Patient Intake Form. Demographic & Contact Information. Address Primary Phone Cell Phone. Address 2 Work Phone Home Phone
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- Philippa Bond
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1 Patient Intake Form Brink Chiropractic Clinic 1047 Main St Sanford, ME Phone: Fax: Once completed, please save this document to your computer or device and the document as an attachment to Demographic & Contact Information First Name: Last Name: Birth Date: SSN: Address Primary Phone Cell Phone Address 2 Work Phone Home Phone City State/Province Postal Code Preferred Communication Preferred Reminder Format Preferred Language Smoking Status Gender, Race and Ethnicity Gender Gender Identity Sexual Orientation OMB Ethnicity CDC Ethnicity OMB Race CDC Race Current Medications Medication Reason Start Date Medication Reason Start Date Medication Reason Start Date Medication Reason Start Date Medication Reason Start Date Medication Allergies Medication Reason Symptom Medication Reason Symptom Medication Reason Symptom
2 Allergies (Check all that apply) Adhesives Latex None Rubber Soaps X-ray Dye Surgeries (Check all that apply) Abdominal Angioplasty Appendix Arm Back Back (Disc) Back (Fusion) Bladder Bone Spurs Brain Breast CAD Cardiac Stent Carpal tunnel Cervical Disc Cervical fusion Chest COLOSTOMY C-SECTION Discectomy Dorsal release Ear Elbow Eye Face Foot Gallbladder Gasrtic Bypass Gynecological Hand Heart Hernia Hip Hysterectomy Joint Replacement Kidney Knee Leg Liver Lumbar fusion Lung Neck Neurological None Nose Oral Plantar fascitiis PROSTATE RCA Shoulder Skin STENT IN HEART STENTS Throat Thyroid TMJ Toes Tonsilectomy Tubes in Ears Wrist UNKNOWN BREAST Augmentation CATARACT GERD OVARIAN CANCER Hemorrhoid HERNIA NONE NOTED UMBILICAL HERNIA WISDOM TEETH Medical History (Check all that apply) Abnormal weight gain Abnormal weight loss Anemia Aneurysm Angioplasty Ankle Pain Arm Pain Arthritis Asthma Back Pain Blood Clots Broken Bones Cancer Chest Pain Chills COPD Corticosteroid use Degenerative Disc Depression/Other disorder Diabetes Dizziness Elbow Pain Epilepsy Eye/Vision Problems Fainting Falls within the last 12 months Fatigue Foot Pain Genetic Spinal Disorder GERD Hand Pain Headaches Hearing Problems Heart Attack Heart disease Hepatitis High Blood Pressure High Cholesterol Hip Pain Hypothyroidism Insomnia Jaw Pain Joint Stiffness Knee Pain Leg Pain Low Back Pain Marked Morning Pain/Stiffness Marked morning stiffness Menstrual Problems Mid Back Pain Migraine Multiple Sclerosis Neck Pain Nerve Damage Neurological Disorder Neuropathy NONE Numbness in Groin/Buttocks Osteoarthritis Osteoporosis Pacemaker Pain at Night Pain Unrelieved by Position or Rest Polio Prostate Problems PTSD Pulmonary Embolism Recent Fever or Chills Restless leg Syndrome Rheumotid Arthritis Scoliosis Seizures Shoulder Pain Sinus Problems Skin Cancer Sleep Apnea Spinal Cord Injury Sprain/Strain Stomach Problems Stroke/Heart Attack Taking Birth Control Pills Taking Blood Thinners Thyroid Urinary Problems Vertigo Visual Disturbances Wrist Pain Factor V Liden CKD Fibromyalgia BIRTH CONTROL BLOOD THINNERS Social History (Check all that apply) Smoking/tobacco use Working Being married Being single Disability Exercising regularly Custom (Check all that apply)
3 Family History Accident Type Accidents Details Accident Type Details Accident Type Details Accident Type Details Accident Type Details
4 Symptom Tell us about your symptom(s) today. Symptom #1 Symptom Start Date Experienced before? On what side are you experiencing the pain? Left Right Bilateral Central None What is the level of pain? None What is the intensity of the pain? None Minimum Mild Moderate Severe Unbearable What is the nature of pain? Burning Dull ache Numb Radiating pain Sharp Shooting Stabbing pain Tightness Tingling Throbbing What is the frequency of pain? None Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) What makes the pain better? Acupuncture Chiropractic Therapy Heat Ice Massage Therapy Nothing works Pain Medicines Physical Therapy Sleep/Rest Stretching Therapy Other What makes the pain worse? Baking Bathing Bending Bending Arm Bending Leg Care of others/pets Caring for Children Carrying Objects Climbing Stairs Concentrating Cooking/Cleaning Crouching/Squatting Doctor s visits Doing Hobbies Doing things on time Dressing Driving Eating Exercise/Sports Financial Management Gardening General Mobility Getting Places Hearing Holding onto objects Housework Jogging Keeping balance Knitting Leaning Lifting Light/Sound Lying down Making decisions Moving Joint/s Mowing Personal hygiene/grooming Pushing/Pulling with feet Pushing/Pulling with hands Reaching out/up/down Reading Running Seeing Sewing Sexual Activity Shopping Sitting Speaking Standing Turning Twisting Using the phone Walking Watching TV Working Yard work
5 What are your expectations regarding this symptom? - Continued What are your expectations regarding this symptom? Become Pain Free Explanation of my Learn how to care for this condition on my own Reduce Symptoms Resume Normal Activity If you have additional symptoms to record, please continue on the next page.
6 Symptom Tell us about your symptom(s) today. Symptom #2 Symptom Start Date Experienced before? On what side are you experiencing the pain? Left Right Bilateral Central None What is the level of pain? None What is the intensity of the pain? None Minimum Mild Moderate Severe Unbearable What is the nature of pain? Burning Dull ache Numb Radiating pain Sharp Shooting Stabbing pain Tightness Tingling Throbbing What is the frequency of pain? None Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) What makes the pain better? Acupuncture Chiropractic Therapy Heat Ice Massage Therapy Nothing works Pain Medicines Physical Therapy Sleep/Rest Stretching Therapy Other What makes the pain worse? Baking Bathing Bending Bending Arm Bending Leg Care of others/pets Caring for Children Carrying Objects Climbing Stairs Concentrating Cooking/Cleaning Crouching/Squatting Doctor s visits Doing Hobbies Doing things on time Dressing Driving Eating Exercise/Sports Financial Management Gardening General Mobility Getting Places Hearing Holding onto objects Housework Jogging Keeping balance Knitting Leaning Lifting Light/Sound Lying down Making decisions Moving Joint/s Mowing Personal hygiene/grooming Pushing/Pulling with feet Pushing/Pulling with hands Reaching out/up/down Reading Running Seeing Sewing Sexual Activity Shopping Sitting Speaking Standing Turning Twisting Using the phone Walking Watching TV Working Yard work What are your expectations regarding this symptom?
7 What are your expectations regarding this symptom? - Continued Become Pain Free Explanation of my Learn how to care for this condition on my own Reduce Symptoms Resume Normal Activity If you have additional symptoms to record, please continue on the next page.
8 Symptom Tell us about your symptom(s) today. Symptom #3 Symptom Start Date Experienced before? On what side are you experiencing the pain? Left Right Bilateral Central None What is the level of pain? None What is the intensity of the pain? None Minimum Mild Moderate Severe Unbearable What is the nature of pain? Burning Dull ache Numb Radiating pain Sharp Shooting Stabbing pain Tightness Tingling Throbbing What is the frequency of pain? None Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) What makes the pain better? Acupuncture Chiropractic Therapy Heat Ice Massage Therapy Nothing works Pain Medicines Physical Therapy Sleep/Rest Stretching Therapy Other What makes the pain worse? Baking Bathing Bending Bending Arm Bending Leg Care of others/pets Caring for Children Carrying Objects Climbing Stairs Concentrating Cooking/Cleaning Crouching/Squatting Doctor s visits Doing Hobbies Doing things on time Dressing Driving Eating Exercise/Sports Financial Management Gardening General Mobility Getting Places Hearing Holding onto objects Housework Jogging Keeping balance Knitting Leaning Lifting Light/Sound Lying down Making decisions Moving Joint/s Mowing Personal hygiene/grooming Pushing/Pulling with feet Pushing/Pulling with hands Reaching out/up/down Reading Running Seeing Sewing Sexual Activity Shopping Sitting Speaking Standing Turning Twisting Using the phone Walking Watching TV Working Yard work What are your expectations regarding this symptom?
9 What are your expectations regarding this symptom? - Continued Become Pain Free Explanation of my Learn how to care for this condition on my own Reduce Symptoms Resume Normal Activity If you have additional symptoms to record, please continue on the next page.
10 Symptom Tell us about your symptom(s) today. Symptom #4 Symptom Start Date Experienced before? On what side are you experiencing the pain? Left Right Bilateral Central None What is the level of pain? None What is the intensity of the pain? None Minimum Mild Moderate Severe Unbearable What is the nature of pain? Burning Dull ache Numb Radiating pain Sharp Shooting Stabbing pain Tightness Tingling Throbbing What is the frequency of pain? None Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) What makes the pain better? Acupuncture Chiropractic Therapy Heat Ice Massage Therapy Nothing works Pain Medicines Physical Therapy Sleep/Rest Stretching Therapy Other What makes the pain worse? Baking Bathing Bending Bending Arm Bending Leg Care of others/pets Caring for Children Carrying Objects Climbing Stairs Concentrating Cooking/Cleaning Crouching/Squatting Doctor s visits Doing Hobbies Doing things on time Dressing Driving Eating Exercise/Sports Financial Management Gardening General Mobility Getting Places Hearing Holding onto objects Housework Jogging Keeping balance Knitting Leaning Lifting Light/Sound Lying down Making decisions Moving Joint/s Mowing Personal hygiene/grooming Pushing/Pulling with feet Pushing/Pulling with hands Reaching out/up/down Reading Running Seeing Sewing Sexual Activity Shopping Sitting Speaking Standing Turning Twisting Using the phone Walking Watching TV Working Yard work What are your expectations regarding this symptom?
11 What are your expectations regarding this symptom? - Continued Become Pain Free Explanation of my Learn how to care for this condition on my own Reduce Symptoms Resume Normal Activity If you have additional symptoms to record, please continue on the next page.
12 Symptom Tell us about your symptom(s) today. Symptom #5 Symptom Start Date Experienced before? On what side are you experiencing the pain? Left Right Bilateral Central None What is the level of pain? None What is the intensity of the pain? None Minimum Mild Moderate Severe Unbearable What is the nature of pain? Burning Dull ache Numb Radiating pain Sharp Shooting Stabbing pain Tightness Tingling Throbbing What is the frequency of pain? None Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) What makes the pain better? Acupuncture Chiropractic Therapy Heat Ice Massage Therapy Nothing works Pain Medicines Physical Therapy Sleep/Rest Stretching Therapy Other What makes the pain worse? Baking Bathing Bending Bending Arm Bending Leg Care of others/pets Caring for Children Carrying Objects Climbing Stairs Concentrating Cooking/Cleaning Crouching/Squatting Doctor s visits Doing Hobbies Doing things on time Dressing Driving Eating Exercise/Sports Financial Management Gardening General Mobility Getting Places Hearing Holding onto objects Housework Jogging Keeping balance Knitting Leaning Lifting Light/Sound Lying down Making decisions Moving Joint/s Mowing Personal hygiene/grooming Pushing/Pulling with feet Pushing/Pulling with hands Reaching out/up/down Reading Running Seeing Sewing Sexual Activity Shopping Sitting Speaking Standing Turning Twisting Using the phone Walking Watching TV Working Yard work What are your expectations regarding this symptom?
13 What are your expectations regarding this symptom? - Continued Become Pain Free Explanation of my Learn how to care for this condition on my own Reduce Symptoms Resume Normal Activity
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION PATIENT INFORMATION First Name: Middle Initial: Last Name: Sex Male Female Date of Birth: Age: SSN: Marital Status: Married Single Divorced Widowed Number of Children: Home Phone:
Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
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Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
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
Re-Exam Questionnaire
Re-Exam Questionnaire Patient Name: Date: The following hi-lighted symptoms are what brought you into our office originally. DIRECTIONS: Please rate ALL hi-lighted symptoms: S = same; B = better; W = worse
Tell Us About You. Tell Us Why You re Here
Case Number Today s Date CA DC Tell Us About You Title: First: MI: Last: Nickname: Birth date: Age: Sex: Male Female Current address: City: State: Zip: SS #: - - Primary Tel: - - H / W / C Alt. Tel: -
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
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
New Practice Member Application
T 1 2 3 Date / / New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Cellular Provider Email Address Occupation Employer s Name Single / Married
PLEASE ASK US FOR HELP IF YOU HAVE ANY QUESTIONS.
Patient Entrance Form Michelle A. Gross, B.Sc. (Hons.), D.C. G. Murray Townsend, B.Sc., D.C. Brianne O Driscoll, B.Sc., D.C Name Date Date of Birth / / DAY MONTH YEAR Age Marital Status Home Address Town
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
NEW SPINE PATIENT. Date Seen: Blood Pressure: Pulse: Weight: Height: O 2. How long (days, weeks, or years) has this complaint/problem been going on?
ROOM #: NEW SPINE PATIENT Date Seen: Blood Pressure: Pulse: Weight: Height: O 2 Sats: For office use only above this line. Patient Name: Referring Physician: Date of Birth: Age: Insurance Carrier: Present
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
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. Thank you for your cooperation. Patient
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
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.
LIST YOUR HEALTH CONCERNS BELOW
Date / / HEALTH PROFILE T C E X Name D.O.B. / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Carrier: Email Address Occupation Employer s Name _ Single / Married / Divorced / Widowed
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
WELLNESS HISTORY. Patient s Name: Date
u:\share\sr dr\wellness history1 08-08-13 1 WELLNESS HISTORY Patient s Name: Date 1) Have you ever been to Acupuncturist? Yes No If Yes: Currently In the past, When: Did it help? What treatment did you
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. If you already completed this form in the last 3 months, please fill
Initial Health Questionnaire
Initial Health Questionnaire 1/5 Patient s name: Date: How would you rate you pain today? None Annoying Uncomfortable Dreadful Horrible Agonizing 0 1 2 3 4 5 6 7 8 9 10 No Distress Unbearable Distress
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Patient Name Date MR#: FLORIDA ORTHOPAEDIC INSTITUTE. Race: Ethnicity: (Circle one) Hispanic / Not Hispanic
FLORIDA ORTHOPAEDIC INSTITUTE LOWER EXTREMITY PATIENT QUESTIONNAIRE Patient Name: Family/Primary Doctor: Phone: Family/Primary Doctor s Address: Who referred you to Florida Orthopaedic Institute? (Name
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
Pain Relief Recover from Injury Chiropractic Therapeutic Laser Therapy. Release & Balance Method Nutritional Counseling Laboratory Testing & Analysis
Health Solutions Center John Gangemi Chiropractic Physician Date Date of Birth Name Mailing Address Home Phone Cell Occupation Email How Did You Hear About Our Office Whom May We Thank For Referring You
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /
Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / / Email Address: Do not have email Do not wish to provide Date of Birth: / / Gender: Male