NEW PATIENT REGISTRATION. First Name MI: Last Name Address Street Apt# City State Zip
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1 Jade Chiropractic N Commercial Ave. Portland, OR NEW PATIENT REGISTRATION First Name MI: Last Name Address Street Apt# City State Zip Date of Birth Cell Phone # ( ) Home Phone # ( ) Address: May we contact you via ? Y / N Emergency Contact Phone# ( ) Employer Phone# ( ) Occupation Whom may we thank for referring you to our office? Insurance Information ** If you are not utilizing insurance, please skip this portion and finish the other side of this form ** Are you the policy holder? Y / N If no, who is the policy holder: Spouse / Parent / Employer / Other Policy Holder Information If different from above: Name (Guarantor) Last First Middle Date of Birth: Address Phone# ( ) Street Apt# City State Zip Employer Phone #( ) Name of Insurance ID# Grp# Secondary Policy Holder Name, DOB, SSN and Employer if Different Than Above: We will also need to make a copy of your insurance card(s)
2 Jade Chiropractic N Commercial Ave. Portland, OR Please initial each item below. Acknowledgment and Understanding 1. I hereby authorize Jade Chiropractic to provide Chiropractic Services for me. I also, hereby assign all chiropractic benefits, including major medical benefits to which I am entitled, Medicare, private insurance and all other health plans, to Jade Chiropractic 5517 N Commercial Ave. Portland, OR I understand and agree that regardless of insurance coverage, I am liable for any charges incurred as a result of services rendered to me at Jade Chiropractic. 3. If this account is assigned to an attorney for collection and/or suit, the prevailing party shall be entitled to reasonable attorney s fees and cost of collections. 4. I authorize release of patient s records to third parties requiring these records for determination of financial liability. 5. I acknowledge the receipt of a copy of the office 'Notice of Patient Privacy Policy' Optional below 6. I give permission for Jade Chiropractic to contact my other medical provider regarding my condition, treatments, and prognosis. Provider name Specialty Phone number By signing this application I affirm under penalty that I have given true complete information. Dated Patient Signature Guarantor Signature / Relationship to Patient AUTHORIZATION TO TREAT A MINOR As a parent or legal guardian, I hereby authorize treatment for the following: DOB Patient s full name to any chiropractic treatment deemed advisable, if a parent or legal guardian is not available when the child is brought in for treatment. This authorization will be effective as of and expires. Signature
3 Patient Name: Date Jade Chiropractic 5517 N Commercial Ave Portland, Oregon Chief Complaint: Pain in: Head Neck Arm Mid back Low back Buttock Leg Other History of Present Illness: When did your pain begin? How did your pain begin? No Apparent Reason Bending Lifting Fall Motor Vehicle Accident Other Have you had a similar episode before? Yes No Has your pain: Improved Worsened No Change Is your pain: Constant Frequent (51-75%) Occasional (26-50%) Intermittent (25% or less) Have you seen another healthcare provider for this problem? Yes, diagnosis No Treatment for Your Current Problem: OTC's: Advil / Motrin Tylenol Aleve Other Result Steroids: Cortisone Pills Cortisone Injection Other Result Other Meds /Results: Injections: Epidural Facet Other Spinal Surgery: Yr /Procedure? Result Phys Ther: Yr/Procedure/Result Chiropractic: Yr/Procedure/Result Other: Yr/Procedure/Result How do the following affect your pain? Worse Better Same Cough/Sneeze: Sitting: Standing: Walking: Lying down: Sit to Stand: Turning Head: Bending: Lifting: Morning: Nighttime: Date of Test:Test/Results [ ] X-Ray [ ] MRI [ ] CT [ ] Lab [ ] Other [ ] Physical/ Ob-GYN Pain Level: (Please Circle) Current - None Most Severe Worst - None Most Severe Please Fill Out the Pain Drawing Below: >>>> Ache ZZZZ Numbness XXXX Burning 0000 Pins and Needles //// Stabbing FOR PROVIDER USE ONLY
4 Jade Chiropractic 5517 N Commercial Ave Portland, Oregon Patient Name: Date: Family Medical History: Heart Disease Cancer Auto-Immune Abnormal Bleeding Diabetes Muscle Disease Scoliosis Arthritis RA Other Living Parents? Mother Yes No; Age ( Adopted) Father Yes No; Age Current Work Status: Regular Duty Limited/Light Duty Since Off Work Since Lifestyle Habits: Tobacco use: never prior current (Pks/Day) Sleep (Hrs/Day) Alcohol (Drs/Day) Caffeine (Drs/Day) Do You Regularly Exercise? Yes; Frequency Duration No; Last Regular Exercise My Condition Currently Prevents Me from Exercising Past Medical History: Cancer Arthritis Alcoholism Kidney Disease Diabetes Seizures Lung Disease Thyroid Ulcers Glaucoma Heart Disease Tuberculosis AIDS/HIV Hepatitis Hernia Hypertension Stroke Anemia Pace Maker Blood Thinners Other Implants Surgeries/Hospitalizations: Complications Injury/Fracture/Dislocation: Known Allergies: Known Diseases: Review of Systems: (Please check all that apply) Constitutional: Fever Night Sweats Unexplained Weight Loss / Gain Excessive Fatigue Eyes: Abrupt Change in Vision ENT: Abrupt Change in Hearing Difficulty Swallowing Sore throat Gum Bleeding/Sensitivity Cardiovascular: Chest Pain Poor circulation Swelling Respiratory: Cough Difficulty breathing GI: Nausea Vomiting Bleeding Diarrhea Food cravings Hemorrhoids Constipation Musculoskeletal: Pain/swollen joints Skin: Rash Broken capillaries Neurologic: Dizziness Numbness Muscle weakness Endocrine: Hot flashes Heat / Cold Intolerance Excessive Hair Growth / Loss Blood/Lymph: Bruise easy Genitourinary: Burning on urination Urinary frequency Loss of bladder/bowel control Vaginal bleeding Uterine cramping Infection (recent): Urinary tract Respiratory Skin Other Immune system: Other Psychosocial: Depression Anxiety Difficulty sleeping I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. Signature Date
