KEY TO LIFE CHIROPRACTIC
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- Kathlyn Agatha Carr
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1 KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office? PARENTAL CONSENT TO EVALUATE AND TREAT A MINOR I, being the parent/legal guardian of hereby grant permission for my child to receive chiropractic care. Witness Signature: CONSENT TO INITIATE CARE At our office, we have one simple goal we want to render the highest quality Chiropractic care at the lowest possible fee. In order to accomplish this goal, we have altered some of our business procedures to keep our fees reduced. Please read over these procedures below to understand how our office functions, and to decide if you wish to participate. If you have any questions, please direct them to the receptionist. You may choose to submit receipts to your insurance company or other third-party health care programs, but payment for such services by insurance companies is neither implied nor agreed to by this office. We take no responsibility for non-payment by insurance companies for services rendered at our office. Our office will not respond to any requests for paperwork for insurance purposes or even acknowledge insurance requests for information on any patient s case. However, patients may have a copy of their records at any time they request. No balances can be kept or run by patients at any time. All visits are paid the same day the service is rendered. Our office reserves the right to deny services to anyone for any reason, or if the doctor feels that the patient s health is not being best served. I wish to initiate care at this office. I have read and understand the Consent to Initiate Care and agree to all terms. I understand that I am under no obligation to receive or continue care. Print Your Name Today s Date Sign Your Name
2 SOME QUESTIONS TO HELP US HELP YOU NAME: DATE: If we could help you with only one health problem, what would it be? What other health problem would you like us to help you with? How did these problems start? When did these problems begin? Have you ever had these problems before? Is it worse in the morning or at night? (check one) Morning or Night Do you ever have numbness, tingling or pain in the arms or legs? How often do you feel the pain and how long does it last? Please list any other doctors seen for the above problem: Please list medications you are currently taking: Please list any surgeries you have had: Please list any auto or work injuries you have had: Please circle any in your family history: -Heart disease -Diabetes -Arthritis -Cancer -Back problems Do you get dizziness? Yes or No Do you have heart, lung or stomach problems? Yes or No Are you right or left-handed? How tall are you? How little do you weigh? Name of previous chiropractor: Are you looking for temporary relief or do you want the cause of your problem fully corrected? Why? What activities or hobbies have you been unable to do because of your problem?
3 NAME: Please mark the areas on the drawings where you have pain. Be as specific as you can. Include all affected areas. Rate your pain today. Circle the appropriate number on the pain scale below. If zero, perfect, you are here for wellness care. Congratulations! If 10, we need to get you to the ER. PAIN SCALE PLEASE CHECK ANY OF THE FOLLOWING WHICH YOU ARE EXPERIENCING TODAY GASTRO-INTESTINAL SYSTEM NERVOUS SYSTEM MUSCULO-SKELETAL EYE,EAR,NOSE,THROAT Numbness SYSTEM Poor appetite Loss of feeling Eye strain Excessive hunger Paralysis Low back problems Eye inflammation Difficult chewing Dizziness Pain between Vision problems Excessive thirst Fainting shoulders Ear pain Difficult swallowing Headaches Neck Problems Ear noises Nausea Muscle jerking Arm problems Hearing loss Vomiting food Convulsions Leg problems Ear discharge Vomiting blood Forgetfulness Swollen joints Nose pain Abdominal pain Confusion Painful joints Nose discharge Diarrhea Depression Stiff joints Difficulty breathing Constipation Sore muscles through nose Black stool CARDIO-VASCULAR Weak nuscles Sore gums Bloody stool RESPIRATORY Walking problems Dental problems Hemorrhoids Chest Pain Ruptures Sore mouth Liver trouble Pain over heart Broken bones Sore throat Gall bladder problem Difficult breathing Hoarseness Weight trouble Persistent cough FEMALE Difficult speech Coughing phlegm Vaginal discharge GENITO-URINARY SYSTEM Coughing blood Vaginal bleeding Rapid heartbeat Vaginal pain Bladder trouble Blood pressure Breast pain Excessive urination problem Lumps on breast Scanty urination Heart problems Painful urination Lung problems ARE YOU PREGNANT? Discolored urine Varicose veins Yes No
4 PURPOSE OF AN ADJUSTMENT DISCLOSURE By signing below, I acknowledge that I understand that chiropractic care is given to correct misalignments of the spine called SUBLUXATIONS. One of the benefits of a chiropractic adjustment is that you MAY feel better but this is not the goal of an adjustment. The GOAL of an adjustment is to correct SUBLUXATIONS, thereby removing the interference to the nervous system allowing the body to heal itself. As a result, WE DO NOT TREAT PAIN OR DISEASE; we remove subluxations so that the body is able to function properly and be better enabled to heal itself. INSURANCE AND INJURY NOTICE I am aware that Key to Life Chiropractic and Dr. Wayne Christianson do not provide care for work related injuries, automobile accident injuries, or personal injuries. I also acknowledge that I must inform this office of any injuries sustained. I also am completely aware that Key to Life Chiropractic and Dr. Wayne Christianson, WILL NOT; bill, submit claims, nor prepare or submit reports for any insurance claims of any kind. I also understand that I must inform this office if I have Medicare coverage and I understand that I am responsible to pay for each visit myself at the time of service. Signed: Date: Please Print Patient Name: Relationship to Patient:
