CHIROPRACTIC ASSOCIATES CLINIC
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1 CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) FAX: (306) CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last Name: First Name: Personal Health #: _ Date of birth: MM DD YY Male Address: _ City: Province: Postal Code: _ Female _ Phone #: Home: ( _ ) _ - Work: ( _ ) _ - Cell: ( _ ) _ - Family Doctor: Referring Practitioner: Place of Employment: Occupation: *NOTE: Text messaging is used to notify patients about upcoming appointments. Would you like to receive text messages from our office? Yes No EMERGENCY CONTACT INFORMATION Emergency Contact Name: Relationship: Phone #: Home: ( _ ) _ - Cell: ( _ ) _ - Work: ( _ ) _ - Will you be claiming your Chiropractic treatment under any of the following? Please check the appropriate box. WCB SGI RCMP DVA CAF Supplementary Services (Government Program) (Senior Income Plan, Family Income Plan and Social Services) Claim #: Contact Person: Phone Number: ( _ ) _ - Have you seen a Chiropractor before? Yes No If so, who? For what complaint? Have you had any imaging on the area of concern? X-ray MRI CT Scan ULTRA SOUND When? Where were the images taken? 1/4
2 PAST AND PRESENT MEDICAL INFORMATION Please circle any conditions that presently cause you problems. Please check any conditions that were a problem for you in the past. General Symptoms: Headache Fever Sweats Fainting Dizziness Convulsions Nervousness Loss of weight Numbness, pain, tingling Genitourinary: Poor appetite Blood in urine Kidney Infection Bed wetting Prostate trouble (men) Respiratory: Chronic cough Spitting up phlegm Spitting up blood Chest pain Difficulty breathing Have you recently had: Recent fever/infection Unexpected weight loss Pain waking you up at night Night sweats Bowel or bladder problems Numbness or tingling History of cancer Muscles and Joints: Stiff neck Backache Swollen joints Painful tailbone Foot trouble Shoulder pain Elbow pain Wrist pain Hand pain Hip pain Knee pain Arthritis Have you had any fractures? Cardiovascular: Pain over heart Stroke Hardening of Arteries High blood pressure Varicose veins Swelling of ankles Poor circulation Angina G.U. for Women: Painful menstruation Excessive flow Cramps or backache Vaginal discharge Swollen breasts Lumps in breasts Hot flashes Number of pregnancies: Number of children: Do you currently have any of the following symptoms: Dizziness Trouble swallowing Trouble speaking Fainting Double vision Unusual balance issues Nausea Numbness Gastrointestinal: Poor appetite Indigestion Excessive hunger Belching (gas) Nausea/vomiting Vomiting with blood Pain over stomach Constipation Diarrhea Hemorrhoids Jaundice Gall bladder problems Ulcer Eyes, Ears, Nose, Throat: Failing vision Crossed eyes Eye pain Deafness Earache Asthma Frequency colds Sinus infections Enlarged glands Enlarged thyroid Skin: Rashes Itching Bruises easily Dryness Boils Please list past/recent surgical procedures: Please list any medications you are currently taking: 2/4
3 REASON FOR VISIT What brings you into the office today? When did this complaint begin? How often does this complaint bother you? How long does it last? Is there ever a time when the pain does not bother you? How would you describe the pain? (Ex: Sharp, stabbing, achy, dull). Do you have any numbness or tingling in the arms or legs? Does your pain radiate down the leg or arm? Is there anything you find relieving (ex: ice, heat, rest)? Is there anything you find aggravating (ex: standing, bending over)? Have you received treatment/surgery for your current complaint? If so, from whom? Has there been a change in bowel/bladder function? No Yes Describe: If the complaint is related to your back, is the pain mainly in the back or leg? Back Dominant. Leg Dominant. Do you have a history of back problems? Do you have, or have you ever had, any medical conditions? (Ex: high blood pressure, high cholesterol, diabetes, cancer, heart attack, stroke, or any other medical condition or event). Please list. Please list any past or present medical conditions that your blood-related family members are affected by. (Ex: high blood pressure, high cholesterol, diabetes, cancer, heart attack, stroke, or any other medical condition or event). Please list. Do you have any allergies? If so, please list. Have you had any falls, motor vehicle accidents, or other traumatic incidents? What is your height? _ What is your weight? _ 3/4
4 PAIN QUESTIONNAIRES Body Pain Diagram Please fill this out carefully. Use the appropriate symbols (provided below) to mark the area on the diagram where you feel the described sensation. Include all affected areas, including radiation of pain. Numbness = = = Burning Pain x x x Aching Pain ( ( ( Pins & Needles o o o Stabbing Pain / / / Level of Disability What is the overall level of disability? (Please check the most appropriate response). No Limitations. Mild Limitations able to do most activities with minor modifications. Moderate Limitations able to do most activities with modifications. Severe Limitations unable to perform most activities. Visual Analog Scale If you had to rate your pain on a scale of 0-10, (0 = no pain, 10 = most pain imaginable), where would you rate your pain right now? Please indicate on this scale with a check or circle Chiropractic Associates Clinic is a multi-disciplinary clinic. If at any time you see more than one health care practitioner at this clinic, presently or in the future, do you agree to allow your health care practitioners to communicate with each other about your case? Yes No If the need should arise, do you agree to allow your health care practitioners to communicate with other members of your health care team outside of this office? (i.e. General Practitioner, other specialists, etc ) Yes No I hereby certify that the above information given are true and correct as to the best of my knowledge. Patient Signature/Legal Guardian 4/4 Date
5 CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) FAX: (306)
6 Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. The consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as paralysis or death. Alternatives Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment. Questions or Concerns You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor s attention. If you are not comfortable, you may stop treatment at any time. Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition. DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby consent to chiropractic treatment as proposed to me. Name (Please Print) Signature of patient (or legal guardian) Date: 20 Signature of Chiropractor Date: 20 CCPA Page 2 of 2
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
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:
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
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:
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
New Adult Intake Form Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. Name: Today s Date: Age: Date of Birth
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.
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)
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 #
Patient Introduction
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:
Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
Dr. Michelle Cruickshank
CHIROPRACTIC INTAKE FORM A Multidisciplinary approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best of
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
AHI - 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
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
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)
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
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
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
New Patient Intake Form
New Patient Intake Form Date: Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. Name: Gender: Date of Birth:
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:
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.
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: 403.243.8114 Fax: 403.212.0880 Full Name: Address: City: Province: Postal Code: Date of Birth (MM/DD/YYYY): Home Phone:
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:
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 #
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
Gentle Chiropractic, LLC Dr. Amy Richard 7919 Big Bend Blvd. Suite B Webster Groves, MO Phone: Patient Data Sheet:
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Cascadia Chiropractic Centre
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Reason forappointment:
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
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
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
PERSONAL INJURY QUESTIONNAIRE
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
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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?
PATIENT ENTRANCE FORM
PATIENT ENTRANCE FORM Name _ Date Address City/ Province Postal Code Home Telephone Work Telephone Email Address Would like email reminders for appointments? Yes No Date of Birth (Day/Month/Year) Age Marital
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:
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)
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Creekside Chiropractic
Creekside Chiropractic ---- - New Patient History Date: Name: Home Phone: Cell Phone: Social Security #: Birthdate: Age: Email Address: Street Address: City: State: Zip: Please circle the best way to contact
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 Age Date. Please list All your current health complaints, including the reason that brought you to our office:
Name Age Date Please list All your current health complaints, including the reason that brought you to our office: List any other doctors see for current problems and list treatment received and results:
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
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Sydney Chiropractic, DR. DAVID DUNN
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Cascadia Chiropractic Centre
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CHIROPRACTIC INTAKE FORM
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GENERAL PATIENT INFORMATION
GENERAL PATIENT INFORMATION Name: Gender: Date of Birth: Age: M/F DD/MM/YY Address: City: Province: Postal Code: Tel: Bus.Tel: Alt. Tel: Emergency Contact: Tel: Relation: E-mail Address: @ Please indicate
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Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
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NEW PATIENT QUESTIONNAIRE
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Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
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?
Patient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
Patient Information. Refurredby. Emergency Contact. Have you ever had chiropractic care before? For what problem? No ----
Patient Information Name ----------------------------------------------------------- Address --------------------------------------------------------- City State Zip Home Phone -------------------------
Creekside Chiropractic
Creekside Chiropractic ---- - New Patient History Date: Name: Home Phone: Cell Phone: Social Security #: Birthdate: Age: Email Address: Street Address: City: State: Zip: Please circle the best way to contact
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
ACUPUNCTURE QUESTIONNAIRE
ACUPUNCTURE QUESTIONNAIRE CHIEF COMPLAINT: PAIN EVALUATION Pain Scale: no pain 0 1 2 3 4 5 6 7 8 9 10 severe pain 1 Mark each area where you are having pain according to the pain scale above. HISTORY HEALTH
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
NEW PATIENT MEDICAL FORM. Name: Date of scheduled appointment: Address: Skype ID: Date of Birth: Gender: Height: Weight:
NEW PATIENT MEDICAL FORM Circle one: Dr. Tent Dr. Senechal Name: Date of scheduled appointment: Address: City: State: Zip: Home Phone: Cell Phone: Email: Skype ID: Date of Birth: Gender: Height: Weight:
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire