Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
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1 Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help. Child s Information Child s Name Birth Date / / Age Mother's Name Father's Name Phone: Home Cell Address Preferred method for appointment reminders: Text If Text - Cell phone provider Address Number & Street City State Zip How did you hear about us? Health History Has your child ever been to a chiropractor before? Yes No If yes, how long has it been? Were you happy with their care? Yes No Explain Has your child ever been told they have any problems/defects in their spine or nerve system? Yes No If yes, what? List any surgeries and the dates which they occurred, if any: List any medications your child currently takes, if any: Were there any complications in the pregnancy or delivery of your child? Yes No If yes, please explain Was your child born by C-Section? Yes No How long was the actual labor and delivery time? Did the doctor use forceps or other devices for delivery? Yes No
2 How Can We Help You? What is the main reason for your child s visit today? Any other specific reasons or concerns? Symptoms are our body s way of telling us something is wrong with our health. Please check off anything that your child is currently experiencing or has experienced in the last 6 months: Headaches Dizziness Fatigue Depression Sore Throat Neck Discomfort Low Back Discomfort Mid-back Discomfort Frequent Colds Ear Aches Hand/Arm Numbness Leg/Foot Numbness Sinus Problems Anxiety Fainting Bed Wetting Gas/Bloating Nausea Heartburn Ulcers Diarrhea Constipation Colitis IBS Gall Bladder Walking Problems Shoulder Problems Convulsions Difficulty Concentrating Asthma Allergies Short breath Chest Congestion Lung Problems Thyroid Problems Diabetes Cancer Liver Problems Kidney Problems Blood Problems Extremity Weakness Extremity Swelling Cold Extremities Bladder Problems Are there any other health problems that concern you? How would you describe the health of your child s eating habits on a scale of 1 to 10? Very Poor Perfectly Healthy Are you satisfied with how healthy they eat? Yes No How would you describe the amount of physical activity your child engages in on a scale of 1 to 10? None Very Active Are you satisfied with their activity level? Yes No Is there anything else you feel we should know? Authorization for Care of Minor I hereby authorize DiMartino Chiropractic Center and its doctors to administer chiropractic care for the treatment of conditions related to the spine for my son/daughter/ward. This includes but is not limited to physical examinations, x- rays, nutritional advice and spinal adjustments. Signature Date: Witnessed:
3 Notice of Privacy Policy Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures You may inspect and receive copies of your records within 30 days with a request You may request to view changes to your records In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and its staff I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly Obtain payment from third party providers Conduct normal healthcare operations such as quality assessment and physician's certifications I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and/or disclosed. Signature Date Minor - Parent Signature Date Would you like to authorize other person(s) to have access to your health records? Yes No If yes, please state name of person(s) X-ray Consent I authorize the taking of diagnostic x-rays as part of my chiropractic spinal examination with DiMartino Chiropractic Center, PC. I have been advised and understand the dangers of radiation. I verify that to the best of my knowledge, I am not pregnant, nor do I have plans for pregnancy for at least 30 days. Signature Date Minor - Parent Signature Date
4 Terms of Acceptance When a patient seeks chiropractic care and we accept a patient for such care, it is essential for both of us to be working towards the same objective. Our only practice objective is to improve vertebral subluxation, a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to improve vertebral subluxations. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Vertebral Subluxation: A misalignment of one or more of the vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of nerve impulses, resulting in a lessening of the body s ability to express its maximum health potential. Adjustment: An adjustment is the specific application of forces to facilitate the body s improvement of vertebral subluxation. Our method of vertebral subluxation improvement is by specific chiropractic adjustment of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. 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 examination or care, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease or disorder is called, we do not offer to treat it, nor do we offer advice regarding treatment prescribed by others. All questions regarding the doctor s objective pertaining to care in this office have been answered to my satisfaction. I have read fully and understand the above statements and I accept chiropractic care on this basis. Signature Date Minor - Parent Signature Date
5 Functional Rating Index In order to properly assess your condition, we must understand how much your neck or back problems have affected your ability to manage everyday activities. For each item below, please circle the number which most closely describes your condition right now. 1) Standing 2) Sitting pain with any standing 5-20 minutes minutes 1 hour No pain after pain with any sitting 1/2 hour 1 hour No pain after 3) Walking 4) Work/Housework No pain No pain pain with all any pain with all with any walking 1/4 mile 1/2 mile 1 mile distance work or housework 5-10 minutes 20 minutes 60 minutes work or housework 5) Bending 6) Lifting Cannot bend No pain No pain No pain No pain Cannot lift without pain bending bending bending when without pain No pain No pain No pain No pain when lifting when lifting when lifting when lifting 10 degrees 50 degrees 80 degrees bending light weight moderate heavy weight weight 7) Sleeping 8) Recreation Totally Greatly Moderately Mildly Non- Cannot Can do Can do Can do Can do all disturbed disturbed disturbed disturbed disturbed do any a few some most activities sleep sleep sleep sleep sleep activities activities activities activities 9) Personal Care (washing, dressing, etc) 10) Travel (driving, flying, etc) Severe pain: Moderate Moderate Mild pain: No pain: Severe pain Moderate Moderate Mild pain No pain need 100% pain: need pain: need no no on short pain on pain on on long on long assistance some to go restrictions restrictions trips short trips long trips trips trips assistance slowly Total score:
RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How
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
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
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
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.
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:
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
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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
Personal and Family Health History
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Practice Member Profile
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PERSONAL INJURY QUESTIONNAIRE
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SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
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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
Welcome To Our Office
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PATIENT APPLICATION FORM
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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
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Insurance. Patient Family Information. Patient Condition
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