5 KEY TO LIFE CHIROPRACTIC Orientation Questionnaire 1. What controls and coordinates all the functions in your body? 2. What is it called when the spine is misaligned? V S 3. Is the purpose of an adjustment to make the body Heal better or Feel better? (circle one) 4. Do Chiropractors: Adjust subluxations or Treat pain? (circle one) 5. What are 3 ways a Chiropractor can find a vertebral subluxation 6. What causes a Subluxation? 7. How often does the research show we should be checked for subluxations? 8. Name 4 things you can do to keep you and your family healthy: Well, Well, Well and Stay Well I have watched the online orientation and understand the purpose of chiropractic and how often to be checked for vertebral subluxations in the office. Signed Date
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 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:
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
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
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
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.
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 DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
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
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
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
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PERSONAL HISTORY AUTO ACCIDENT QUESTIONNAIRE. Personal Injury Questionnaire. Name Date. Date of Accident: Time. Location of Accident (Streets)
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INFORMATION/APPLICATION FOR CARE
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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:
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 PATIENT INFORMATION Last
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
MacKay Chiropractic, LTD., 7450 W. Cheyenne Ave. #114 Las Vegas, NV (702)
Personal History Date Patient # Name: Address: City: State: Postal Code: Birth date: Age: Sex: M F Home Phone: _ Cell Phone: Social Security #: Type of Work Email (for appt/e-news letter): Business/Employer:
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
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Acknowledgment of Clinic Terms
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Patient History (Please Print)
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Name: First Name Middle Initial Date: Last Name Mailing Address: City State Zip: Social Security #: Age: Sex: Male Female Height: Work Phone: ( Birth Date: Home Phone: ( Weight: Cell Phone: ( Email Address:
HEALTH INFORMATION FORM
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PATIENT INTRODUCTION
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PATIENT HEALTH QUESTIONNAIRE
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CHIROPRACTIC ASSOCIATES CLINIC
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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)
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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
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Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
136 Wilson Pike Circle Brentwood, TN 37027 NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider
SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
New Member Contact Information
New Member Contact Information Date: Social Security #: - - File Number: First Name: Middle Initial: Last Name: Age: Birth Date: / / Gender: M F Marital Status: S M D W Home Address: Home Phone: - - City,
Welcome to Manna Family Chiropractic!
Welcome to Manna Family Chiropractic! Today s date Who should we thank for referring you here? Is your visit today regarding you, or your whole family? Family Just Me Your name Date of Birth Street Address
HEALTH HISTORY: Reason(s) for seeking care: When did this injury or condition begin: How did this happen:
Date: PERSONAL INFORMATION: Name Goes By: DOB Address City State Zip Phone (Cell) Phone (Home) Sex: M/F Marital Status: S/M/D/W Occupation Social Security # Spouse s Name # of Children Ages Email address_
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
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below.
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below. Please describe your current primary complaint? Difficulty in: Standing, Sitting, Bending, Walking, Reaching Cannot
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
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
Cascadia Chiropractic Centre
Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
INSURANCE... ACCIDENT INFORMATION PATIENT CONDITION _.
WELCOME 3 LOCATIONS TO SERVE YOU BETTER! PINES WEST CHIROPRACTIC EAST SIDE CHIROPRACTIC MARTINEZ CHIROPRACTIC 18501 Pines Blvd., Suite 104 8228 Biscayne Blvd. 12595 S.W. 137 Ave., Ste 108 Miami, FL 33029