has affected your ability to manage everyday life. Please answer every section & mark in each section only ONE CHOICE, which applies to you. We realize that you may consider that two of the statements in any one section relate to you, but please just mark the one (1) letter which most closely describes your problem right now.

SECTION 1 – Pain Intensity
SECTION 2--Personal Care (Washing, Dressing etc.)
SECTION 3 – Lifting
SECTION 4 --Reading
SECTION 5--Headache
SECTION 6 - Concentration
SECTION 7--Work
SECTION 8--Driving
SECTION 9--Sleeping
SECTION 10--Recreation

Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

5 REVISED OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE

PLEASE READ: This questionnaire is designed to enable us to understand how much your low back pain has affected your ability to manage your everyday activities. Please answer each section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but PLEASE JUST

CIRCLE ONE CHOICE WHICH MOST CLOSELY DESCRIBES YOUR PROBLEM RIGHT NOW.

SECTION 1 – Pain Intensity
SECTION 2 – Personal Care
SECTION 3 – Lifting
SECTION 4 – Walking
SECTION 5 – Sitting
SECTION 6 – Standing
SECTION 7 – Sleeping
SECTION 8 – Social Life
SECTION 9 – Traveling
SECTION 10 – Changing Degree of Pain

Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

6 HEADACHE DISABILITY INDEX QUESTIONNAIRE

INSTRUCTIONS:Please CIRCLE the correct response:

1. I have headache:

2. My headache is:

Please read carefully:The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check off “YES”, “SOMETIMES”, or “NO” to each item. Answer each question as it pertains to your headache only.

Because of my headaches I feel disabled.

Because of my headaches I feel restricted in performing my routine daily activities.

No one understands the effect my headaches have on my life.

I restrict my recreational activities (eg, sports, hobbies) because of my headaches.

My headaches make me angry.

Sometimes I feel that I am going to lose control because of my headaches.

Because of my headaches I am less likely to socialize.

My spouse (significant other), or family and friends have no idea what I am going through because of my headaches.

My headaches are so bad that I feel that I am going to go insane.

My outlook on the world is affected by my headaches.

I am afraid to go outside when I feel that a headaches is starting

I feel desperate because of my headaches

I am concerned that I am paying penalties at work or at home because of my headaches

My headaches place stress on my relationships with family or friends.

I avoid being around people when I have a headache.

I believe my headaches are making it difficult for me to achieve my goals in life.

I am unable to think clearly because of my headaches.

I get tense (eg, muscle tension) because of my headaches.

I do not enjoy social gatherings because of my headaches.

I feel irritable because of my headaches.

I avoid travelling because of my headaches.

My headaches make me feel confused.

My headaches make me feel frustrated.

I find it difficult to read because of my headaches

I find it difficult to focus my attention away from my headaches and on other things.

Instructions:1. Using this system, if "YES" is checked on any given line, that answer is given 4 points... a "SOMETIMES" answer is given 2 points and a "NO" answer is given zero. 2. Using this system, a score of 10-28% is considered to constitute mild disability; 30-48% is moderate; 50-68% is severe; 72% or more is complete.


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

7 Acknowledgment of receipt of Notice of Privacy Practice (HIPAA)

(Please Only Sign the Highlighted Box Below)

Regarding the Use & Disclosure of Protected Health Information

("Consent Form")

For the purposes of this Consent Form, “Office” shall refer to: Oregon Spine and Disc

I understand that some of my health information may be used and/or disclosed by the Office to carry out treatment, payment, or health care operations, and that for a more complete description of such uses and disclosures I should refer to the Office’s privacy notice entitled, “Our Privacy Practices.” I understand that I may review this privacy notice at any time prior signing this form.

I understand that over time the Office’s privacy practices may need to change in accordance with law and that if I wish to obtain a copy of the notice as revised, I can call the Office to request such copy

I understand that I may request restrictions on how my information is used or disclosed to carry out treatment, payment, or health care operations, and that I can also revoke this Consent in, but only to the extent that the Office has not taken action in reliance thereon and also provided that I do so in writing.

