Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
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1 Basic Information Full Name: Address: City: State: Zip: Cell: Home: Work: Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S Occupation: Emergency Contact: Phone: Children: O No O Yes / Ages: How were you referred into our office?: Is this a O Wellness visit, or is there a O Specific concern? Have you ever received chiropractic care? O No O Yes When? Who How was your experience?: Do you have any concerns about seeing a chiropractor?: Chiropractic Care My initials show: I understand Chiropractic health care seeks to restore health through natural means without the use of medicine or surgery. When a patient seeks chiropractic care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic evaluates the spine for vertebral subluxation and uses specific adjustments to assist the body in correcting the subluxation in order to restore the body s natural healing ability. We do not diagnose or treat any disease. (We only offer to diagnose and adjust vertebral subluxations). If in the course of the chiropractic examination non-chiropractic or unusual findings are present, you will be advised to seek the services or another health care provider. My initials show: I authorize Drs. James and/or Elizabeth Phillip to examine and administer care to my child as they deem appropriate through the use of chiropractic health care, and I give authority for these procedures to be performed. Insurance My initials show: I understand and agree that if I have health and/or accident insurance, those policies are an arrangement between the insurance carrier and myself. Further, I understand that this health care provider will prepare reports and forms to assist in reimbursement from the insurance company. Any amount authorized to be paid directly to this office will be credited to my account on receipt. I understand and agree that I am personally responsible for payment for services rendered to me. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. It is understood and agreed that the amount paid to the doctor for x-rays is for examination and interpretation only and the actual films remain the property of this office, being on file where they may be viewed. My initials show: I authorize this health care facility to release all information related to the care I receive, to my HMO, insurance company, third party payer, or their designee, as may be necessary for the payment of my bill, determining benefits, or for utilization and quality review purposes. Notice of Privacy Practices My initials show: I further acknowledge that Phillip Family Chiropractic s Notice of Privacy Practices has been provided to me. I understand I have a right to review Phillip Family Chiropractic s Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of heath care operations of Phillip Family Chiropractic. The Notice of HIPAA Privacy Practices for Phillip Family Chiropractic is also provided on request at the main administration desk of this practice and on the website at This Notice of Privacy Practices also describes my rights and Phillip Family Chiropractic s duties with respect to my protected health information. Phillip Family Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by accessing Phillip Family Chiropractic s website, calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment. Patient/Parent-Guardian Signature: Date:
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3 Case History Name: Date: Please fill out the paperwork to the best of your ability. Even if some questions may seem unrelated to your current condition, they all serve a purpose in helping us understand your health and give you the best care possible! Please check areas of stress that apply to your life, either in the past (P) as well as current (C). Physical Stress Emotional Stress Chemical Stress P C P C P C Birth Trauma Slips / Falls Car Accidents Sports Injuries Physical Abuse Work Injuries Repetitive movements Poor Posture Sitting on your wallet Sleeping position (stomach) Extensive Computer Work Heavy purse/backpack Heavy lifting/bending Driving for many hours Continuous sitting/standing Bone fracture/s Surgery Please list any MAJOR or MINOR accidents, falls and injuries: Relationships Work Children Money/bills Homework Exams High Stress Fast paced life Hold in feelings Quick tempered Verbal abuse Perfectionist Procrastinator Sickness/loss of a loved one Self esteem Environment Smoker/second hand Poor diet Caffeine amount? Excessive sugar Processed foods Artificial sweeteners Conventional meat Antibiotics Prescription drugs Over-the-counter drugs Recreational drugs Energy drinks Fast food Microwaveable food Soda Sports Injuries: Surgeries: Current medications/drugs (prescription/non-prescription) and what for: List all nutritional supplements, vitamins, homeopathic remedies you presently take and why: Family History of: O Cancer O Heart Disease O Diabetes O Stroke O Arthritis What signals has your body been communicating? P = Past, C = Current P C P C P C P C Dizziness Elbow, Wrist, Hand Pain IBS (Constipation or Diarrhea) Disc Problems Headaches Arm &/or Hand Numbness Digestive Disorders Chronic Fatigue Ear Infections Shoulder Pain Low back Pain Lupus TMJ Mid Back Pain Sciatica Fibromyalgia Neck Pain Heart Disorders Leg &/or Feet Numbness ADD/ADHD Migraines Stomach Disorders Hip Pain GERD Sinus Issues Unexplained Nausea Leg Pain Anxiety Thyroid Issues Reflux Knee Pain Depression Asthma Kidney Disorders Reproductive Disorders Nervousness Ulcers Bladder Problems Fertility Issues Epilepsy Chest Pains Growing Pains (past) Menstrual Issues
4 Present Complaint/s Please show us the area of your complaint/s by circling the area as accurately as possible. Be sure to label complaint #1 & complaint #2 Complaint #1 When did the problem/s start? Is the pain: O Constant O Random O Off and on O : Describe the pain (check all that apply): O Sharp O Dull O Ache O Pinch O Throbbing O Shooting O Burning O Tightness/stiffness O Tingling O Numbness O : Does the pain radiate/travel to other body parts? Rate your Pain: No Pain Worse Pain Is there anything that makes your condition better? Is there anything that makes your condition worse? When is your condition worse? O Morning O Afternoon O Evening O During the night O No specific time Is your condition interfering with: O Work O Sleep O Driving O Exercise O daily activities: Have you seen anyone else for this condition? Complaint # 2 When did the problem/s start? Is the pain: O Constant O Random O Off and on O : Describe the pain (check all that apply): O Sharp O Dull O Ache O Pinch O Throbbing O Shooting O Burning O Tightness/stiffness O Tingling O Numbness O : Does the pain radiate/travel to other body parts? Rate your Pain: No Pain Worse Pain Is there anything that makes your condition better? Is there anything that makes your condition worse? When is your condition worse? O Morning O Afternoon O Evening O During the night O No specific time Is your condition interfering with: O Work O Sleep O Driving O Exercise O daily activities: Have you seen anyone else for this condition?
5 Your Commitment and Goals People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your plan of care. Please check the type of care desired so that we may be guided by your wishes whenever possible. Patch Care: Short term relief of pain & discomfort. (I want the doctor to recommend a short term care plan to get rid of my pain). Restoration Care: Relief of pain & discomfort with correction and restoration of the problem and improvement of overall function in the body. (I want the doctor to recommend an appropriate schedule to correct my problem and keep it from returning). Wellness Care: After your problems are corrected, you have the option to keep it that way. This type of care occurs after completion of Restoration Care. Self Controlled Care: I don t want the doctor to recommend care, I would like to come in on my own schedule when I feel the need to. Please rate your commitment to your care: Not Committed Very Committed What are your 3 goals in receiving care here? On a scale of 1-10, where do you rate your health at now? Sick Healthy On a scale of 1-10, where would you like your health to be? Sick Healthy Chiropractic is Health Insurance Premiums small, Dividends large! -B.J. Palmer I would like to learn more about; We strive to keep our practice members educated so they can make the best decisions regarding their health. What topics are you interested in learning more about be it via handouts, workshops or general conversations during your adjustments? Chiropractic for Babies & Kids Healthy Diet & Nutrition Living with Less Stress Shoe Orthotics Chiropractic for Pregnancy Exercise & Fitness Better Posture Supplements for health Preconception & Fertility Proper lifting technique Essential Oils Lifestyle Fixer Upper Core & Pelvic floor Rehab Chiropractic & Athletics Raising Healthy Kids : How long you decide to benefit from chiropractic care is always up to you! Any other questions, comments or concerns? Anything we missed?
Current Health Information
Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms
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
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
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
Who may we thank for referring you?
NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
Revelation Chiropractic Health Profile
Revelation Chiropractic Health Profile Name Date / Age Male / Female Address Apt City Zip Phone Numbers: Home Cell Circle best number to reach you at: Home Cell Date of Birth / / Occupation Email Address
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
LIST YOUR HEALTH CONCERNS BELOW
8209 Natures Way Unit 115 Lakewood Ranch, Florida 34202 (941) 877.1507 Name Date / / Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name
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
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
ADIO CHIROPRACTIC HEALTH PROFILE
ADIO CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
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
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
LIST YOUR HEALTH CONCERNS BELOW
T 1 2 3 ROOTS CHIROPRACTIC HEALTH PROFILE In Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Work Email Address Date of Birth / / Occupation Employer's Name Single / Married / Divorced
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
Chiropractic Case History/Patient Information
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Welcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
LIST YOUR HEALTH CONCERNS BELOW
LOCATION COMING SOON Lakewood Ranch, FL 32402 941.877.1507 Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name Position Single
CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
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
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
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
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634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
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SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
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RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
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LIST YOUR HEALTH CONCERNS BELOW
Date / / HEALTH PROFILE T C E X Name D.O.B. / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Carrier: Email Address Occupation Employer s Name _ Single / Married / Divorced / Widowed
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3. How Long Has This Been An Issue?
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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.
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New Practice Member Application
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MEDICAL HISTORY QUESTIONNAIRE
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1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Race: Marital: M S W D Occupation: Office Phone:
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)
Re-Exam Questionnaire
Re-Exam Questionnaire Patient Name: Date: The following hi-lighted symptoms are what brought you into our office originally. DIRECTIONS: Please rate ALL hi-lighted symptoms: S = same; B = better; W = worse
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?
PERSONAL INFORMATION. First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip:
ADULT INTAKE FORM Date: PERSONAL INFORMATION First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip: Cell Phone: ( ) Alternate Phone: ( Text Reminders: Y N Before
Rise Chiropractic 239 S. French Broad Ave Asheville, NC
Rise Chiropractic 239 S. French Broad Ave Asheville, NC 28801 828.989.8369 1 Name: of Birth: Age: Sex: M F Address: City/State: Zip: Phone: (H) (W) (C) SS# Email: Occupation: Employer: Marital Status:
Pain Relief Recover from Injury Chiropractic Therapeutic Laser Therapy. Release & Balance Method Nutritional Counseling Laboratory Testing & Analysis
Health Solutions Center John Gangemi Chiropractic Physician Date Date of Birth Name Mailing Address Home Phone Cell Occupation Email How Did You Hear About Our Office Whom May We Thank For Referring You
DR. MOSCOW & ASSOCIATES PATIENT INFORMATION
DR. MOSCOW & ASSOCIATES PATIENT INFORMATION Name Date / / Sex: Male Female Date of Birth Age Cell Phone ( ) Home ( ) Work ( ) Email address Preferred Method of contact Social Security # Address City State
Sincerely, Dr. Justin & Woodbury Spine Staff
Welcome to our office! We are sure that you will be provided the most appropriate and professional chiropractic care possible. Our most important goal is the constant improvement and maintenance of your
ADULT CHIROPRACTIC INTAKE FORM
ADULT CHIROPRACTIC INTAKE FORM Welcome to our office! It is well known that families who maintain strong, healthy, wellaligned spines have greatly improved health. People whose spines are not healthy and
Today s Date: Have you ever received chiropractic care? No Yes, (Please list the City, State, & Doctor):
Evan Pridmore, D.C. 11227 Lebanon Rd. Mount Juliet, TN 37122 P: 615.583.9788 summitfamilychiropractictn.com ADULT INTAKE FORM Discover Your True Health Potential. Welcome to the Summit Family Chiropractic
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
WELCOME TO SOULSTICE WELLNESS CENTRE
WELCOME TO SOULSTICE WELLNESS CENTRE Name: Date: Age: Birth date: (mm/dd/yr) Address: Residence City Prov Postal Code Primary phone: ( ) Male Female Insurance Company:. Alberta Health Care # E-Mail Occupation
Patient Re-Examination Form
Harrisburg Family Chiropractic 220 S. Cliff Ave. Ste 106 Harrisburg SD 57032 (605) 767-7463 Name: Date: / / Patient Re-Examination Form Please fill out the information that has changed since your last
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/
NEW CHIROPRACTIC PATIENT INFORMATION Dr. Bryan Mock, LLC 2101 Greentree Rd Pittsburgh, PA
NEW CHIROPRACTIC PATIENT INFORMATION Dr. Bryan Mock, LLC 2101 Greentree Rd Pittsburgh, PA 15220 412-668-2089 Allergies: WELCOME The doctor and staff would like to welcome you and want to provide you with
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
Chiropractic Case History/Patient Information
Family Chiropractic and Wellness. 1 Chiropractic Case History/Patient Information Date: Patient # Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Birth
PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
Patient# WELCOME Today s Date / / Please fill out this form as completely as possible. Please print. PERSONAL INFORMATION Name What you prefer to be called Age Date of Birth / / Sex SS# E-Mail Home Address
Who may we thank for referring you? When did this episode start?
NEW PRACTICE MEMBER APPLICATION Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL