Personal and Family Health History
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- Alison Franklin
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1 Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W Spouse s Name Date of Birth Age Spouse s Occupation Referred by: Number of Children and Ages Previous Chiropractic care? Name Age Yes No Reason Name Age Yes No Reason Name Age Yes No Reason You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blueprints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your health can be interfered through accidents and challenges that cause a disruption to your health expression. Through your examination and through your involvement in chiropractic care, we will work to remove these interferences to your natural health expression so that you can live the quality of life you deserve. Circle all that apply Patient Spouse Child #1 Child #2 Child#3 Chiropractor s Comments 1. Was your birth Traumatic? Long Delivery? Y Y Y Y Y Difficult Delivery? Y Y Y Y Y Forceps? Y Y Y Y Y Caesarian? Y Y Y Y Y Breech/cephalic? Y Y Y Y Y 2. Growth and Development Did you ever once. Learn to care for your spine? Y Y Y Y Y Fall out of bed? Y Y Y Y Y Bang your head? Y Y Y Y Y Breastfeed? Y Y Y Y Y Have childhood sickness? Y Y Y Y Y Have any accidents? Y Y Y Y Y Have surgery? Y Y Y Y Y Fall while learning to walk? Y Y Y Y Y Bullied by your siblings? Y Y Y Y Y Chair pulled out when sitting? Y Y Y Y Y Fall down stairs? Y Y Y Y Y Pulled by your arm? Y Y Y Y Y Experience other trauma? Y Y Y Y Y
2 Circle all that apply Patient Spouse Child # 1 Child # 2 Child # 3 Chiropractor s Comments 3. Current Health Habits Did/ do you Smoke/Use tobacco products? Y Y Y Y Y Drink alcohol/take Drugs? Y Y Y Y Y Diet (do you eat healthy foods?) Y Y Y Y Y Drink water, how many glasses? Y Y Y Y Y Exercise regularly? Y Y Y Y Y Have teeth problems? Y Y Y Y Y Have eye problems? Y Y Y Y Y Have hearing problems? Y Y Y Y Y Have sleeping problems? Y Y Y Y Y Have occupational stress? Y Y Y Y Y Have physical stress? Y Y Y Y Y Have mental stress? Y Y Y Y Y Have hobbies/sports injuries? Y Y Y Y Y Sleeping posture: side stomach back 4. Current Health Condition Present complaint (be brief) / Reason for your visit today? Pain or Problem started on Pains are: Sharp Dull Constant Intermittent Does your pain radiate (travel)? What aggravates your condition/pain? Is condition worse during certain times of the day? Is this condition interfering with work? Sleep? Routine? Other? Is this condition getting progressively worse, better, or staying the same? Other Doctors seen for this condition Any home remedies? 5. Other Past Health Conditions And/Or Symptoms Headaches Muscular In coordination Prostate Problems Depression Neck Pain Visual Disturbances Abnormal Weight Light Bothers Eyes Upper Back Pain Dizziness Gain/Loss Loss of Memory Lower Back Pain Loss of Balance Loss of Appetite Ears Ring Shoulder Pain Nervousness Abdominal Pain Fever Irritability Elbow/Upper Arm Pain Ulcer Fainting Wrist pain High Blood Pressure Hepatitis Loss of taste Hand Pain Heart Attack Liver/Gall Bladder Diarrhea Chest Pains Hip/Upper Leg Pain Disorder Feet Cold Stroke Knee/Lower Leg Pain Cancer Hands Cold Ankle/Foot Pain Angina Tumor Stomach Upset Jaw Pain Kidney Stones Asthma Constipation Kidney Disorders Joint Swelling/Stiffness Pins & Needles in legs Loss of Balance Arthritis Bladder Infection Pins & Needles in arms Buzzing Painful Urination Rheumatoid Arthritis Numbness in fingers General Fatigue Loss of bladder control Numbness in Toe
3 5. Other Past Health Conditions And/ Or Sym ptom s ( cont d) What is your height? Weight? Have you been under medical and/or drug care? Do you have a primary care physician? Who? What medications are you taking? What side effects have you experienced from the medications and/or surgery? Do you take vitamins or supplements? 6. Further Family History: Fathers Side Mothers Side Heart Disease Arthritis Cancer Diabetes Other How old is, or was, your oldest living relative? years old As a result of my chiropractic care, I would like to: Please check all that apply Feel better quickly Have a healthier spine Have a healthier body by keeping my nervous system healthy Live a healthier life style Insurance Information: (Please present your card to be copied) What insurance do you have? Is a referral required? What is your co-payment? Assignment of benefits I irrevocably assign to Dr. Emil A. Tocci, IV all my rights and benefits under any insurance contracts for payment services rendered to me by Dr. Emil A. Tocci, IV. I irrevocably authorize all information regarding my benefits under any insurance policy relating to any claims by Dr. Tocci to be released to him. I irrevocably authorize Dr. Emil A. Tocci, IV to file insurance claims on my behalf for services rendered to me. I irrevocably direct that all such payments go directly to Dr. Tocci. I irrevocably authorize Dr. Emil A. Tocci, IV to act in my behalf and report any suspected violations of proper claims practices to the proper regulatory authorities. This assignment of benefits has been explained to my full satisfaction and I understand its nature and effect. I understand that I am personally responsible for payment for all services rendered in accordance with the regulations of New York. Signature Date
4 Terms of Acceptance When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxations. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. (Print name) All questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. (Signature) (Date)
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7 Emil A. Tocci, D.C Long Beach Road Oceanside, NY (516) NOTICE OF PRIVACY PRACTICES PATIENT ACKNOWLWDGEMENT Patient Name: Date of Birth: I have received this practice s Notice of Private Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice s legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Private Practices, and to make changes regarding all protected health information resident at, or controlled by this practice. I understand I can obtain this practice s current Notice of Privacy Practices on request. Signature: Relationship to patient (if other that self): Date:
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New Patient Form Date:
New Patient Form Date: Patient name: M F Date of Birth: / / SS# Address: City: State: Zip Code: Home Phone #: Cell #: Work #: Email: Emergency Contact: Emergency Phone #: Referred by: Primary Care Physician
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
Welcome To Our Office
Welcome To Our Office CASE HISTORY: Patient s Name: Street/City/State/ZIP Email Address: Home Phone: Work Phone: Birthdate: Age: Sex: Martial Status: M S W D Social Security #: Driver s License#: Spouse
APPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
Registration and History Form
Registration and History Form PATIENT INFORMATION Date: / / Patient Address City State Zip Sex M F Age Birthdate Occupation _ Employer Spouse s Name _ Sex M F Age Birthdate Occupation Spouse s Employer
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
7035 Beracasa Way, Suite 103 Boca Raton Florida, 33433 Phone# (561)674-1217 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name middle Address City State Zip Date of Birth Age Social Security
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability.
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability. Patient Information Title: Mr. Mrs. Miss Ms. Dr. (circle one)
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address: Gender: Date of Birth: Occupation: Best Time to Contact: Number of
NPM INTAKE FORM. INFORMATION: Name: Age: Date: Home Phone No.: Work Phone No: Cell Phone: Address:: Gender: Date of Birth:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
CHIROPRACTIC CENTER OF ANNAPOLIS 108 Old Solomons Island Rd., Bldg. 2 Annapolis, MD (410) Dr. William J. Boro Dr. Mary X.
CHIROPRACTIC CENTER OF ANNAPOLIS 108 Old Solomons Island Rd., Bldg. 2 Annapolis, MD 21401 (410) 266-5054 Dr. William J. Boro Dr. Mary X. Psaromatis New Patient History Form Patient Name: Date: Please list
NPM INTAKE FORM INFORMATION: Name: Age: Date:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA (570)
PATIENT Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA 17745 (570) 748-3590 PERSONAL INFORMATION: Please Circle: Mr. Mrs. Ms. Miss Dr. Male Female Name: Nickname: Age: DOB: Address: City/State/
Carriage House Chiropractic and Acupuncture
Chiropractic Patient History Questionnaire Date: Name: Date of birth: Address: City: St: Zip: Phone: (home) (cell) (work) May we send appointment reminders to you via text messages on your cell phone Email:
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Date of Birth Age Address City State Zip NATURE OF ACCIDENT: 1. Date of Accident Time of Day (AM / PM) 2. Please state how the accident happened in your own words: 3.