LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
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- Kellie Horton
- 5 years ago
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1 Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital Status: Single Married Do you have Insurance: Yes No Work Phone: Social Security #: Driver s License #: Employer: Occupation: Spouse s Name Spouse s Employer Number of children and Ages: Name & Number of Emergency Contact: Relationship: HISTORY of COMPLAINT Please identify the condition(s) that brought you to this office: Primarily: Secondarily: Third: Fourth: On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by circling the number: Primary or chief complaint is : Second complaints is : Third complaint: : Fourth complaint: : When did the problem(s) begin? When is the problem at its worst? AM PM mid day late PM How long does it last? It is constant OR I experience it on and off during the day OR It comes and goes throughout the week How did the injury happen? Condition(s) ever been treated by anyone in the past? No Yes If yes, when: by whom? How long were you under care: Name of Previous Chiropractor: What were the results? N/A *PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling What relieves your symptoms? What makes them feel worse? LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
2 Is your problem the result of ANY type of accident? Yes, No Identify any other injury(s) to your spine, minor or major, that the doctor should know about: PAST HISTORY Have you suffered with any of this or a similar problem in the past? No Yes If yes how many times? When was the last episode? How did the injury happen? Other forms of treatment tried: No Yes If yes, please state what type of treatment:, and who provided it: How long ago? What were the results. Favorable Unfavorable please explain. Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body: If you have ever been diagnosed with any of the following conditions, please indicate with a P for in the Past, C for Currently have and N for Never have had: Broken Bone Dislocations Tumors Rheumatoid Arthritis Fracture Disability Cancer Heart Attack Osteo Arthritis Diabetes Cerebral Vascular Other serious conditions: PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem: HOW LONG AGO TYPE OF CARE RECEIVED BY WHOM INJURIES SURGERIES CHILDHOOD DISEASES ADULT DISEASES SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes How often? Daily Weekends Occasionally Never 2. Alcoholic Beverage: consumption occurs Daily Weekends Occasionally Never 3. Recreational Drug use: Daily Weekends Occasionally Never 4. Hobbies Recreational Activities Exercise Regime: How does your present problem affect the following, See pg 2 Activities of Life FAMILY HISTORY: 1. Does anyone in your family suffer with the same condition(s)? No Yes If yes whom: grandmother grandfather mother father sister s brother s son(s) daughter(s) Have they ever been treated for their condition? No Yes I don t know 2. Any other hereditary conditions the doctor should be aware of. No Yes: I hereby authorize payment to be made directly to [CLINIC NAME], for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to [CLINIC NAME] for any and all services I receive at this office. Patient or Authorized Person s Signature Doctor s Signature Date Completed - - Date Form Reviewed Patient s Name: HR#: / / JDD,DC 5/2011
3 Activities of Daily Living/Symptoms/Medications Patient Name: Date: File# Daily Activities: Effects of Current conditions On Performance Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life: Bending No Effect Painful (can do) Painful (Limits) Unable to Perform Concentrating No Effect Painful (can do) Painful (Limits) Unable to Perform Doing computer Work No Effect Painful (can do) Painful (Limits) Unable to Perform Gardening No Effect Painful (can do) Painful (Limits) Unable to Perform Playing Sports No Effect Painful (can do) Painful (Limits) Unable to Perform Recreation Activities No Effect Painful (can do) Painful (Limits) Unable to Perform Shoveling No Effect Painful (can do) Painful (Limits) Unable to Perform Sleeping No Effect Painful (can do) Painful (Limits) Unable to Perform Watching TV No Effect Painful (can do) Painful (Limits) Unable to Perform Carrying No Effect Painful (can do) Painful (Limits) Unable to Perform Dancing No Effect Painful (can do) Painful (Limits) Unable to Perform Dressing No Effect Painful (can do) Painful (Limits) Unable to Perform Lifting No Effect Painful (can do) Painful (Limits) Unable to Perform Pushing No Effect Painful (can do) Painful (Limits) Unable to Perform Rolling Over No Effect Painful (can do) Painful (Limits) Unable to Perform Sitting No Effect Painful (can do) Painful (Limits) Unable to Perform Standing No Effect Painful (can do) Painful (Limits) Unable to Perform Working No Effect Painful (can do) Painful (Limits) Unable to Perform Climbing No Effect Painful (can do) Painful (Limits) Unable to Perform Doing Chores No Effect Painful (can do) Painful (Limits) Unable to Perform Driving No Effect Painful (can do) Painful (Limits) Unable to Perform Performing Sexual Activity No Effect Painful (can do) Painful (Limits) Unable to Perform Reading No Effect Painful (can do) Painful (Limits) Unable to Perform Running No Effect Painful (can do) Painful (Limits) Unable to Perform Sitting to Standing No Effect Painful (can do) Painful (Limits) Unable to Perform Walking No Effect Painful (can do) Painful (Limits) Unable to Perform