I understand that for my protection, any requests to amend my health information or to access my medical records must be made in writing.

"IF PATIENT IS A MINOR"(must be completed in person at the clinic)


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

8 OREGON SPINE AND DISC FINANCIAL POLICY

(Please Only Sign the Highlighted Box Below)

  • CO-PAY IS DUE AT TIME OF SERVICE.
  • WE DO NOT SEND A BILL FOR YOUR CO-PAY.
  • WE DO NOT BILL YOUR SECONDARY INSURANCE BUT WE WILL BE HAPPY TO GIVE YOU A LEDGER FOR IT.
  • IT IS THE PATIENTS RESPONSIBILITY TO KNOW THEIR INSURANCE BENEFITS (YOUR CO-PAY OR DEDUCTABLE). WE WILL HELP YOU IN ANY WAY WE CAN BUT NOT ALL INFORMATION IS AVAILABLE TO US.
  • IF THE DEDUCTABLE HAS NOT BEEN MET, PATIENT IS RESPONSIBLE TO PAY IN FULL AT THE TIME OF SERVICE.
  • ANY SERVICE RENDERED, BUT NOT COVERED BY YOUR INSURANCE (ELECTRO-STIM, LASER, TRIGGER POINT OR MASSAGE, FOR EXAMPLE) IS DUE AT THE TIME OF SERVICE AT A DISCOUNTED FEE*.
  • WE DO NOT OFFER PAYMENT PLANS, BUT WE DO ACCEPT MAJOR CREDIT CARDS WITH NO FEES TO YOU.
  • IF THERE ARE ANY PATIENT BALANCES, OR INSURANCE ADJUSTMENT CREDITS, WE WILL NOTIFY YOU PROMPLY BY MAIL AND PHONE.

PLEASE NOTE: THE PATIENT IS ULTIMATELY RESPONSIBLE FOR ANY BALANCE NOT PAID BY INSURANCE.

*REMEMBER - WE OFFER GREAT DISCOUNTED " TIME OF SERVICE " (CASH) FEES FOR ANYONE WHO DOES NOT HAVE INSURANCE OR CHOOSES NOT TO USE THEIR INSURANCE.

THANK YOU, BILLING STAFF

I have read and understand the policy.

*ChirohealthUSA.com is a discount medical plan which provides you and your family discounts on many services. They offer several plans which may include Chiropractic, Vision and Dental. Please go online or ask us for more information


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

9 FINANCIAL AGREEMENT

(Please Only Sign the Highlighted Box Below)

Please remember that insurance is considered a method to reimburse the patient for fees put to the doctor and it is NOT A SUBSTITUTE FOR PAYMENT. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance.

IN ORDER TO CONTROL YOUR OUTSTANDING BALANCE, IT IS OUR POLICY TO COLLECT CO-PAYS, COINSURANCE AND DEDUCTIBLE AT TIME OF SERVICE

If this account is assigned to an attorney/outside agency for collection an/or suit, Oregon Spine and Disc shall be entitled to reasonable attorney’s fees and for cost of collection.

I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim.

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Oregon Spine and Disc all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy an/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions

I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under any applicable insurance policies and/or employee healthcare plan, any claim, chose in action, or other right I may have to such insurance and/or employee healthcare benefits coverage under any applicable insurance policies and/or employee healthcare plan with respect to any medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation. I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee healthcare plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee healthcare plan in my name but at such doctor and clinic’s expenses

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

10 Informed Consent to Treat Self Minor

The material risks inherent with Spinal Decompression: Certain complications may arise such as muscle spasm or increased pain. The spasm & pain is generally temporary and more common in the first weeks of beginning treatment. Please ask for copies of available studies.

The nature of the chiropractic manipulation: We may use our hands, an instrument, or both, to move the joints of your body; this may result in an audible "pop" or "click".

The material risks inherent in an adjustment: As with any healthcare procedure, certain complications may arise during a chiropractic manipulation. This may include: strains, dislocations, fractures, disc injuries and stroke. This list is not all inclusive.

The probability of those risks: Fractures are rare & can result from underlying weakness in the bones. Muscular strain (rare), ligamentous sprain (rare), fractures (rare), and injury to intervertebral discs, nerves or spinal cord (very rare), cerebrovascular injury, or stroke (very, very rare – chances are one in one million to one in ten million

Ancillary treatments recommended: Ice, Moist Heat Packs, Ultrasound, Electrical Muscle Stimulations, Stretching/Strengthening Exercises, Massage Therapy, Diathermy, Laser, Neuromuscular Re-education, Graston Technique and Decompression Spinal Traction

Risks involved with recommended ancillary treatments: Ice, Heat & Electrical Muscle Stimulations (EMS) can cause burning. EMS can cause skin irritation underneath active pads. Stretching/Strengthening Exercises & Decompression can cause muscle strains. This list is not all inclusive.

Other treatment options can include: Medical care, prescription drugs, self management with over-the-counter medication, rest, and/or surgery.

Medical care: Typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include numerous undesirable side effects, usually more serious than those listed above, and the patient dependence increases in a significant number of cases. The material risks include but not limited to: addiction to medication, side effects of medication and improper self dosages.

Surgery: In conjunction with medical care adds the risks of adverse reaction to anesthesia (which includes death) as well as an extended convalescent period in a significant number of cases

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and possibly include chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

CONSENT TO TREAT MINOR - PLEASE FILL THE BELOW ONLY IF CONSENTING TO TREATMENT FOR A MINOR

I, the undersigned, attest that I am the custodial parent or legal guardian of the above-noted minor, and hereby authorize Oregon Spine and Disc to administer treatment as it so deems necessary to the minor. If the minor has received treatment at your practice previous to the date of this consent form, I hereby authorize such treatment in addition to the treatment mentioned above. I further authorize the minor to complete and sign any documents at Oregon Spine and Disc, which are customarily completed and signed by patients at your practice as a condition to treatment, and such signature shall serve as my own. In no event shall my signature to any other such document have any effect on this consent form. As of this date, I have the legal right to select and authorize health care services for the minor child named above


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

11 Massage Informed Consent 

Because a massage therapist must be aware of existing physical conditions I have stated all my known medical conditions and take it upon myself to keep the massage therapist update on my physical health. This massage is not a substitute for a medical exam and it is recommended that I see a physician for any physical ailments I might have. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist prescribes neither medical treatment nor pharmaceuticals nor performs any spinal manipulations.

  • I understand that, although rare, side effects may result from massage therapy. These may include but are not limited to: minor muscle pain or tenderness that may last a few days, skin irritation from lotions, headache, bruising, and temporary aggravation of pre-existing conditions.
  • I’ve had an opportunity to discuss with the massage provider the nature, benefits and understand that results are not guaranteed. I understand that I may stop treatment at any time during the session.
  • I do not expect the massage provider to be able to anticipate all risks and complications. I wish to rely on the therapist to exercise judgment during treatment that the therapist feels are best, based upon the facts then known.
  • I understand that the massage therapy procedures and techniques used by the provider listed below are for therapeutic relief and stress management.
  • I understand that I can request a copy of this consent. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
  • If you are obviously ill (fever, cold symptoms, rashes, etc.) you will need to reschedule
  • Therapist may refuse service if at any time the massage appears inappropriate including sexual behavior (remarks or requests). Therapist or client has the right to end the session at any time.
  • You are liable for all services rendered and any balance that insurance does not pay or cover.
  • Please ask questions to thoroughly understand all aspects of the treatment.

Understanding all of this, I give my consent to receive care.

Please check all that applies to you:



Thank you, Oregon Spine and Disc

You will have a choice to print a copy for yourself at the end


Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com        Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken