Health Intake Form Connected Chiropractic 32 S. Rutherford Ave.
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- Karin Barrett
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1 Health Intake Form Connected Chiropractic 32 S. Rutherford Ave. Johnstown, CO (970) Name: Date: Address: City: State: Zip: Cell Ph: Home Ph: Work Ph: Best Number to contact you: Home Work Cell Social Security #: Address: Birth date: Age: Sex: M F circle one: single married partnered widowed divorced separated Occupation & Employer: # of hours worked per week: Significant Other s Name & Occupation: Name(s) and Age(s) of Kid(s): Who can we thank for referring you to Connected Chiropractic: Main reason for consulting our office today: Any information about your spine and nerve system we should know: What is your level of commitment to yourself, your life and wellbeing? High Medium Low Have you ever sought the services for this or any other health concern from the following: Massage therapist Acupuncturist Naturopath Yoga Studio Physical Therapist Personal Trainer Nutritionist Rolfer Pilates Other Chiropractor Have you been adjusted by a chiropractor before? Yes No Office: Date of last Adjustment: Frequency of care: x per week/month Duration of care: weeks/months/yrs What is your daily fluid intake: Coffee /week Alcohol /week Water /day Soda /week Sleep/Rest Habits: Daytime naps: Y N Hours a night: /hrs Do you wake up refreshed? Y N Exercise Habits: (please describe what you do and how often) What type of work do you do? Satisfied/Enjoy your work? Y N Do you use prescription, over the counter and/or recreational drugs/medications? Y N (If yes, please list on back) What are your current play and relaxation activities?
2 Check any of the symptoms or conditions below that you experience. Headaches Carpal Tunnel Asthma Digestive Problems/Heartburn Neck Pain Problem Sleeping Vertigo Pain Between Shoulder Blades Mid-Back Pain Ringing in Ears Cancer Shortness of Breath Low-Back Pain Loss of Balance Allergies Tension Across Top of Shoulders Sciatic Pain High or Low Blood Pressure Dizziness Numbness in Arms/Legs Leg or Hip Pain Weight Trouble Depression Menstrual Pain Jaw Pain/TMJ Scoliosis Seizures/Convulsions Shoulder/Arm Pain Low Energy/Fatigued Other Which one of the above symptoms is worst? How long have you had it? When it is at its worst, how does it feel? The following 3 areas can contribute to nerve interference and diminished quality of life. Circle the areas that apply to you and when. C=Child T=Teenager A=Adult N=Not at all Physical Stress Emotional Stress Chemical Stress Birth Stress C T A N Relationships C T A N Environmental C T A N Slip/ fall C T A N Career C T A N Smoker C T A N Car Accident C T A N Family C T A N Second Hand Smoke C T A N Sports Injury C T A N Money C T A N Caffeine C T A N Physical Abuse C T A N Fast paced life C T A N Artificial Sweeteners C T A N Work Injury C T A N Hold in Feelings C T A N Prescription Drugs C T A N Poor Posture C T A N Quick Tempered C T A N Recreational Drugs C T A N Sitting on wallet C T A N Perfectionist C T A N Self-Medicate C T A N Stomach sleeper C T A N Procrastinator C T A N Poor Diet C T A N Computer work C T A N Loss of loved one C T A N Repetitive lift/bending C T A N Prolonged Driving C T A N What do you feel is the primary stressor in your life? Prolonged Standing C T A N Prolonged Sitting C T A N Surgery/Broken bones C T A N Rate (circle) your combined overall level of stress from all sources listed above: Lack of Physical Activity C T A N No Stress High Stress Excess Physical Activity C T A N T e r m s o f S e r v i c e When a person seeks chiropractic health care and we accept someone for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal, to detect and correct/reduce the vertebral subluxation. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method is by specific adjustments of the spine. HEALTH: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. VERTEBRAL SUBLUXATION: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate wisdom/ability to express its maximum health potential. 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 evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. If a lifetime of a better functioning body is what you want for you, your family, and friends then welcome, you are in the right place. I,(Printed name) (Signature) undertake any care with the understanding of, and agreement with, the above explanation. (Date). Consent to evaluate and adjust a minor and/or child: I, (Print name) being the parent or legal guardian of (Print name) give permission for my child to receive any care.
3 Activities of Daily Living/Symptoms/Medications Patient Name: Date: Daily Activities: Effects of Current conditions On Performance Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life: Bending No Effect Painful (can do) Painful (Limits) Unable to Perform Concentrating No Effect Painful (can do) Painful (Limits) Unable to Perform Doing computer Work No Effect Painful (can do) Painful (Limits) Unable to Perform Gardening No Effect Painful (can do) Painful (Limits) Unable to Perform Playing Sports No Effect Painful (can do) Painful (Limits) Unable to Perform Recreation Activities No Effect Painful (can do) Painful (Limits) Unable to Perform Shoveling No Effect Painful (can do) Painful (Limits) Unable to Perform Sleeping No Effect Painful (can do) Painful (Limits) Unable to Perform Watching TV No Effect Painful (can do) Painful (Limits) Unable to Perform Carrying No Effect Painful (can do) Painful (Limits) Unable to Perform Dancing No Effect Painful (can do) Painful (Limits) Unable to Perform Dressing No Effect Painful (can do) Painful (Limits) Unable to Perform Lifting No Effect Painful (can do) Painful (Limits) Unable to Perform Pushing No Effect Painful (can do) Painful (Limits) Unable to Perform Rolling Over No Effect Painful (can do) Painful (Limits) Unable to Perform Sitting No Effect Painful (can do) Painful (Limits) Unable to Perform Standing No Effect Painful (can do) Painful (Limits) Unable to Perform Working No Effect Painful (can do) Painful (Limits) Unable to Perform Climbing No Effect Painful (can do) Painful (Limits) Unable to Perform Doing Chores No Effect Painful (can do) Painful (Limits) Unable to Perform Driving No Effect Painful (can do) Painful (Limits) Unable to Perform Performing Sexual Activity No Effect Painful (can do) Painful (Limits) Unable to Perform Reading No Effect Painful (can do) Painful (Limits) Unable to Perform Running No Effect Painful (can do) Painful (Limits) Unable to Perform Sitting to Standing No Effect Painful (can do) Painful (Limits) Unable to Perform Walking No Effect Painful (can do) Painful (Limits) Unable to Perform
4 How we protect your Health Information: PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR HEALTHCARE PURPOSES By signing this Consent, I acknowledge and provide permission to Connected Chiropractic (Practice) as follows: 1. Connected Chiropractic s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information ( PHI ) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out is health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. 2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. 3. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) telephoning my home and leaving a message on my answering machine or with the individual answering the phone; b) an sent to the address provided by me; c) a text message sent to the cell phone number provided by me. 4. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations. 5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice. 6. I understand that this Consent is valid for seven (7) years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent. 7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me. 8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice reserves the right to not treat me. I have read and understand the health information disclosure and protection in the foregoing notice, PRINTED Name SIGNATURE DATE Signature of Legal Guardian (e.g. if a minor) Relationship to minor
5 Informed Consent REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures: I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments. Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at Connected Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. / / Witness Initials Patient or Authorized person s Signature Date REGARDING: X-rays/Imaging Studies: FEMALES ONLY please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation. The first day of my last menstrual cycle was on - - Date I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant. By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case. / / Witness Initials Patient or Authorized person s Signature Date TRC, CA 12/2011
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Raleigh Specific Chiropractic Chiropractic for pediatric development and adult health 7721 Six Forks Rd. Suite 138 Raleigh, NC 27615 (919) 846-7004 Items to bring to your first visit: All new patient paperwork
H e a l t h S t o r y : A d u l t P r a c t i c e M e m b e r
Vital Information Name Date / /_ I prefer to be called Address City _ State Zip Home # - - Work # - - Cell # - - Preferred contact # H W C Email _ Birthday / / Age Gender F M Occupation Employer Marital/Relationship
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
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED Patient Information Name: DOB: / / Gender: M F Home Address: Home Phone: City, State, Zip: Work Phone: Email Address: Cell Phone: I do not want
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability.
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability. Patient Information Title: Mr. Mrs. Miss Ms. Dr. (circle one)
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: DOB: Age: Male Female Address: City: State: Zip: E-mail: Home
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
MVA Patient Health Record
Name: Date: AHC #: Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email for appointment reminders and information regarding your
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:
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
PATIENT APPLICATION FORM
2105 E. Clairemont Ave., Eau Claire, WI 54701 Phone (715)835-9514 Fax (715)835-2602 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level
Personal Injury Questionnaire. Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number:
Personal Injury Questionnaire Name: Address: City: State: Zip: Cell Phone: Home phone: Work Phone: Social Security Number: Email: Date of birth Sex: Male Female Marital States S M D W Date of Accident:
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,
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX
Liberty Chiropractic Clinic, -6154 Patient's Name Patient's Address City State Zip Code Age D.O.B. Single Married Divorced Widowed No. of children Occupation Employer Home Phone Work Phone Cell Phone Email
APPLICATION FOR CARE AT Rochester Family Chiropractic
Whom may we thank for referring you to this office? Today s Date: PATIENT DEMOGRAPHICS APPLICATION FOR CARE AT Rochester Family Chiropractic HRN: Name: Birth Date: - - Age: Male Female Address: City: State:
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
Physical Evidence Chiropractic 7035 Beracasa Way Suite 103 Boca Raton FL, Phone# (561) Fax# (561)
7035 Beracasa Way Suite 103 Boca Raton FL, 33433 Phone# (561)361-4888 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name Address City State Zip Date of Birth Age Social Security # Circle
Health and History Assessment ACCOUNT #: HIPPA: CTT:
ACTION Chiropractor LLC Health and History Assessment ACCOUNT #: HIPPA: CTT: NAME: SEX: M/ F BIRTHDATE: / / ADDRESS: CITY: STATE: Zip: PHONE # s: HOME: ( ) WORK: ( ) CELL: ( ) HEIGHT: WEIGHT: MARITAL STATUS:
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
Pediatric Health Story Form
Pediatric Health Story Form Child s Personal Information Name Age Date of Birth Gender: M F Home Address City State Zip Names and Ages of Siblings Parent A Name Home phone ( ) Cell phone ( ) Employer E-mail
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
Registration and History Form
Registration and History Form PATIENT INFORMATION Date: / / Patient Address City State Zip Sex M F Age Birthdate Occupation _ Employer Spouse s Name _ Sex M F Age Birthdate Occupation Spouse s Employer
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
Personal Information. Reason for Seeking Care. What is your reason for seeking care at Strive Chiropractic?
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
Last Name First Name M.I Nickname Address City State Zip_. Date of Birth Age Gender: M F Marital Status: S M W D INJURY INFORMATION
PATIENT REGISTRATION Date: Last Name First Name M.I Nickname Address City State Zip_ Mobile Phone Home Phone Work Phone E-Mail SSN Date of Birth Age Gender: M F Marital Status: S M W D Employer Name Occupation_
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY Welcome! PLEASE PRINT CLEARLY PERSONAL DATA Today s Date First name MI: Last name: Nickname Gender M F Age Date of Birth SS# (optional) Current address
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