4 Please mark P for in the Past, C for Currently have and N for Never Headache Pregnant (Now) Dizziness Prostate Problems Ulcers Neck Pain Frequent Colds/Flu Loss of Balance Impotence/Sexual Dysfun. Heartburn Jaw Pain, TMJ Convulsions/Epilepsy Fainting Digestive Problems Heart Problem Shoulder Pain Tremors Double Vision Colon Trouble High Blood Pressure Upper Back Pain Chest Pain Blurred Vision Diarrhea/Constipation Low Blood Pressure Mid Back Pain Pain w/cough/sneeze Ringing in Ears Menopausal Problems Asthma Low Back Pain Foot or Knee Problems Hearing Loss Menstrual Problem Difficulty Breathing Hip Pain Sinus/Drainage Problem Depression PMS Lung Problems Back Curvature Swollen/Painful Joints Irritable Bed Wetting Kidney Trouble Scoliosis Skin Problems Mood Changes Learning Disability Gall Bladder Trouble Numb/Tingling arms, hands, fingers ADD/ADHD Eating Disorder Liver Trouble Numb/Tingling legs, feet, toes Allergies Trouble Sleeping Hepatitis (A,B,C) List Prescription & Non Prescription drugs you take:
5 Patient Name File#/HRN Date INITIAL NERVE SYSTEM PROFILE When was your most recent auto accident? What speed was the collision? Type of impact: Front Impact / Side Impact / Rear Impact Was treatment received? Please describe When was your most recent strain / stress at work? Please describe the manner of the injury Was treatment received? Please describe Does your job require you remain in long term stressful postures? (i.e. all day seating, repeated lifting, long term computer use) Spinal traumas in the past? Collision, quick burst, or repetitive motion sports: football, wrestling, basketball, baseball, soccer, tennis, golf, track and field Trauma as a child! i.e. fall on your head, impact to your head, concussion, fall onto your back or tailbone, biking accident Work around the house lifting, bending, woke up with stiff neck, back went out Doctor Signature Date JDD, DC 5/2011
APPLICATION FOR CARE AT CORE CHIROPRACTIC
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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: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
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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
APPLICATION FOR CARE AT
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SPARROW FAMILY CHIROPRACTIC
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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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APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
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Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
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New Practice Member Application
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New Practice Member Application
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New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Molland Spinal Care, LLC 124 Hwy 35 South Red Bank, NJ Phone:
Molland Spinal Care, LLC 124 Hwy 35 South Red Bank, NJ 07701 Phone: 908-601-5600 Welcome to Molland Spinal Care, LLC. Enclosed please find the patient health questionnaire. Please fill out the parts that
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female
Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
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
Who may we thank for referring you? When did this episode start?
NEW PRACTICE MEMBER APPLICATION Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
CHIROPRACTIC NEW PATIENT HEALTH HISTORY
CHIROPRACTIC NEW PATIENT HEALTH HISTORY Name: Last: First: MI: Address: City: Province: Postal Code: E-mail address: Cell Phone: Home Phone: Age: Birth Date: Alberta Health #: Occupation: Employer: Marital
New Patient Intake Forms. Patient Data Date. Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other. First Name Middle Initial Last Name
New Patient Intake Forms Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address Line City State Zip Code Home Phone ( ) -
(Must be completed with blue ink pen) Last Name First Name Date / / Address City Zip. Home Phone Cell Phone. Social Security# Driver s License # State
(Must be completed with blue ink pen) (MR #: ) Last Name First Name Date / / Address City Zip Home Phone Cell Phone Email Birthday / / Sex: M F Social Security# Driver s License # State Occupation Employer
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
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
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
AUERBACH CHIROPRACTIC
AUERBACH CHIROPRACTIC ARTS AND SCIENCE Dr. Gary Auerbach 2730 N. Pantano Road Tucson, AZ 85715 Phone: 520-721-7177 Welcome to the office of Auerbach Chiropractic Arts and Science. In order to better serve
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
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address
ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address Home phone number MD Phone number Work number Any other MD you request we send information to?