CURRENT HEALTH CONDITIONS. Patient Name: Date:
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- Dorthy Dorsey
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1 Patient Name: Date: Is this your first pregnancy? 0 Yes 0 No - If not, please tell us about your previous pregnancy and/or birth experience(s). (Duration, frtervent/ons, etc) Do you plan to follow the same plan as your previous delivery? 0 Yes 0 No - If no, what would you like to change? CONCEPTION Et EARLY PREGNANCY When is your expected or calculated due date? Did you have any difficulty conceiving? OYes ONo Have you ever used any form of hormonal or oral contraceptives? OYes ONo - If yes, which ones, and for how long? When was your last menstrual cycle? What was your pre-pregnancy weight? Current weight? Have you experienced morning sickness? 0 Yes 0 No - If yes, please explain: CURRENT HEALTH CONDITIONS What type of exercise(s) are you currently performing? Please tell us about your current diet, and any dietary restrictions. Have you taken any medications or supplements during your pregnancy? 0 Yes 0 No Have you had any slips, falls, or other physical traumas during the pregnancy? OYes 0 No Have you had any major emotional stressors during your pregnancy? OYes 0 No
2 YOUR BIRTH PLAN Your top three goals for this pregnancy: ::.. _... Do you currently have a birth pan? OYes 0 No Are you taking any pre-natal or birthing classes? OYes 0 No Who is your OB/GYN or midwife? Will they be present for delivery? OYes 0 No Who is your birth provider? Do you intend to have a doula or birth coach present? 0 Yes 0 No Do you wish to have a natural vaginal labor and delivery? OYes 0 No - If not, what concerns do you have? 0 /. Do you plan on breastfeeding your child? 0 Yes 0 No What do you intend to do for vaccines? Is there anything else you'd like to tell us about your pregnancy or birth plan? What would you like to gain from chiropractic care during your pregnancy? Are there any burning questions you want to be sure to ask today?
3 1 First Name: Last Name: Date: SS #: DOB: Sex: OM OF Marital Status: # of Children: Occupation: Street Address: City, State, Zip: Height: Weight: Cell Phone: Other Phone: Emergency Contact: Emergency Relation: Emergency Phone: How did you hear about us? Who is your primary care physician? Date and reason for your last doctor visit: Are you also receiving care from any other health professionals? 0 Yes - f yes, please name them and their specialty: 0 No Please note any significant family medical history: What health condition(s) bring you into our office? X= Current condition 0= Past condition Have you received care for this problem before? 0 Yes 0 No When did the condition(s) first begin? How did the problem start? OSuddenly O Gradua ly OPost-Injury s this condition: O Getting worse O Improving O ntermittent OConstant OUnsure What makes the problem better? What makes the problem worse? Your top three health goals: 2 3
4 _ilmiiropractic HISTORY What would you like to gain from chiropractic care? C Resolve existing condition(s) 0 Overall wellness 0 Both Have you ever visited a chiropractor? 0 Yes 0 No If yes, what is their name? What is their specialty? 0 Pain Relief 0 Physical Therapy & Rehab 0 Nutritional 0 Subluxation-based 0 Other: Do you have any health concerns for other family members today? Have you ever had any significant falls, surgeries or other injuries as an adult? 0 Yes 0 No - lfyes, please explain: L Notable childhood injuries? 0 Yes 0 No If yes, please explain: Youth or college sports? C Yes 0 No If yes, list major injuries: L Any auto accidents? 0 Yes 0 No_lf yes, please exp la in'. Exercise Frequency? 0 None 0 1-2x per week 0 3-Ex per week 0 Daily What types of exercise? How do you normally sleep? 0 Back 0 Side 0 Stomach Do you commute to work? 0 Yes 0 No If yes, how many minutes per day? List any problems with flexibility. (ex PuttAg or shoes/socks, etc) How many hours per day you typically spend sitting at a desk or on a computer, tablet or phone? Do you wake up: 0 Refreshed and ready 0 Stiff and tired None Moderate Hiq/7 Alcohol :id z BD Processed Foods Water D T c Artificial Sweeteners Sugar &Sweets :D OD f Sugary Drinks Dairy LD z T Cigarettes Gluten (.D LI: L Recreational Drugs Please list any drugs/medications/vitamins/herbs/other that you are taking, and why. None Moderate H(qb O ( c None Moderate H(q/7 None Moderate HIgh Home Money Work Health Life Family 0 ACKNOWLEDGMENT Et CONSENT Patient Name: Date:
5 ' Please check the corresponding boxes for each symptom or condition you have experienced - including both past and present. Al Cervical Autonomic Nervous System ENT System Vision, Balance & Coordination Speech Immune System Digestive System Nerve Supply to Shoulders, Arms & Hands Sympathetic Nucleus Metabolism Colic & Excessive Crying l Ear & Sinus Infections Allergies & Congestion Immune Deficiency Headaches & Migraines Vertigo & Dizziness LI1 Sore Throat & Strep Swollen Tonsils & Adenoids Vision & Hearing Issues Low Energy & Fatigue Difficulty Sleeping Pain, Numbness & Tingling in Arms to Hands q'q ELI Lilill Epilepsy & Seizures Sensory & Spectrum Focus & Memory Issues Anxiety & Stress Balance & Coordination Speech Issues TMJ / Jaw Pain Stiff Neck & Shoulders Depression High Blood Pressure Poor Metabolism & Weight Control Upper Thoracic. UpperG.l. Respiratory System Cardiac Function LJII Ref lux / GERD LIE Asthma Chronic Colds & Cough Lilill Bronchitis & Pneumonia Lifli Functional Heart conditions Major Digestive Center Detox & Immunity LI1 Jaundice Fever Gallbladder Pain I Issues LI1I1 Indigestion & Heartburn Stomach Pains & Ulcers Blood Sugar Problems Lower Thoracic Stress Response Filtration & Elimination Gut & Digestion Hormonal Control I1I1 Behavior Issues Elillil Hyperactivity Chronic Fatigue Chronic Stress LILI E1 ElIlil Allergies & Eczema Skin Conditions I Rash Kidney Problems Gas Pain & Bloating Lumbar, Sacrum & Pelvis LowerG.I. (Absorption & Motility) Gut-Immune System Major Hormonal Control Constipation Diarrhea Bed-wetting Chrohn's, Colitis & IBS Bladder & Urination Issues Cramps & Menstrual Issues Cysts & Endometriosis Elillil Infertility LI.1 Impotency l Hemorrhoids l LI1I Sciatica & Radiating Pain Lumbopelvic I SI Joint Pain Hamstring Tightness Disc Degeneration Leg Weakness & Cramps Knee, Ankle & Foot Pain Weak Ankles & Arches LI1I Lower Back Pain Poor Circulation & Cold Feet Elilli Gluten & Casein Intolerance Patient Name Date
On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below:
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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)
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
Health History Questionnaire Date: / /.
Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:
NPM INTAKE FORM. INFORMATION: Name: Age: Date: Home Phone No.: Work Phone No: Cell Phone: Address:: Gender: Date of Birth:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
NPM INTAKE FORM INFORMATION: Name: Age: Date:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
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
New Patient Medical History Intake Form
New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd
Child History Form. Personal Information. Legal Guardian & Occupation: Home Phone: Alternate Phone: Provincial Health Care Plan
Child History Form (Ages 6-12) The data on this form is essential if we are to render the best professional care. We appreciate your cooperation in filling it out so that we will have accurate records.
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster
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.
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
Health History Questionnaire
Health History Questionnaire Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Mobile Phone: Email: Date of Birth: Place of Birth: Height: Weight: Relationship Status: Employer: Single
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for