Patient Identification. a Yes. a No. Patient: First. Last. Address: Street. Apt. State. City. Zip. Date of Birth: Weight: Age: Race:
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- Nora Golden
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1 Ptient Medicl History Ptient Identifiction Hve you been ptient heree before? Ptient: First MI Lst Miling Address: Street Apt City Stte Zip Home Phone Cell/Alternte Phone Age: Height: Weight: Dte of Birth: Gender: F M Rce: Mritl Sttus: Mrried I m: : Left Hnd Dominn Primry Cre Physicin: Socil Security.: Single Divorced Widowed Right Hnd Dominnt Emil: Spouse s Nme: Employer: Responsible Prty: Nme: Gender: F M Dte of Birth: Socil Security.: Reltionship to Ptient: Address: Phone: Emergency Contct Nme: Need different ddress Nme/Reltionship to Ptient Home Phone Cell/Alternte Phone Medicl Insurnce Informtion: 1. Willl you be filing tody s visit through your personl helth insurnce? 2. Is this job relted injury? 3. Is your visit tody prt of legl, disbility or libility relted issue? If so, present crd to front desk. If so, complete section I. (below) If so, complete section II. (below) I. Workmen s Compenstion Clims: (Plese complete if your visit is the result of work relted injury.) DATE OF INJURY/ACCIDENT: DID YOU REPORT THIS TO YOUR EMPLOYER? Employer Work Compenstion Contct Person Contct s Phone Employer s Address City Stte Zip Code Work Compenstion Crrier Phone Clim Number Adjuster
2 II. Legl/Disbility/Libility Clims: (Plesee complete if your visit is the result of legl, disbilityy or libility issue.) ) Legl/Disbility/Libility Clims: (Plese complete if your visit is the result of legl, disbility or libility issue.) DATE OF INJURY/ACCIDENT: Lw Office/Disbility/L Libility Office Nme Lwyer/Agent s Nme Phone Address City Stte Zip Code I gree tht Wrner Orthope edics & Wellness my request nd use my prescription mediction history from other helthcre providers or third prty phrmcy benefit pyers for tretment purposes. I hereby uthorize Wrner r Orthopedics & Wellness to relese ny medicl informtion nd/or medicl records mintined t the hospitl s needed to my insurnce compny, the socil security dministrtion or crriers, to my ttorney s listed bove, or to the ttorney responsible for the pyment for medicl services or evlution to be provided. I permit copy of this uthoriztion to be used in plce of the originl. I hereby ssign to the fcility listed bove ll insurnce compny or Medicre reimbursements for medicl nd/or surgicl expenses. Regultions pertining to Medicre ssignment of benefits pply. I hve been given copy of the tice of Privcy Prctices of Wrner Orthope edics & Wellness. Visit Dte Signture (Ptient or Responsible Prty) Nme of Person Completing Form Reltionship to Ptient Bton Rouge, LA Phone: Fx:
3 Ptient Medicl History WHO RECOMMENDED YOU TO SEE US: Nme: Primry Doctor? o Other: Plesee explin: CHIEF COMPLAINT: Why re you here? Dte of Injury or Onset of Symptoms: (Check ll tht pply) Body Prt to be Exmined: Left Rightt Min Problem: Pin Other Numbness Wekness Stiffness Unstble Swelling Popping/Grinding Where Complint/Injury Occurred: Work Other At Home Sport/Recretion Cr Accident At School Hs Lwsuit Been Filed? How Complint/Injury Occurred: Other Grdul Onset Sudden/Trumtic Unknown PREVIOUS AND/OR CURRENT TREATMENTS FOR THIS CONDITION: (Checkk ll tht pply) ) ne X-rys/Tests: Regulr x-rys Other: MRI Scns CAT Scn Myelogrm Nerve Tests (EMG, NCV ) Did you bring your X-rys with you? Therpies: Physicl Therpy Chiroprctic Cre Injections Other: IS THERE A CHANCE THAT YOU COULD BE PREGNANT? Bton Rouge, LA Phone: Fx:
4 CURRENT MEDICATION: ne Phrmcy Preference nd Phone #: Plese list ny prescriptions, drugs, nd/or non-prescription medictions including herbs, vitmins, nutritionl supplements, or nything tken orlly.. Nme Strength Frequency Nme Strength Frequency Do you hve ny metl frgments in your body or eyes? NO Hve you hd ny metl removed from your body or eyes? Do you work with metl, welding, or grinding? GENERAL MEDICAL HISTORY: Medicl Problems Are you ffected by ny of the following? (Check ll tht pply) Crdic (Hert/Circultion) Kidneys Chest Pin Kidney Filure Congestive Hert Filure Recurrent Kidney Infection High Blood Pressure Urinry Retentionn Hert Vlve Problems Hert Murmur Endocrine (Hrmone) Hert Attck Thyroid Problems Pcemker Chronic Ftigue Plpittions High Blood Sugr Rheumtic Fever Excessive Thirst Irregulr Hert Bet Dibetes Pulmonry (Lung) Hemtologic (Blood) Shortness of Breth Anemi Wheezing Immune Deficiency Emphysem/COPD Leukemi P.E./Pulmonry Embolism Clotting Problems/DVT Asthm (Deep Vein Thrombosis) Chest Tightness Lung Cncer Infectious Disese Recurrent Bronchitis Heptitis (A, B, or C) Recurrent Cough Chronic Ftigue Syndrome Bloody Cough AIDS/HIV Productive Cough Chronic Epstein-Brr Digestive (Stomch/Intestines) Tuberculosis Hert Burn Musculoskeletl Ulcers Chronic Bck Problems Abdominl Pin TMJ Syndrome Acid Reflux Disese Chronic Neck Problems Pncretitis Arthritis MS or MD Diverticulitis Fibromylgi Cirrhosis Crohn s s/colitis Irritble Bowel Syndrome Constiption Skin Psorisis Eczem Jundice Slow Heling Scrring/Keloids Neurologic Seizure Multiple Sclerosis Loss of Strength Stroke/TIA Prkinson s Migrine Hedches Numbness Psychologicl Depression Bipolr Disorder Anxiety/Nervousness Schizophreni Prnoi Immune System Lupus Autoimmune Disese Immune Deficiency Bton Rouge, LA Phone: Fx:
