WELCOME TO OUR FAMILY!
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- Jocelin Garrison
- 5 years ago
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1 WELCOME TO OUR FAMILY! We know you have many options for your wellbeing, and truly embrace that you have chosen us to take care of you and any other of your family members. Our goal is to provide you with the best coordinated, highest quality care. To reach this goal our skilled team take a personalized approach to care by sitting down with you and discussing your needs and treatment. Your health and overall wellness is our primary concern. Our team of integrated Practitioners cover many areas of your total health including: spinal decompression and chiropractic care, registered massage therapy, preventative care, diagnostic and genetic testing, nutrition and weight-loss, non-surgical medical spa treatments including laser hair removal, skin tightening, photofacial RF and Velashape. The partnership we are about to embark on is one which we hope will renew your health and keep it that way for as long as possible. Our professional team will impart our skills and knowledge, and hope that in return you are responsible for your part in the treatment and healing process, and in sustaining what we achieve together. Health is a lifetime of work. We are here for you. Let's get started! Together we hope to set goals and assist you in the amazing process of healing and total wellness. As our gift to you for becoming a new patient at our clinic, we offer a 15 minute complimentary consultation on genetic testing and/or nutrition, as well as a free 15 minute skin analysis with recommendations. Please book these at your first appointment in conjunction with your follow-up visits. Again, our sincerest thanks to you for choosing us. It is our pleasure to serve you and any other members of your family that may benefit from our outstanding care. THE VITALITY CENTER TEAM The Vitality Center 330 Dupont Street, #100 info@thevitalitycenter.net
2 Patient Introduction Personal History: Your Name: First Middle Last Your Complete Address: Telephone: Home: Cell: Please check here if you want to receive updates and promotions Please check here if you would like auto-reminders for your appointments Extended Health Care Provider : Birth Date: Day: Month: Year: Marital Status: Occupation: Employer: Previous Chiropractor: City: Date of Last visit to this Chiropractor: Reason for leaving: Present MD: City: Referred to our Centre by:
3 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 many years 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: 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?
4 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? Do they have any health problems that you are aware of? Is there any other information you would like us to know? For Women Only Date of your last menstrual period: Are using any means of contraception? Do you experience severe cramping with your menstrual period? Do you suffer from PMS?
5 FAMILY HEALTH HISTORY Patient Name: _ Date: _ Please review the diseases and conditions listed below and indicate those that are current health problems of a family member by the designation C under his or her column. The designation P should be used to indicate a past problem. Leave blank those spaces that do not apply. Condition Father Mother Spouse Siblings Children Self Age Age Age Age Age Age Age ADHD Allergies Arthritis Asthma Autism Back Trouble Bed Wetting Bursitis Cancer Chest Pain Colic Constipation Crohn s Disease Depression Diabetes Diarrhea Disc Problems Down s Syndrome Ear Infection Emotional Issues Emphysema Epilepsy Headaches Migraines Heartburn Heart Trouble High Blood Press IBS Indigestion Infertility Insomnia Kidney Trouble Neck Pain Neuritis Nervousness Pinched Nerve Scoliosis Sinus Trouble Signature of Patient: Date:
Patient Introduction (age 13-21)
#204, 1740 Gordon Drive Kelowna, BC V1Y 3H2 250-868-4880 www.lifeworkschiropractic.ca wecare@lifeworkschiropractic.ca Patient Introduction (age 13-21) Personal History: Your Name: First (Nick-name) Last
Patient Introduction Child (to age 12)
#204, 1740 Gordon Drive Kelowna, BC V1Y 3H2 250-868-4880 www.lifeworkschiropractic.ca wecare@lifeworkschiropractic.ca Patient Introduction Child (to age 12) Personal History: Your Name: First (Nick-name)
Life Story. Vital Information. Street City State Zip. Home Phone: May we leave a message? Cell Phone: Emergency Contact
Today s date: Life Story Patient Number Vital Information Patient s Name I prefer to be called Marital Status Spouse/Partner Name Birth date: Age: Adderss Street City State Zip Email Home Phone: May we
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
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
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Chiropractic Case History/Patient Information
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Child (0-17) New Patient Intake Form. Child s Health Summary
Child (0-17) New Patient Intake Form Child s Name Age Birth Date / / Soc. Sec. # - - Parent/Guardian Name: Address: City: State: Zip: Parent/Guardian Email: Parent/Guardian Phone: Whom may we thank for
Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Tassin Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
Patient Information Form
Patient Information Name: First Middle Last Address: City: State: Zip: Telephone: Home Cell Work Date of Birth: Social Security Number: (SSN is only needed if getting super-bills for potential insurance
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
New Practice Member Application
T 1 2 3 Date / / New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Cellular Provider Email Address Occupation Employer s Name Single / Married
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
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Chiropractic Case History/Patient Information
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LIST YOUR HEALTH CONCERNS BELOW
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Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
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Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
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Patient Introduction
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Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address:
PATIENT HISTORY FORM
PATIENT HISTORY FORM NAME: DATE: DATE OF BIRTH/AGE: Name of the physician who referred you to see a neurosurgeon: City and State of referring physician: Is your referring physician a chiropractor? Yes
I choose not to specify
Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.
Health and History Assessment ACCOUNT #: HIPPA: CTT:
ACTION Chiropractor LLC Health and History Assessment ACCOUNT #: HIPPA: CTT: NAME: SEX: M/ F BIRTHDATE: / / ADDRESS: CITY: STATE: Zip: PHONE # s: HOME: ( ) WORK: ( ) CELL: ( ) HEIGHT: WEIGHT: MARITAL STATUS:
WELCOME TO The Chiropractors at Commerce Place
WELCOME TO The Chiropractors at Commerce Place For Office Use Only live well adjusted Doctor: Date: _ Referred by: MVA WCB Date of injury: Previous Chiro Care: Y / N Previous Chiro: _ Last adj date: Spine