Name: Date: DOB: Full Address: Phone: Home: Cell: Occupation: Emerg. contact and phone: Relationship to pt.
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1 Client Registration Name: Date: DOB: Full Address: Phone: Home: Cell: Occupation: Emerg. contact and phone: Relationship to pt. How did you hear about ALIGN? ALIGN Integration Movement does not participate with any insurance companies. Clients are required to pay at the time of service and will be given a receipt to submit to their insurance provider for reimbursement. ALIGN cannot be responsible should your insurance company decide not to reimburse you. Please understand your out-of-network medical coverage and prescription requirements. Patient Signature Date
2 This is a very thorough questionnaire asking very important questions for our evaluation process. Please fill this out as completely as possible to provide me with a clear picture of your present symptoms, abilities and goals. Name: Medical History Disclosure Form 1. What is the primary complaint that brings you to ALIGN Integration Movement? a) When did your symptoms first appear? Have you had it before this occurrence? b) Have you ever been treated for this/these problem(s) before? When, what, where, by who, for how long? c) Did prior treatment successfully manage or resolve the problem at that time? please explain d) How did your symptoms begin? ie. after an accident, injury, physical or emotional trauma, or without reason? e) Is it the SAME, BETTER or WORSE since onset? Circle one 2. Secondary complaint? Please summarize above questions here: 3. What activities increase your pain/symptoms? 4. What activities ease your pain/symptoms?
3 5. What are your functional goals for this treatment program? What activities from above would you like to be able to perform/tolerate, and for how long? ex: Be able to walk for 3 miles without pain in order to maintain exercise program. ex: be able to sleep for 5 hours without waking up due to symptoms Place a check mark in front of each item that you experience at least monthly. Place an X in front of anything you experience more frequently than that. headache cold hands/feet blurred vision teeth grinding high personal stress severe menstrual cramps trembling painful urination stiff/sore joints heart racing coughing earache, ringing difficulty sleeping anxiety stomach cramps skin rashes urinary leakage fibrotic breasts irregular heartbeat sinus congestion allergies fatigue thoughts of suicide acid reflux water retention irregular bowels back problems chest pain/tightness hopelessness nausea, vomiting faint/dizzy urinary frequency numbness, tingling tense/nervous incomplete urination constipation asthma feeling overwhelmed unable to have sex sore, aching muscles
4 7. Please circle any/all illnesses you ve either had in the past or currently have: Cardiovascular disease Asthma/Breathing difficulty Heart disease Depression High Blood Pressure Diabetes Epilepsy/Seizures Anemia Osteoporosis Multiple Sclerosis Thyroid Condition Migraines/headaches Stroke or Heart Attack Fibromyalgia Kidney disease Chronic infections Arthritis HIV/AIDS Eating disorder Drug or Alcohol Abuse Dizzy/Vertigo Hepatitis/liver disease Neurological condition Fibromyalgia Cancer (Type) ; Location(s) ; Year: Please list surgeries: Do you have any implanted medical device? Are you pregnant or is there a possibility that you are? 8. MEDICATIONS: Please indicate below ALL medications you are currently taking, the problem for which you are using them for, dosage, and effectiveness. Medication Treatment for Dose/amt/day Effectiveness I CERTIFY, TO THE BEST OF MY KNOWLEDGE, THAT THE ABOVE INFORMATION IS COMPLETE & TRUE. IF MY MEDICAL/HEALTH STATUS CHANGES I WILL INFORM YOU IMMEDIATELY. Signature & Date:
5 Pelvic Floor Therapy Questionnaire Please fill in the following questionnaire to the best of your ability. The therapist will review the answers with you at your appointment. History Number of pregnancies Number of vaginal deliveries Birth weight of largest baby Number of cesarean deliveries Number of episiotomies Date of last Pap smear Did you have any trouble healing after delivery Y N Do you have a history of sexual abuse or trauma Y N Are you having regular periods/ menstrual cycles Y N Do you have frequent urinary tract infections Y N Pain Do you have pain with: Sexual intercourse Y N Pelvic exam Y N Tampon use Y N Back, leg, groin, abdominal pain Y N Tests Urodynamics test Cystoscope Urine test Bowel test Results: Results: Results: Results:
6 Please shade in areas of pain or symptoms. On side view, please indicate if your symptoms are on the left or right side. Rate shaded areas 1-10 based on severity (10 is worst pain).
7 Bladder symptoms Do you lose urine when you: Cough/ sneeze/ laugh Y N Lift/exercise/dance/jump Y N On the way to the bathroom Y N Have a strong urge to urinate Y N Hear running water Y N Do you wet the bed Y N Have burning/ pain with urination Y N Strain to empty your bladder Y N Difficulty starting a stream of urine Y N Feel unable to empty bladder fully Y N Have a falling out feeling or pressure in your pelvis Y N Have pain with a full bladder Y N Have an urgency of urination(a strong urge to urinate) Y N Urinate more than 7 times/day Y N Bowel symptoms Strain to have a bowel movement Y N Include fiber in your diet Y N Take laxatives / enema regularly Y N Leak / stain feces Y N Have diarrhea often Y N Have pain with bowel movement Y N Have a very strong urge to move your bowels Y N How often do you move your bowels: per day, week Most common stool consistency: liquid soft firm pellets other: Thank you for taking the time to fill out this questionnaire.
8 Cancellation Policy ALIGN Integration Movement believes that each appointment you have scheduled is very important for your healing process. If you know that will need to cancel and reschedule your appointment, please allow 24 hour notice to allow us to reschedule another person who could potentially fill the time slot. ALIGN has instated the following cancellation policy: 1. Please allow 24 hour notice with all cancellations. 2. Align charges $50 for all cancellations made within 24 hours prior to your scheduled appointment time. This applies to all cancellations regardless of cause. 3. You will receive an invoice for the cancellation fee of $50. Please note that an appointment is only CHARGED as a cancellation if you do not give 24 hour notice. I have READ and UNDERSTAND this cancellation policy for Align Integration & Movement, PLC. If I have any questions regarding this policy, I have clarified them with the staff. Signature: Date:
9 PELVIC FLOOR CONSENT FOR EVALUATION AND TREATMENT I acknowledge and understand that I have been referred for evaluation and treatment of pelvic floor dysfunction. Pelvic floor dysfunctions include, but are not limited to, urinary or fecal incontinence; difficulty with bowel, bladder, or sexual functions; painful scars after childbirth or surgery; persistent sacroiliac or low back pain; or pelvic pain conditions. I understand that to evaluate my condition it may be necessary, initially and periodically, to have my therapist perform an internal pelvic floor muscle examination. This examination is performed by observing and/or palpating the perineal region including the vagina and/or rectum. This evaluation will assess skin condition, reflexes, muscle tone, length, strength and endurance, scar mobility, and function of the pelvic floor region. Such evaluation may include vaginal or rectal sensors for muscle biofeedback. Treatment may include, but not be limited to, the following: observation, palpation, use of vaginal or rectal sensors for biofeedback and/or electrical stimulation, stretching and strengthening exercises, soft tissue and/or joint mobilization, and educational instruction. I understand that in order for therapy to be effective, I must come as scheduled unless there are unusual circumstances that prevent me from attending therapy. I agree to cooperate with and carry out the home program assigned to me. If I have difficulty with any part of my treatment program, I will discuss it with my therapist. 1. The purpose, risks, and benefits of this evaluation have been explained to me. 2. I understand that I can terminate the procedure at any time. 3. I understand that I am responsible for immediately telling the examiner if I am having any discomfort or unusual symptoms during the evaluation. Date: Patient Signature Patient Name: Signature of Parent/Guardian (if applicable)
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Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
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
UNC Urogynecology and Reconstructive Pelvic Surgery Division of Female Pelvic Medicine and Reconstructive Surgery (FPMRS)
UNC Urogynecology and Reconstructive Pelvic Surgery Division of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) We look forward to your upcoming visit with us. Our goal is to provide you with
New Patient Information
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IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth: