THE HEALTH RESTORATION SYSTEM
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- Elinor Mitchell
- 5 years ago
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1 THE HEALTH RESTORATION SYSTEM The Health Restoration System is a unique approach to achieving and maintaining optimal health. Today in North America and the rest of the western world, the priority in health care is to help people after they are already sick. That backwards approach to health care, and is why we are getting sicker and sicker. Recently a medical researcher stated it plainly, We are not living longer we are dying longer. In other words, we have the capacity to keep people alive for longer and longer durations, but the majority of these people do not have a good quality of life. They cannot do most of the things that would allow them to live fulfilling lives. Wouldn t it be great if we could work at staying healthy, instead of waiting to get sick? What if we could rol back the biological clock on the average person? What if 50 really was the new 40? Or 60 was the new 50? What if we could set up a system to allow you to do things at the age of 50, that you thought were impossible to do at the age of 40, or 30 for that matter? That is exactly what the Health Restoration System is designed to do. We are here to help you live longer and healthier, not die longer!! How does the Health Restoration System work? 1. DISCOVERY HEALTH DANGERS Unique questions will lead to new answers. We will begin by looking at the current state of your health and wellness. In essence, how are you doing right now? We will also ask you some detailed questions about your history and your family health history. It is important to understand that your current health problem started years ago and was multi-factorial in origin. The only exception would be an acute trauma like a car accident or severe sports injury. Even with acute traumas the extent of the injuries is most often dependent on your health before the accident. Your answers to the following questions offer up clues to what dangers your body is currently encountering and will give us a base line for comparison to future outcomes. 2. THE DISEASE CAUSATION ANALYSIS We will explore which lifestyle factors are affecting your overall health and your ability to live fully alive. It is a well-known fact that 80% of the risk factors for the two most feared killers; heart disease and cancer, are lifestyle related. The same is true for the majority of chronic illnesses affecting patients today. Lets get started in understanding your problem and finding a solution. 1
2 PERSONAL INFORMATION Name: Address: City: Postal Code: Home #: Age: Birth date: (M) (D) (Y) Workplace: Office #: Occupation: Referred by: Single Widowed Married (SPOUSE S NAME): # of Children: and their ages: Single Widowed Married In Relationship (spouse/partner name) : PREVIOUS TRAUMAS MOTORIZED VEHICLE ACCIDENTS Year: Injuries: Year: Injuries: Year: Injuries: High Speed Collisions >40km/h? Vehicles unrepairable? Whiplash injury? Un-belted accident? SPORTS & RECREATION: Sports injuries: Participation in High Impact Activities: Hockey Wrestling Basketball Running Mountain bike Climbing Football Gymnastics FALLS Falls from heights Falls down stairs Other falls Broken bones _ Childhood falls Falls from: Trees Roof Play structure Bicycle OCCUPATIONAL STRESSES Occupation Tasks Work injuries Home injuries My job requires: Heavy Lifting Awkward positions Repetitive stresses Sitting long periods POSTURES & HABITS Sitting >6 hours/day Head forward posture Stomach sleeper BIRTH TRAUMA was your delivery Difficult Forceps C-section Epidural Suction Resuscitation 2
3 WHAT IS YOUR PRESENT HEALTH CONCERN? How long have you had this condition? Have you had a similar condition in the past? What activities aggravate your condition? What relieves your condition? Are you getting pain or numbness in your arms or legs? Is your condition getting progressively worse? Yes No It s constant It comes and goes Pains are: Sharp Dull Burning Tightness Throbbing Pain severity (mark on the line, 0 no pain; 10 most severe) How is this condition interfering with your life? Work Daily Routine Other doctors) who treated this condition: MARK WITH AN X ON THE DIAGRAM ANY PAST OR PRESENT PAIN OR PROBLEMS AND CHECK THE APPROPRIATE CIRCLE BELOW: Headaches Facial pain Vision problems Hearing problems Shoulder: Pain / Numbness / Tingling (circle) Arm: Pain / Numbness / Tingling (circle) Hand: Pain / Numbness / Tingling (circle) Hip: Pain / Numbness / Tingling (circle) Knee: Pain / Numbness / Tingling (circle) Foot: Pain / Numbness / Tingling (circle) Neck Pain Upper Back Pain Middle Back Pain Low Back Pain FAMILY HEALTH PROBLEMS? Sacroiliac Pain OTHER HEALTH PROBLEMS? 3
4 PLEASE CHECK ANY OF THE FOLLOWING SIGNS OF ORGAN MALFUNCTION OR DIS-EASE YOU HAVE EXPERIENCED: Blurred /failing vision Deafness /ringing in ears Earaches Sore throat /tonsilitis Thyroid problems Sinus problems Cardiovascular system Chest Pain Shortness of Breath Heart Medication High Blood Pressure Medication High Cholesterol Medication Swelling of Legs Respiratory system Frequent bronchitis History of pneumonia Chronic cough Spitting up phlegm /blood Difficulty breathing Tuberculosis Pneumonia Digestive system Heartburn / indigestion Stomach Cramps Constipation /diarrhea Food Allergy Irritable Bowel Syndrome Crohn s Disease Ulcers Belching /gas Nausea or vomiting Liver /gall bladder trouble Colon trouble Black /bloody stool General Symptoms Fever / chills / sweats Frequent colds Fainting / dizziness Seizures / convulsions Headaches /migraine Neck pain /stiffness Tension across shoulders, L R Mid-back pain /stiffness Numbness /tinglining: hands /arms General Symptoms Skin problems Tremors Loss of balance Unexplained weight loss/gain Anemia Alcoholism HIV/AIDS Loss of sleep Poor memory /concentration Learning disability Irritable /nervous /tension Depression /emotional problems Decreased energy / fatigue Tired /lethargic Autoimmune Disease Antibiotic Use Cancer: Allergies / Asthma Scoliosis / spinal curvature Low back pain / stiffness Faulty posture Painful tailbone Foot trouble, L R Musculoskeletal system Painful Joints Painful Muscles Tendinitis Bursitis Arthritis Females Only Painful menstruation Cramps or backaches Passed menopause Currently pregnant? Y N Excessive /irregular flow Abnormal discharge Miscarriages # Date of last menstrual period: 4
5 PERSONAL INFORMATION How has your condition affected your quality of life? How has your condition affected you emotionally? How has your condition affected your family life and/or relationships? If left uncorrected, how do you see your condition affecting your life over the next 1-5 years? If you are a candidate for spinal reconstruction and if we were having this conversation 12 months from today, what has to happen over that time to make you feel happy with your progress? What is your greatest motivation (other than pain) for seeking out a solution for your condition? (Mobility, quality of life, family, participation in sports, etc.) Do you believe that this condition can improve? INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE I understand that any insurance coverage is an arrangement between the insurance company and myself. I understand that will prepare any necessary reports and forms to assist me i the insurance company. Fu t ur more, I and agree that all services rendered, are charged directly to me and that I am personally responsible for payment. Our goal is to locate and correct vertebral subluxation, thereby restoring normal function to the spine, and removing any interference to nerve function, and maximizing the transmission of nerve impulses from brain to body. While we often see dramatic improvements in many diseases and conditions by restoring function to the spine and removing nerve interference, Chiropractic is not a treatment of any disease condition. I understand and I am informed that, as in all health care, in the practice of Chiropractic there are some possible risks to care including, but not limited to, minor strains and sprains, and disc injuries. Physicians, Chiropractors, Osteopaths and Physiotherapists are required to advise patients with neck problems of the following there have been very rare incidents of injury to the vertebral artery during the course of treatment. This has caused strokes, or stroke-like occurrences, which are usually of a temporary nature. The chances of this happening are less than 1 in 5.8 million. Tests with or without X-Rays have been performed on you to minimize this risk to yourself. Chiropractic is considered to be one of the safest, most effective forms of therapy for neck conditions. If you have any questions about this, please ask your Chiropractor. I have read the above statements and consent to treatment. Signature Date 5
6 DISEASE CAUSATION ANALYSIS EXERCISE Do you participate in aerobic exercise at least 30 minutes per day? 0 days /week 1-2 days /week 3-4 days /week 5-7 days /week Do you lift weights or do resistance training? P90x Crossfit Gym Other What activities are you involved in that require balance? None How often do you stretch per week? 0 days /week 1-2 days /week 3-4 days /week 5-7 days /week EMOTIONAL STRESS Are you currently experiencing, or have you ever experienced significant stress in the following areas? Marriage Kids Finances Work Elderly Parents - Caregiver Recent Major Life Events (births, deaths) FAMILY HEALTH HISTORY What significant health concerns have your family members experienced? Parents / Siblings: Spouse / Partner: Children: _ CHEMICAL STRESSES: NUTRITION Do you feel that you make healthy food choices? Do you have a high intake of fruits and vegetables? Do you have a high intake of lean meat for protein? Are you at your ideal body weight? CHEMICAL STRESSES: TOXIC LOAD Do you presently, or have in the past: Smoke? Carry excessive weight? Consume Alcohol? Take recreational drugs? MEDICATIONS For what condition(s)? SURGERIES For what condition(s)? List (year performed) Any other details that may assist the Doctor in understanding your lifestyle and health status: 6
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
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CONSULTATION ADMITTANCE FORM
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Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
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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 Which Chiropractor are
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
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ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
Johanna M. Hoeller, DC PS
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634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell 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
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
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PATIENT INTRODUCTION
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Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
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RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
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3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
SPARROW FAMILY CHIROPRACTIC
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#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Health History Name Address City State Zip Day Phone Evening Phone E-mail Address Employer Birth Date Age Gender Emergency
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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.
PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS
Dr. Kenzie Maloy, DC, DABCI, DACCP, DACBN 505 E. Main St. Suite B Hermiston, OR 97838 Phone:541-371-3700 Fax:541-515-7022 PERSONAL INFORMATION: First Name: Last Name: Middle Initial: Email for doctor communications:
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Revelation Chiropractic Health Profile
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ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
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Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
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Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
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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
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New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
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Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Chiropractic Intake Form Name Date Address City State Date of Birth Age Phone Email Address Employer Emergency Contact Phone
Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
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Welcome to Compass Chiropractic!
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Adult Health Questionnaire
Health for Life Chiropractic At Cloverdale Mall Unit #143-250 The East Mall Etobicoke, ON, M9B 3Y8 416-232-1822 416-232-0060 Dr. Chrystopher Sly B.Sc, D.C. Dr. Jesse Cracknell B.A., D.C. Adult Health Questionnaire
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
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WELCOME TO The Chiropractors at Commerce Place
WELCOME TO The Chiropractors at Commerce Place For Office Use Only live well adjusted Doctor: Date: _ Referred by: MVA WCB Date of injury: Previous Chiro Care: Y / N Previous Chiro: _ Last adj date: Spine
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
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APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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New Patient Intake Form
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Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one) Date of
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
AUERBACH CHIROPRACTIC
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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
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
Gentle Chiropractic, LLC Dr. Amy Richard 7919 Big Bend Blvd. Suite B Webster Groves, MO Phone: Patient Data Sheet:
Gentle Chiropractic, LLC Dr. Amy Richard 7919 Big Bend Blvd. Suite B Webster Groves, MO. 63119 Phone: 314-537-1461 Patient Data Sheet: Date Name: Address: City: State: Zip: Social Security Number: - -
APPLICATION FOR CARE
3023 Eastland Blvd. Suite 101 Clearwater, FL 33761 Ph: 727-797-9900 Fax: 727-797-7695 APPLICATION FOR CARE Date: Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email Address: Birth
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KEY TO LIFE CHIROPRACTIC
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WINFIELD CHIROPRACTIC RELIEF & WELLNESS
WINFIELD CHIROPRACTIC RELIEF & WELLNESS Patient Information & Forms 1913 E. 19 th Ave Winfield, KS 67156 Phone# 620-221-1990 Fax# 620-221-4523 Website: www.winfieldchiropractic.com Email: winfieldchipractic@gmail.com
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:
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
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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
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
Practice Member Profile
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intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
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PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
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
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
Today s Date: APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC PATIENT DEMOGRAPHICS Name: Birth Date: / / Age: Male Female Address: City: State: Zip: E-mail Address: Home Phone: Cell Phone: Martial
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
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
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
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Sydney Chiropractic, DR. DAVID DUNN
PERSONAL HISTORY Name: Address: City: Province: Postal Code: Home Phone: Birthdate: Age: Sex: M F # of Children Business/Employer: Business Phone: Type of Work You Do: E-mail: Emergency Contact: Phone
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
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
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:
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
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
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
Address: Yes! I would like to receive your Monday Morning Health Tips.
Welcome to our Office! New Patient Intake Form Date Name Preferred Name Birthdate (D/M/Y) Age Sex F M Address Unit City Province Postal Code Home # Cell # May we contact you at work? Yes No Work # Extension
What is your occupation? Company Name Do you have extended healthcare benefits? Yes No Benefits are personal or from work
Welcome to our Office! New Patient Intake Form Date Name Preferred Name Birthdate (D/M/Y) Age Sex F M Address Unit City Province Postal Code Home # Cell # May we contact you at work? Yes No Work # Extension
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
Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
Basic Information Full Name: Address: City: State: Zip: Cell: Home: Work: Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S Email: Occupation: Emergency Contact: Phone: Children: O No
Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
APPLICATION FOR CARE AT
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address: Home
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
NPM INTAKE FORM: ADULT 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
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Zammito at
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
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: