Patient Intake Sheet
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- Stewart Stanley
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1 Patient Intake Sheet Patient Information Name: Cell Phone: ( ) Address: Work Phone: ( ) Emergency Phone: ( ) Address: Date of Birth: Age: Who referred you? Weight: Height: Who is your primary care provider? Employer: Today s Date: Your Occupation: What is the medical reason that brought you to Arcadia Wellness Center? Medications: Allergies: Past Surgeries: Dates: General Health Questions Are you or might you be pregnant? Are you breastfeeding? Are you trying to become pregnant? Are there any other health concerns we should be made aware of?
2 Medical History: General: Fatigue Cancer Weakness Tremors Head, Eyes, Ears, Nose and Throat: Eye problems Ringing in ears Hearing problems Cardiovascular: Chest pain Poor circulation Heart attack Murmur Respiratory: Asthma Valley fever Tuberculosis Low Sex Drive Bruise easily Diabetes Other: Ear aches Sinus problems Headaches Irregular heartbeats Swelling in feet Pacemaker High cholesterol Short of breath Cough (Please mark all appropriate boxes) Insomnia Fevers Alcohol (Quantify ) Dental problems Thyroid problems Head injury Fainting High blood pressure Valve replacement Pneumonia Emphysema Gastrointestinal: Nausea/vomiting GI bleeding from meds Constipation Musculoskeletal: Neck pain Joint pain Osteoarthritis Renal: Kidney infections Hepatitis (Active? ) Neuropsychological: Depression Stress problems Do you take any of the following: Antiobiotics Aspirin or Ibuprofen Blood Pressure Medication Sedatives Fish Oils Accutane in the past 12 months Back pain muscle Rheumatoid spasms Bursitis Kidney problems Anxiety Seizure disorder Anti-coagulants Coritsone or Steroids Insulin Thyroid Medication Tumeric Retin A Tennis elbow Carpal tunnel syndrome Bladder infections Drug/alcohol abuse Anti-depressants Hormones/Contraceptives NSAIDS Vitamin D Blood Thinners Other:
3 Skin Care History: Have you had unprotected sun exposure or been in a tanning booth in the last 2 weeks? Are you planning a vacation in the sun in the next 2-4 months? Please list all injectable procedures (Botox, Filler, etc.) and dates performed: Any history of allergic or other reactions to a skin care product or treatment? If yes, please explain: Please indicate your current skin care products/regimen: Do you tan easily? Yes No Do you burn easily? Yes No Do you suffer from extreme sensitivity to sunlight? Eye Color: Amber Gray Ethnicity: Asian Hispanic/Latino Mixed Race Skin Care History: Blue Green African American Native American Other Brown Hazel Caucasian Pacific Islander Dry Skin Oily Skin Acne/Breakouts Brown Spots Redness Skin Care Concerns: Fine Lines Deep Wrinkles Rosacea Skin Texture Scars Skin Care Products Facial Veins Thin Lips Nasolabial Creases Facial/Body Hair
4 Disease: Headaches Heart disease Stroke Diabetes High blood pressure Increased cholesterol Arthritis Rheumatoid arthritis Kidney problems Liver problems Seizures Osteoporosis Cancer Other medical problems: Family History: Which family member(s)? Consent for Treatment NAME DOB I, the undersigned, hereby authorize Sarah Quinn, FNP-C and whomever he/she may designate as his/her assistant(s) to perform diagnostic tests, and to administer treatment as necessary. I, also certify that no guarantee or assurance has been made to the results that may be obtained and release all liability related to care and that I have provided my complete health history, medications, and health concerns in the Patient Intake Form. I hereby authorize Arcadia Wellness Center, hereafter referred to as Arcadia Wellness Center, to publish photographs taken of me, and my name and likeness, during my appointment for use in Arcadia Wellness Center s print, online and video-based marketing materials, as well as other Company publications. To opt-out, please place your initials in the spot indicated here. INITIALS I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse remittances for the conveyance of credit to my account. HOWEVER, I CLEARLY UNDERSTAND AND AGREE THAT ALL SERVICES RENDERED TO ME ARE CHARGED DIRECTLY TO ME AND THAT I AM PERSONALLY RESPONSIBLE FOR PAYMENT. Patient s Signature Date Witness
5 2701 E. Camelback Road, Suite #163 Phoenix, AZ Phone: Fax: We are a boutique Wellness Center located in the heart of the Arcadia/Biltmore district in Phoenix. We specialize in a variety of different services including:
Patient Intake Sheet
Patient Intake Sheet Patient Information Name: Cell Phone: ( ) Address: Work Phone: ( ) Emergency Phone: ( ) Email Address: Date of Birth: Age: Who referred you? Weight: Height: Who is your primary care
PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
PATIENT DEMOGRAPHIC SHEET
PATIENT DEMOGRAPHIC SHEET Name: Date: Occupation: Gender: Marital Status: Date of Birth: SSN: HOME Street: City: State: Zip: Phone: Cell: Emergency contact : E-Mail Address WORK / SCHOOL Street: City:
GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):
GASTROCARE, P.C. DR. A.B. REDDY, M.D., F.A.C.G. DR. REKHA KHURANA, M.D. Referring Physician: First Name: Date of Birth: Last name: Age: Pharmacy (include location): Fax Number: Email Address: Gender: Male
Name: Age: DOB: / / City Zip Wk Tel: ( ) Cell: ( ) Referring Physician: How did you hear about Dr. Ordon?
Andrew P. Ordon, M.D., F.A.C.S. 465 N. Roxbury Drive, Suite 1001, Beverly Hills, CA 90210 Tel: (310) 248-6250 w Fax: (310) 861-1529 www.drordon.com Date: Name: Age: DOB: / / Address: Home Tel: ( ) City
6140 W Atlantic Avenue * Delray Beach, FL Tel: (561) * (888) 357-DERM * Fax: (561)
Cosmetic Patient Information Today s Date: Reason for visit: Patient Name: (Last) (First) (Middle) Permanent Address (Local): Street City/State/Zip Secondary (Out of State) Address: Street City/State/Zip
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
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.
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS TODAY S PATIENT NAME ADDRESS OF BIRTH APT# CITY STATE ZIP CODE HOME PHONE CELL PHONE SEX MALE FEMALE RACE CAUCASIAN AFRICAN AMERICAN ASIAN/PACIFIC ISLANDER HISPANIC/LATINO PHARMACY
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
New Patient Information. Which Physician will you be seeing today? How did you hear about our practice?
New Patient Information Which Physician will you be seeing today? How did you hear about our practice? Local Pharmacy Name: Pharmacy Phone #: Pharmacy Location/Address: Name Preferred Age: (Last) (First)
Retinal Consultants of San Antonio PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Patient Information. Account #: Date: Person Responsible For Payment (Other than patient):
Patient Information Account #: Date: Race: Ethnicity: Tobacco Use: White or Hispanic Asian Black or African American Native Hawaiian or Pacific Islander American Indian or Alaskan Native Hispanic or Latino
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
PATIENT REGISTRATION PATIENT NAME: DOB: SS#: CITY: STATE: ZIP: CELL PHONE: EMPLOYER: EMPLOYER PHONE: ( ) EMERGENCY CONTACT PH# ( ) RELATIONSHIP:
PATIENT NAME: DOB: SS#: NAME OF PARENTS (if patient is a minor) PATIENT REGISTRATION HOME ADDRESS HOME PHONE: CITY: STATE: ZIP: CELL PHONE: MAILING ADDRESS (if different) CITY: STATE: ZIP: EMPLOYER: EMPLOYER
Cell Phone #: Home Phone #: ** Address (prefer your forever address):
NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:
Patient Enrollment Sheet
Patient Enrollment Sheet PATIENT INFORMATION: LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE CELL PHONE WORK PHONE E-MAIL ADDRESS EMPLOYER YOUR OCCUPATION
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Patient Information. Address: Street Apt. # City State Zip. Seasonal Address: (If different than above address) Address: Street Apt.
Page 1 of 6 Patient Information Name: Date of Birth: Age: Address: Seasonal Address: (If different than above address) Address: S.S. #: - - Sex: M F Marital Status: M S D Sep W Partnered Phone: Home (
NEW PATIENT QUESTIONNAIRE
Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
PATIENT REGISTRATION
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intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Email Address: Birthday: Marital Status: Married
BOCA RATON PODIATRY, P.A. 950 GLADES ROAD #2A BOCA RATON, FL (561) fax Patient Information
Page 1 of 6 Patient Information Name: Date of Birth: Age: Address: Apt. # City State Zip S.S. #: - - Sex: M F Marital Status: M S D Sep W Partnered Phone: Home ( ) Work ( ) Cell ( ) Email: Employer: What
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
MICHAEL J. SUNDINE, M.D., F.A.C.S., F.A.A.P.
MICHAEL J. SUNDINE, M.D., F.A.C.S., F.A.A.P. Certified by the American Board of Plastic Surgery Facial Aesthetic-Cosmetic-Craniofacial Surgeon-Reconstructive-Pediatric Plastic Surgery Reason for Consultation
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Pharmacy and Referrals Pharmacy Name, Street Address & Telephone #: Primary Care Physician s Name, Location & Telephone #:
Patient Registration Please Print Clearly Date: Last Name: First Name: Middle Initial: Sex: Date of Birth: / / Age: Social Security: - - Address: City: State: Zip Code - Circle Preferred Phone Number Home
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?