Patient Introduction
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- Ernest Cook
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1 Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 Patient Introduction Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: Birth Date: (DD-MM-YYYY) - - Age: Male: Female: Occupation: Employer: Marital Status: Spouse s Name: Previous Chiropractor: Last visit to this Chiropractor: City: Reason for leaving: Present MD: Phone #: City: Referred to our Centre by: MVA Only Claim # - Policy # - Other Ins Max Claimable. 0 0 Spouse Ins Max Claimable. 0 0 Fill greyed out boxes only if applicable WSIB Only SIN # - - WSIB/ MVA ONLY I am fully aware that I am responsible for any balances on the account, in the event that your insurance does not approve the treatment plan given by the Doctor.
2 MERIVALE CHIROPRACTIC CLINIC Our Fee Structure Please note our fees for your initial visit: Consultation Complimentary Examination $90.00 Radiology $0.00-$84.00 (subsidized by OHIP) X-Ray Reading/Prescription $30.00 /Report Adjustment /Visit Modality / Traction Acupuncture with Adjustment $40.00 ($30.00 senior & student rate) $20.00 (in addition to regular visit fee) $25.00 (in addition to regular visit fee) Acupuncture 15 minute $ minute $ minute $ hour $ Please note that if you have been involved in a motor vehicle accident, our fee structure may differ due to the complexity of your needs in such cases. Please also note that your clinical Report of Findings, the time that your doctor will spend with you to go over your results, will be included in your initial fee. I fully understand the above fees and give my consent. I also give my consent to have the doctor take any x-rays he/she deems appropriate to better understand my problem and monitor my progress. Who is responsible for your bill: You: Spouse: Auto Ins.: WSIB: Extended Health Ins.: PLEASE SIGN IN PERSON: SIGNATURE: DATE: (Signature of Parent/Guardian required if patient under age 18) Thank You!
3 Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 Adult Consultation History Your Name: Your Main Complaint: Any other Complaints: How long have you suffered with this problem? What have you tried to do to get rid of this problem that DID NOT work? Have you become discouraged about handling this problem? When your problem is at its worst, how does it make you feel? How does this problem interfere with the following areas of your life? WORK: FAMILY: HOBBIES: LIFE: Does handling this problem cause stress for you? What do you do that makes this problem worse? How much older does this make you feel: On a scale of 1 to 10, with 10 being the highest, rate your commitment in helping us solve this problem:
4 What gives you some temporary relief? What is the pattern of this problem? Constant, Intermittent, Occasional Cyclic What is the effect it has on your body functions? How did it start? Are you on any type of medication?, Please list all: Could your problem have been caused by an injury at work? If yes, please give us the details: Have you been involved in an auto accident? Date of accident: Any difficulties from this? Do you have any children? # of children: Children s Names: Do they have any health problems that you are aware of? Is there any other information you would like us to know? SIGNATURE: DATE: For Women Only Date of your last menstrual period: Are using any means of contraception? Do you suffer from PMS? Do you experience severe cramping with your menstrual period? Thank You!
5 Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 MCC Symptom Diagram Patient Name: File #: Date: When you arrive at the clinic, in the diagrams provided below, please mark the areas on your body, which you feel best represent the pain(s) or sensation(s) you are experiencing. Please include all areas. Use the symbols provided below. Also, in order to complete the picture, please draw in your face. Symbols: Numbness Pins & Needles Burning Stabbing & Sharp Dull & Aching Stiff & Tight
6 Health Status Survey Patient Name: File #: Date: PLEASE FILL THIS PAGE OUT BEFORE COMING TO THE CLINIC: Please circle (O) any conditions or symptoms presently causing you problems. Please check ( ) those conditions or symptoms, which have been a problem to you in the past. GENERAL SYMPTOMS Loss of consciousness Blackouts Headache Fever Sweats Fainting Dizziness Clumsiness Convulsions Loss of sleep Numbness, pain or tingling Nervousness Loss of weight MUSCLES & JOINTS Stiff neck Backache Swollen joints Painful tailbone Foot trouble Shoulder pain Arm/Forearm pain Elbow pain Wrist pain Hand pain Arthritis Weakness or loss of strength E.E.N.T. Blurred vision Failing vision (one/both eyes) Crossed eyes Double vision Eye pain Deafness, Earache Ringing, buzzing, any noise in the ears Asthma Frequent colds Sinus infection Enlarged glands Enlarged thyroid Slurred or other speech problems Difficulty swallowing RESPIRATORY Chronic cough Spitting up phlegm Spitting up blood Chest pain Difficulty breathing CARDIOVASCULAR Bleeding Disorder High blood pressure Pain over heart Stroke Hardening of arteries Varicose veins Swelling of ankles Poor circulation Heart of blood disease Angina GENTOURINARY Trouble urinating Blood in urine Kidney infection Bed-wetting Prostate trouble G.U. FOR WOMEN Painful menstruation Excessive flow Hot flashes Irregular cycle Cramps or backache Vaginal, discharge Swollen breasts Lumps in breasts Have you ever been on birth control pills? Yes No Are you currently taking the birth control pill? Yes No # of pregnancies # of children Please inform the doctor if you have ever been tested for HIV or Hepatitis A/B/C. SKIN Rashes, itching Bruise easily Dryness Boils Hives (allergy) GASTROINTESTINAL Poor appetite Indigestion Excessive hunger Belching or gas Nausea Vomiting (blood?) Pain over stomach Constipation Diarrhea Hemorrhoids (piles) Jaundice Gall bladder trouble Intestinal worms Ulcer Diabetes Have you ever had any fractures? Have you ever been in a car accident? Yes No Have you ever been hospitalized? If yes, why? Are you currently a smoker? Yes No Have you ever smoked in the past? Yes No Have you ever been diagnosed with cancer? Yes No Do you take medication on a regular basis? Yes No If so, what? (blood thinner, blood pressure, etc.)
7 Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 CLINIC POLICIES Welcome to our office. Our goal is to serve you with exceptionally friendly and prompt service and provide the best family health care available. In return, you will receive restored health. It is our experience that our patients who follow these simple guidelines obtain the best results and greatest benefits to their health. CLINIC HOURS Our day is divided into office hours, adjustment hours and report hours. Reports and consultations should be scheduled during report hours only. Adjustment times are as follows: Dr. Leo Lachowich Dr. Tatyana Lachowich Monday: 3:00pm 06:45pm 7:30 11:45am Tuesday 7:00am 11:45am 03:00pm 06:45pm Wednesday 7:00am 11:45am 3:00pm 06:45pm 12:00pm 05:00pm Thursday: 3:00pm 06:45pm 03:00pm 06:45pm Friday: 7:00am 11:45am 7:00am 11:45am Saturday 10:00am 11:45am APPOINTMENT SCHEDULING/MISSED APPOINTMENTS The Chiropractor has designed a specific course of action to allow proper care, a must for spinal and postural correction. A personal appointment calendar has been designed for you to save time on each visit. If an appointment must be changed, 24 hours notice is required. All missed appointments should be made up later the same day or within 24 hours, let our front desk know and changes will be made accordingly. BROKEN APPOINTMENTS No show appointments are subject to a $40.00 (Forty Dollars) charge. Please give 24 hours notice so that the doctor may service others in need at your time. If appointments are repeatedly missed we will, regretfully, dismiss you from care. CHILDREN/FAMILY Once you understand that the nervous system controls and coordinates all functions of the body and subluxation interferes with nerve flow, we expect that you would want everyone in your family checked. We have costeffective family programs, and extend the opportunity to have your family checked at our expense within 7 days of starting care. FINANCIAL AGREEMENTS It is your payment that allows us to continue providing high levels of professional care, maintain our facility, and pay our staff. If for any reason you cannot keep your financial agreement, inform us immediately to eliminate any misunderstandings. INTERRUPTION OF CARE In the unlikely event it is necessary to discontinue your care for any reason, outstanding fees become payable and due immediately to eliminate any misunderstandings. REMEMBER Spinal correction and healing take time. If you do not feel satisfied with your body s responses, you agree make an appointment to discuss this with the Chiropractor. We want you to get the most from your chiropractic care. MODALITIES Patients receiving modality or traction table treatment are charged $20.00 in addition to regular visit fees. WSIB/ MVA ONLY I am fully aware that I am responsible for any balances on the account, in the event that your insurance does not approve the treatment plan given by the Doctor. PLEASE SIGN IN PERSON: Signed I have read and understand the above policies and agree to abide by them. Date:
8
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
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 PATIENT INFORMATION Last
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
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
New Adult Intake Form
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WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one) Date of
Reason forappointment:
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Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
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Dr. Michelle Cruickshank
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Gentle Chiropractic, LLC Dr. Amy Richard 7919 Big Bend Blvd. Suite B Webster Groves, MO Phone: Patient Data Sheet:
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History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Pediatric Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
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HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Full Name Preferred name. Home Street Address. City, State, Zip. Cell phone Home or Work. # Children Ages:
Health History Full Name Preferred name Home Street Address City, State, Zip Cell phone Home or Work Email # Children Ages: Occupation Hours/day on computer Hours/day sitting Who can we thank for referring
Chiropractic Case History/Patient Information
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COMPREHENSIVE HEALTH & WELLNESS PROFILE
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New Patient Intake Form
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Patient Intake Form Please Write Legibly
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PERSONAL INJURY QUESTIONNAIRE
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Patient Name (last, first) Sex: Male / Female
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
KINESIS HEALTH ASSOCIATES PATIENT PAST HISTORY FORM
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PLEASE ASK US FOR HELP IF YOU HAVE ANY QUESTIONS.
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Child History Form. Personal Information. Legal Guardian & Occupation: Home Phone: Alternate Phone: Provincial Health Care Plan
Child History Form (Ages 6-12) The data on this form is essential if we are to render the best professional care. We appreciate your cooperation in filling it out so that we will have accurate records.
Welcome to our office!
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PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
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WELCOME TO OUR FAMILY!
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Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
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Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
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KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
Brisbin Family Chiropractic
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Patient Introduction
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Matthews Family Chiropractic
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ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
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Chiropractic Case History/Patient Information
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CHIROPRACTIC INTAKE FORM
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PATIENT INFORMATION Please print clearly and complete all blanks
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New Patient Information
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AHI - New Patient Information
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Patient Information Name ----------------------------------------------------------- Address --------------------------------------------------------- City State Zip Home Phone -------------------------
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
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New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
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