5 ALLERGIES: Do you hve history of ltex llergy? Do you hve ny known drug llergies? If yes, explin below: PREVIOUS SURGERIES: Plese list the type nd dte the surgery ws performed: Type Dte Mo/Yr ne Type Dte Mo/Yr Hve you ever been hospitlized? If, plese describe: SOCIAL HISTORY: (Check ll tht pply) A. Occuption: B. Are you on: Full Duty Light Duty (Since: ) Disbled (Since: ) C. Do you use tobcco products? Less thn one pck/dy One pck/dy More thn 1 pck/dy D. Do you use lcohol? Occsionlly Dily > 2 perr dy > 5 per dy E. Wht is your living sttus? Alone With Spouse With Prents With Roommte Assisted Living/Nursing Home F. Children? How Mny? Are you required to tke ntibiotics before procedures? Hve you ever hd problems with generl nesthetic? If yes, plese describee ny problems: FAMILY HISTORY: Plese indicte if nyone in your fmily hs hd the following: (Check ll tht ll tht pply) CANCER/TYPE HIGHH BLOOD PRESSURE HEART PROBLEMS HEPATITIS BLEEDING PROBLEMS DIABETES SEIZURES/ EPILEPSY ASHTMA YES NO RELATIONSHIP TO YOU Bton Rouge, LA Phone: Fx:
6 REVIEW OF SYSTEMS: Are you experiencing ny of the following? (Check ll tht pply) Constitutionl Symptoms YES NO Gstrointestinl YES NO Recent weight chnge Fever Unexplined sweting Loss of ppetite Nuse or vomiting Frequent dirrhe Eyes Constiption Wer glsses or contcts Blurred or double vision Glucom ENT Hering loss Regulr nose or gum bleeding Sore throt Swollen glnds in neck CV Irregulr hertbets Shortness of breth w/wlking or lying flt Swell ing in feet, nkles nd hnds Finting spells Elevted cholesterol Respirtory Chronic or frequent coughing Spitting up blood Regulr shortness of breth Rectl bleeding or blood in stool Blck trry stools Regulr bdominl pin or hertburn Genitourinry Frequent urintion Burning of pinful urintionn Blood in urine Incontinence or dribbling Femle: # of pregnncies Femle: # of miscrriges Musculoskeletll Joint pin Joint stiffness nd swelling Morning stiffness Difficulty wlking Muscle crmping Integumentry Rsh or itching Emphysem Chnges in skin color Regulr wheezing Vricose veins Neurologicl YES Frequent hedches Light heded or dizzy Seizures Numbness or tingling Tremors Prlysis Psychitric Memory loss or confusion Anxiety Depression Insomni Endocrine Glndulr or Hormone Problem Excessive thirst or urintion Het or cold intolerncee Chnges in hir or nils Hemtology Bruising tendency Anemi Need for pst trnsfusion NO Signture of ptient, prent or legl gurdin Dte Physicin s Signture Dte Reviewed by MD Dte Initil Dte Initil Dte Initil D Bton Rouge, LA Phone: Fx:
7 Ptient Pin Digrm PATIEN NT NAME: First PAIN DIAGRAM: On scle of 1 to 10, how would you describee your pin level when it is t its worst? Complints MI Lst 10 Extremee Pin Plce n X on the re of pin; Use the pproprite symbol of other symptoms you feel. If f you re being seen for you foot or hnd/wrist, use the digrms on the right. Pin xxx Aching Numbness Pins & Needles Burning Stbbing /// / Signture Dte
Welcome to our Practice
Welcome to our Prctice PATIENT INFORMATION: Mr. Mrs. Ms. Dr. First Nme_ Sex: Mle Femle Street Home. Referred By Dentist. Driver's Lic.# Employer. Birth Dte In cse of emergency, plese contct..cell.i..m.i..
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
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Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
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Oregon Individual and Family Plans OREGON APPLICATION AND STANDARD HEALTH STATEMENT
B CDE Regence BlueCross BlueShield of Oregon Oregon Individul nd Fmily Plns Blue Selections Premier Blue Selections Plus Blue Selections Bsic Regence HS Helthpln nd Individul Dentcre OREGON PPLICTION ND
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
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ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
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Supplementary Online Content
Supplementry Online Content Zulmn DM, Pl Chee C, Ezeji-Okoye SC, et l. Effect of n intensive outptient progrm to ugment primry cre for high-need Veterns Affirs ptients: rndomized clinicl tril. JAMA Intern
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In case of emergency, please notify:
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Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
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John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
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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
Preferred(Nick) Name: Address: City State Zip. Home Phone: Cell: Date of Birth: Age: Social Security(last four #'s): Gender:
Preferred(Nick) Name: Address: City State Zip Home Phone: Cell: Email: Date of Birth: Age: Social Security(last four #'s): Gender: Marital Status: O Single O Married O Divorced O Widowed Primary Care Physician:
San Francisco Ear Nose & Throat Medical Group, Inc
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Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
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Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
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Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
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Please list any treatments you have previously had for current illness. (Physical Therapy, Surgery, Radiation, etc.)
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725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
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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
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician: