INTRODUCTION PATIENT CASE HISTORY
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- Josephine Lucas
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1 INTODUCTION PATIENT CASE HISTOY Today s Date: / / PATIENT INFOMATION Name: (First MI ast) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #:_ Home: Mobile: Work: Preferred Method of Contact: Text Home Phone Other: *eferred By: (Name) Family Friend Co-Worker Doctor Other: ace & Ethnicity: (Choose up to 2) Preferred anguage: African American or Black English American Indian or Alaskan Native Spanish Asian Other: Hispanic or atino Decline Native Hawaii or Other Pacific Islander White Decline EMEGENCY CONTACT INFOMATION Name: (First MI ast) Home: Mobile: elationship: Child Parent Spouse Other: Primary Care Physician: _ Doctor s Phone: FINANCIA INFOMATION Is today s visit the result of an accident? No Auto Work Other: Will we be working with insurance? No Yes (Details) Primary: ID#: Secondary: ID#: Where would you like statements sent? Self Other (Details below) Name: Address: _ Phone: It is Usual and Customary to Pay for Services as endered Unless Otherwise Arranged
2 HISTOY OF PESENT INESS (Please describe) Major Complaint: When did it start? / / HISTOY OF PESENT INESS Secondary Complaints: What happened? Which daily activities are being affected by this condition? ocation of Symptoms and adiation P Pain T Tender N Numb H Hypoesthesia S Spasm Grade Intensity/Severity: (0/10) Mild (1-2/10) Mild-Moderate (2-4/10) Moderate (4-6/10) Moderate-Severe (6-8/10) Severe (8-10/10) Frequency: Off & On Constant MAJO COMPAINT Quality: Sharp Stabbing Burning Achy Dull Stiff & Sore Other: Does it radiate? No Yes (Please indicate on drawing) Improves with: Ice Heat Movement Stretching OTC Medications: Worsens with: Sitting Standing/Walking ying Down/Sleeping Overuse/ifting Previous Treatment: Chiropractor Medical Doctor Physical Therapy E/Urgent Care Orthopedic Previous Diagnostic Testing: X-rays MI CT *Women: Are you pregnant? No Yes ast Menstrual Period: / / Due date: / / Present Illness Comments: Prescription Medications & Supplements: Yes (ist Name, dosage, frequency) Allergies to Medications: No known drug allergies Yes (ist - Name and reaction) Print Name: (First MI ast)
3 Mother Father Sibling1 Sibling2 Sibling3 Child1 Child2 Child3 PAST, FAMIY, AND SOCIA HISTOY PAST MEDICA HISTOY Have you ever had any of the following? (Please select all that apply and use comments to elaborate.) Illnesses: Asthma Autoimmune Disorder (Type) Blood Clots Cancer (Type) CVA/TIA (stroke) Diabetes Migraine Headaches Osteoporosis Injuries: Back Injury Broken Bones Head Injury Neck Injury Falls Hospitalizations: (Non-surgical with Date) Surgeries: (If yes, provide type & surgery date) Cancer Orthopedic Shoulder / Elbow/Forearm / Wrist/Hand / Hip / Knee / Ankle/Foot / Spinal Surgery Neck: Back: Medical History Comments: FAMIY HISTOY (Please mark X to all that apply and use comments to elaborate.) Unknown Age at death (if Deceased) Aneurysms CVA (Stroke) Cancer Diabetes Heart Disease Hypertension Other Family History Unremarkable Gender F M Family History Comments: SOCIA AND OCCUPATIONA HISTOY Marital Status: Single Married Divorced Other Children: Other: Student Status: Full Student Part Student Non-Student Highest level of Education: High School College Grad. Post Grad. Employed: No Yes (Occupation) Dominant Hand: ight eft Ambidextrous Smoking/Tobacco Use: If current smoker, amount = Every Day Some Days Former Never Alcohol Use: Every Day Weekly Occasionally Never Caffeine Use: Coffee Tea Energy Drinks Soda Never Exercise frequency: Daily 3-4xs/week 2-3xs/week arely Never Social History Comments: Print Name: (First MI ast)
4 EVIEW OF SYSTEMS EVIEW OF SYSTEMS Many of the following conditions respond to Chiropractic and Acupuncture treatment. Are you currently experiencing any of these symptoms? (Please select all that apply and use comments to elaborate.) Constitutional: (General) Fever Fatigue in this Category Musculoskeletal: Joint Pain/Stiffness/Swelling Muscle Pain/Stiffness/Spasms Broken Bones in this Category Neurological: Dizziness or ightheaded Convulsions or Seizures Tremors in this Category Psychiatric: (Mind/Stress) Nervousness/Anxiety Depression Sleep Problems Memory oss or Confusion in this Category Genitourinary: Frequent or Painful Urination Blood in Urine Incontinence or Bed Wetting Painful or Irregular Periods in this Category Gastrointestinal: oss of Appetite Blood in Stool or Black Stool Nausea or Vomiting Abdominal Pain Frequent Diarrhea Constipation in this Category Cardiovascular & Heart: Chest Pains/Tightness apid or Heartbeat Changes Swelling of Hands, Ankles, or Feet in this Category espiratory: Difficulty Breathing Cough Other: in this Category Eyes & Vision: Eye Pain Blurred or Double Vision Sensitivity to ight in this Category Head, Ears, Nose, & Mouth/Throat: Frequent or ecurrent Headaches Ear - Ache/inging/Drainage Hearing oss Sensitivity to oud Noises Sinus Problems Sore Throat in this Category Endocrine: Infertility ecent Weight Change Eating Disorder in this Category Hematologic & ymphatic: Excessive Thirst or Urination Cold Extremities Swollen Glands in this Category Integumentary: (Skin, Nails, & Breasts) ash or Itching Change in Skin, Hair, or Nails Non-healing Sores or esions Change of Appearance of a Mole Breast Pain, ump, or Discharge in this Category Allergic/Immunologic: Food Allergies Environmental Allergies in this Category eview of Systems Comments: Print Name: (First MI ast)
5 unnels Chiropractic,..C. Authorization and elease I authorize payment of insurance benefits directly to Dr. Steven K. unnels or unnels Chiropractic, C. I authorize unnels Chiropractic, C to release any information pertinent to my case to any insurance company, adjusters, and/or attorney involved in the case, I hereby release unnels Chiropractic, C of any consequence thereof. I agree to be financially responsible for all charges incurred at unnels Chiropractic, C including my insurance deductible, co-payment, and any other services rejected by my insurance company. Any account unpaid after 30 days of the date of service shall bear interest at the rate of 16% per month. Should it become necessary to resort to collections, the patient shall be responsible for all costs of collections including a reasonable attorney s fee. Insurance: Yes No Company: Patient s Signature:_ Date: Guardian s Signature:Date: Clinical Summary eport (CC) I understand that a clinical summary report is created after each visit for the purpose of EH and is available for my review. At this time, I am asking unnels Chiropractic to save these electronically for me and not print them out after each visit. I understand that, upon request, these reports are available to be printed or ed to me for review. Patient s Signature: Date:
INTRODUCTION PATIENT CASE HISTORY
INTODUCTION PATIENT CASE HISTOY Today s Date: / / PATIENT INFOMATION Name: (First MI ast) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #:_ Home: Mobile:
INTRODUCTION PATIENT CASE HISTORY
INTRODUCTION PATIENT CASE HISTORY Today s Date: / / PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #: Home: Mobile:
INTRODUCTION PATIENT CASE HISTORY
INTRODUCTION PATIENT CASE HISTORY Today s Date: / / PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #:_ Home: Mobile:
INTRODUCTION PATIENT CASE HISTORY
INTRODUCTION PATIENT CASE HISTORY Today s Date: / / PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #: Home: Mobile:
INTRODUCTION PATIENT CASE HISTORY
INTRODUCTION PATIENT CASE HISTORY Today s Date: / / PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #: Home: Mobile:
Introduction Patient Case History
Introduction Patient Case History Date: PATIENT INFORMATION Name: (First MI Last) Preferred Name: Street: Apt.: City: State: Zip: Social Security #: Date of Birth: Gender: M F Martial Status: [ ] S [ ]
INTRODUCTION PATIENT CASE HISTORY
Today s Date: / / INTRODUCTION PATIENT CASE HISTORY PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Date of Birth: Gender: Male Female Social Security #: _ Home: Mobile:
INTRODUCTION PATIENT CASE HISTORY
Today s Date: INTRODUCTION PATIENT CASE HISTORY PATIENT INFORMATION Name: (First MI Last) Preferred Name: Address: City: State: Zip: Home: Mobile: Mobile Carrier: Work: Email: Gender: M / F Marital Status:
INTRODUCTION PATIENT CASE HISTORY
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PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
Patient Interview Form
Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
PATIENT INTAKE AND HISTORY FORM
PATIENT INTAKE AND HISTORY FORM (Please print) Name Date of Birth Race: American Indian or Native Alaskan Asian Black/African-American Native Hawaiian or Other Pacific Islander White Refused to report/unreported
New Patient Intake Forms. Patient Data Date. Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other. First Name Middle Initial Last Name
New Patient Intake Forms Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address Line City State Zip Code Home Phone ( ) -
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com