5 Jade Chiropractic 5517 N Commercial Ave Portland, OR Consent Jade Chiropractic is committed to make sure that every patient be informed of the risks of, and the alternatives to, treatment prior to beginning said treatment. We intend this consent form to cover the entire course of treatment for your present condition, and for any future conditions for which you seek treatment at this office. Jade Chiropractic takes your health and safety very seriously. Every precaution will be taken to assure your comfort and health. Every chiropractic patient s treatment is unique and your personalized treatment may include some or all of the following treatments and procedures: -Adjustments of the spine or extremities -Neuromuscular re-education -Heat pack/ice pack application -X-Rays -Massage therapy/soft tissue manipulation -Exercise Rehab, stretching, and strengthening -Spinal traction -Nutritional Counseling -Craniosacral Therapy Chiropractic examination and therapeutic procedures (including spinal adjustment, ultrasound, heat application, electrotherapy and manual muscle therapy) are considered safe and effective methods of care. With chiropractic adjustments the doctor will use his/her hands or a mechanical device in order to adjust your joints. You may hear a click or pop, and you may feel movement of the joint. Though this therapy is unlikely to have negative repercussions, complications may arise occasionally, as any treatment may have unforeseen repercussions. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them. Side effects to treatments include, but are not limited to, soreness, skin discoloration, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More serious complications are extremely rare and their association with spinal adjustments is debated. These rare complications include injury to the arteries in the neck which could lead to stroke and serious neurologic impairment, injuries to the spinal discs, and spinal fractures. Serious complications are estimated to be in the range of.5 2 incidents per million adjustments for adjustments. The exams that are performed by doctors at Jade Chiropractic are aimed at minimizing these risks. Alternatives to chiropractic care include home exercise and stretching, weight control, medication, care from other medical providers, and choosing to have no treatment. (None of these options are without risk either.) Item(s) of concern & discussion: (inital) I accept treatment and have consulted with the doctor regarding any concerns or questions I have regarding the recommended treatment. I have been informed of the risks and notified of alternative care options. Patient s Signature Printed Name Date I have discussed the procedures, alternatives and risks of the treatment with the patient and have asked them if they have any questions. Doctor s Signature Date
NEW PATIENT REGISTRATION. First Name MI: Last Name Address Street Apt# City State Zip
Jade Chiropractic. 5517 N Commercial Ave. Portland, OR 97217 NEW PATIENT REGISTRATION First Name MI: Last Name Address Street Apt# City State Zip Date of Birth Cell Phone # ( ) Home Phone # ( ) E-mail
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
3. How Long Has This Been An Issue?
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1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:
Back In Balance Chiropractic, LLC
Back In Balance Chiropractic, LLC Date Name What do you prefer to be called Address City State Zip Code Birth Date: / / Social Security Number: - - Height: Weight: E-mail Home Phone ( ) - Cell ( ) - Contact
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
Patient Intake Form Please Write Legibly
Chiropractic Wellness Center Date: Patient Intake Form Please Write Legibly Patient Legal Name: Male Female Preferred Name: Date of Birth: Age: Home Address: Apt#: City: State: Zip: Home Phone: Cell Phone:
Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status
Workers Compensation Intake Form File Number (Office Use) Patient Information: Today s Date Home Phone Name Cell Phone I prefer to be called Preferred Contact Home Cell Email Social Security No. Date of
Medical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?
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,
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
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
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
INFORMATION/APPLICATION FOR CARE
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
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 REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single
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: