WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
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1 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) AGE MARITAL STATUS SPOUSE S NAME # CHILDREN OCCUPATION EMPLOYER PHONE ADDRESS OHIP # & LETTER CODE EXP. DATE: EXTENDED HEALTH CARE COMPANY POLICY # EMERGENCY CONTACT RELATION HOW DID YOU HEAR ABOUT OUR OFFICE (IF REFERRED, BY WHO?) ARE YOU HERE BECAUSE OF A: MOTOR VEHICLE ACCIDENT YES NO WORK RELATED ACCIDENT YES NO PRIOR CHIROPRACTIC CARE: NAME PHONE WHEN X RAYS TAKEN YES NO RESULTS MEDICAL DOCTOR: NAME PHONE DATE OF LAST VISIT Dr. Anthony Adams, 1066 Brant Street, Burlington, ON L7R 2J
2 CURRENT HEALTH CONDITION(S) BNHC 1066 Brant Street, Burlington, ON L7R 2J9 CURRENT COMPLAINT(S) HOW DID THIS CONDITION BEGIN DATE OF ONSET HAS IT OCCURRED BEFORE YES NO WHAT AGGRAVATES YOUR CONDITION SITTING STANDING BENDING LIFTING WALKING LYING COLD DAMPNESS WHAT RELEIVES YOUR CONDITION BED REST ICE HEAT MASSAGE MEDICATION IS THE PAIN CONSTANT INTERMITTENT WORSENING IMPROVING TYPE OF PAIN SHARP DULL ACHE PINS & NEEDLES NUMB BURNING SHOOTING TO WHAT DEGREE DOES THE PAIN HAMPER YOUR ABILTY TO (1 Not at all, 10 Completely) WORK 1 10 ENJOY FAMILY / SOCIAL LIFE 1 10 ENJOY HOBBIES / SPORTS 1 10 OTHER DOCTORS SEEN FOR THIS CONDITION YES NO WHO TYPE OF TREATMENT RESULTS DRUGS YOU NOW TAKE NERVE PILLS PAIN KILLERS MUSCLE RELAXERS BLOOD PRESSURE INSULIN DO YOU SUFFER FROM ANY OTHER CONDITION OTHER THAN THAT FOR WHICH YOU ARE NOW CONSULTING US? PLEASE COMPLETE THE FOLLOWING DIAGRAMS 1. DRAW IN YOUR FACE 2. CIRCLE AREAS OF PAIN 3. USE THE FOLLOWING SYMBOLS Pins & Needles Radiation Numbness x x x x x x x x Burning / / / / / / / / / / Aching s s s s s s s s Stabing
3 PAST HEALTH HISTORY Dr. Anthony Adams, 1066 Brant Street, Burlington, ON L7R 2J SURGERY / OPERATIONS MAJOR ACCIDENTS / INJURIES HOSPITALIZATION (Other than above) FAMILY HEALTH CONDITIONS OR PROBLEMS PREVIOUS X - RAYS PLEASE CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE OR HAVE HAD Aneurysm Osteoporosis Diabetes Arthritis Respiratory Conditions Epilepsy Cancer Strokes Allergies Heart Conditions Hepatitis Fatigue Polio Pneumonia Sleeping Difficulty Pleurisy Asthma V.D. Psoriasis HIV OTHER HEALTH CONDITIONS PLEASE CHECK ANY OF THE SYMPTOMS YOU HAVE OR HAVE HAD GENERAL MUSCLE&JOINT RESPIRATORY EENT CARDIO-VASCULAR Allergy Bursitis Chest Pain Colds Rapid Heart Beats Chills Foot Trouble Chronic Cough Crossed Eyes Slow Heart Beats Convulsions Hernia Hard To Breath Deafness Ankle Swelling Dizziness Low Back Pain Spitting Blood Dental Decay Hardening of Arteries Fainting Neck Pain Throat Phlegm Asthma High Blood Pressure Fevers Neck Stiffness Wheezing Ear Aches Low Blood Pressure Headaches Shoulder Pain GENITOURINARY Ear Discharge Pain Over Heart Loss of Sleep SKIN Smell of Urine Ear Noises Poor Circulation Nervousness Varicose Veins Bed Wetting Sinus Infections PAIN OR NUMBNESS Depression Boils Blood in Urine Enlarged Glands Head Neuralgia Bruise Easily Frequent Urine Enlarged Thyroid Shoulders Numbness Dryness Bladder Control Sore Throats Arms Sweats Hives / Allergy Kidney Infection Tonsillitis Hands Weight Loss Itching Painful Urination Eye Pain Hips Tremors Rashes Prostate Trouble Failing Vision Legs WOMEN ONLY Pus in Urine Far Sighted Knees Cramps Irregular Cycle Painful Cycle Heavy Flow Light Flow Discharge Sore Breasts Menopausal : Yes No Since Pregnant: Yes No Due Date Gum Trouble Ankles Hay Fever Feet Hoarseness Tail Bone Nasal Obstruction Sciatica Near Sighted Swollen Joints Nosebleeds DO YOU SMOKE Yes No DO YOU CONSUME ALCOHOL Yes No DO YOU EXERCISE Yes No
4 CONSENT TO CHIROPRACTIC TREATMENT Burlington Natural Health Centre Dr. Anthony Adams 1066 Brant Street, Burlington, Ontario L7R 2J It is important for you to consider the benefits, risks and alternatives to the treatment options offered by your chiropractor and to make an informed decision about proceeding with treatment. Chiropractic treatment includes adjustment, manipulation and mobilization of the spine and other joints of the body, soft-tissue techniques such as massage, and other forms of therapy including, but not limited to, electrical or light therapy and exercise. Benefits Chiropractic treatment has been demonstrated to be effective for complaints of the neck, back and other areas of the body caused by nerves, muscles, joints and related tissues. Treatment by your chiropractor can relieve pain, including headache, altered sensation, muscle stiffness and spasm. It can also increase mobility, improve function, and reduce or eliminate the need for drugs or surgery. Risks The risks associated with chiropractic treatment vary according to each patient s condition as well as the location and type of treatment. The risks include: Temporary worsening of symptoms Usually, any increase in pre-existing symptoms of pain or stiffness will last only a few hours to a few days. Skin irritation or burn Skin irritation or a burn may occur in association with the use of some types of electrical or light therapy. Skin irritation should resolve quickly. A burn may leave a permanent scar. Sprain or strain Typically, a muscle or ligament sprain or strain will resolve itself within a few days or weeks with some rest, protection of the area affected and other minor care. Rib fracture While a rib fracture is painful and can limit your activity for a period of time, it will generally heal on its own over a period of several weeks without further treatment or surgical intervention. Injury or aggravation of a disc Over the course of a lifetime, spinal discs may degenerate or become damaged. A disc can degenerate with aging, while disc damage can occur with common daily activities such as bending or lifting. Patients who already have a degenerated or damaged disc may or may not have symptoms. They may not know they have a problem with a disc. They also may not know their disc condition is worsening because they only experience back or neck problems once in a while. Chiropractic treatment should not damage a disc that is not already degenerated or damaged, but if there is a pre-existing disc condition, chiropractic treatment, like many common daily activities, may aggravate the disc condition. The consequences of disc injury or aggravating a pre-existing disc condition will vary with each patient. In the most severe cases, patient symptoms may include impaired back or neck mobility, radiating pain and numbness into the legs or arms, impaired bowel or bladder function, or impaired leg or arm function. Surgery may be needed. Stroke Blood flows to the brain through two sets of arteries passing through the neck. These arteries may become weakened and damaged, either over time through aging or disease, or as a result of injury. A blood clot may form in a damaged artery. All or part of the clot may break off and travel up the artery to the brain where it can interrupt blood flow and cause a stroke.
5 Many common activities of daily living involving ordinary neck movements have been associated with stroke resulting from damage to an artery in the neck, or a clot that already existed in the artery breaking off and travelling up to the brain. Chiropractic treatment has also been associated with stroke. However, that association occurs very infrequently, and may be explained because an artery was already damaged and the patient was progressing toward a stroke when the patient consulted the chiropractor. Present medical and scientific evidence does not establish that chiropractic treatment causes either damage to an artery or stroke. The consequences of a stroke can be very serious, including significant impairment of vision, speech, balance and brain function, as well as paralysis or death. Alternatives Alternatives to chiropractic treatment may include consulting other health professionals. Your chiropractor may also prescribe rest without treatment, or exercise with or without treatment. Questions or Concerns You are encouraged to ask questions at any time regarding your assessment and treatment. Bring any concerns you have to the chiropractor s attention. If you are not comfortable, you may stop treatment at any time. Please be involved in and responsible for your care. Inform your chiropractor immediately of any change in your condition. Initial Examination I hereby consent to an initial examination by the Chiropractor and understand that some procedures may cause immediate and/or temporary lasting discomfort. I have the right to ask questions and/or ask that the examination be terminated at anytime. The examination procedures are commonly accepted practices with very low risk, however, the practitioner can not be expected to predict all potential effects. Please initial here that you have read the above Initial above PLEASE SIGN AND CONSULT WITH THE CHIROPRACTOR IF YOU HAVE ANY QUESTIONS I hereby acknowledge that I have discussed with the chiropractor the assessment of my condition and the treatment plan. I understand the nature of the treatment to be provided to me. I have considered the benefits and risks of treatment, as well as the alternatives to treatment. I hereby consent to chiropractic treatment as proposed to me. Patient s Name Patient s Signature Date Witness
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
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
Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#
Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
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 #
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
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
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
PATIENT ENTRANCE FORM
PATIENT ENTRANCE FORM Name _ Date Address City/ Province Postal Code Home Telephone Work Telephone Email Address Would like email reminders for appointments? Yes No Date of Birth (Day/Month/Year) Age Marital
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
Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
ACTIVE EDGE CHIROPRACTIC
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
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
Cascadia Chiropractic Centre
Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card
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
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
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
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
PEDIATRIC HISTORY FORM
PEDIATRIC HISTORY FORM Today s Date: MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code:
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
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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
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
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Please complete this profile, the answers will help determine if Chiropractic can help your child. Child s Name: Parent 1 Name: Parent 2 Name:
Pediatric Patient Profile Dear Parent: Please complete this profile, the answers will help determine if Chiropractic can help your child. Personal Information Date: Child s Name: Parent 1 Name: Parent
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET ADDRESS: PROVINCE: HOME PHONE: (CHECK WHICH PREFERRED) WORK PHONE: EMAIL ADDRESS: NEW LEGISLATION REQUIRES THAT WE OBTAIN CONSENT PRIOR TO SENDING EMAILS TO
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
Patient Introduction
Date: Patient Introduction Name: First Middle Last Birth Date: Month: Day: Year: Age: Gender: Male Female Address: PC: Telephone: Home: Cell: Work: Emergency contact name and #: Alberta Health Care Number:
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
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
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
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
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Pediatric Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one)
GENERAL PATIENT INFORMATION
GENERAL PATIENT INFORMATION Name: Gender: Date of Birth: Age: M/F DD/MM/YY Address: City: Province: Postal Code: Tel: Bus.Tel: Alt. Tel: Emergency Contact: Tel: Relation: E-mail Address: @ Please indicate
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
KINESIS HEALTH ASSOCIATES PATIENT PAST HISTORY FORM
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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
PEDIATRIC PRE-EXAM INFORMATION
PEDIATRIC PRE-EXAM INFORMATION Name: Date of Birth dd /mm /YY Sex: M F Age Address Postal Code Mother s Name Home Phone: Occupation : Work Phone: Father s name Home Phone: Occupation: Work Phone: Siblings
Universal Health & Rehabilitation, PC
28 Finch Avenue West, Suite 212 Tel: (416) 628-1336 Pain.Drs@gmail.com www.pain-drs.com Your Multidisciplinary Healthcare Solution Thank you for choosing our office! To ensure your visit with us is a pleasant
Full Name Preferred name. Home Street Address. City, State, Zip. Cell phone Home or Work. # Children Ages:
Health History Full Name Preferred name Home Street Address City, State, Zip Cell phone Home or Work Email # Children Ages: Occupation Hours/day on computer Hours/day sitting Who can we thank for referring
NEW PATIENT QUESTIONNAIRE
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Reason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
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
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
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New Patient Pain Evaluation
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CHIROPRACTIC INTAKE FORM
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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
Creekside Chiropractic
Creekside Chiropractic ---- - New Patient History Date: Name: Home Phone: Cell Phone: Social Security #: Birthdate: Age: Email Address: Street Address: City: State: Zip: Please circle the best way to contact
NEW PATIENT MEDICAL FORM. Name: Date of scheduled appointment: Address: Skype ID: Date of Birth: Gender: Height: Weight:
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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
PERSONAL INJURY QUESTIONNAIRE
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ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
HEALTH INFORMATION FORM
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Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
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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,
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New Patient Intake Form
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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:
Patient Intake Form Please Write Legibly
Chiropractic Wellness Center Date: Patient Intake Form Please Write Legibly Patient Legal Name: Male Female Preferred Name: Date of Birth: Age: Home Address: Apt#: City: State: Zip: Home Phone: Cell Phone:
Patient Introduction
Merivale Chiropractic Clinic Merivale Mall 1642 Merivale Rd., Unit 360 Ottawa, ON K2G 4A1 Patient Introduction Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov:
intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Email Address: Birthday: Marital Status: Married
Patient Information (please print clearly) Name: Date of Birth: mm/dd/yyyy / / Age: (to receive appointment reminders)
YOUR HEALTH Wellness Centre 1158 Winston Churchill Blvd Oakville, ON L6J 0A3 Chiropractic New Patient Form Patient Information (please print clearly) Name: Date of Birth: mm/dd/yyyy / / Age: Address: City:
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
Have you ever been in a vehicular collision? (Please list date(s) and severity):
Physical History: Have you had any impacts or falls that you feel may have injured your spine? Please explain: Broken Bones? Surgeries? Are you ac@ve in any par@cular sports? Do you exercise? DAILY / 2-3x
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below.
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below. Please describe your current primary complaint? Difficulty in: Standing, Sitting, Bending, Walking, Reaching Cannot
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.
BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D. PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC Name: Age: Sex: Male Female Occupation: Job description: Date: PLEASE ANSWER THE FOLLOWING QUESTIONS: Major
Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Tassin Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
B wel Chiropractic & Health Associates 3020 East College Avenue, Suite H Appleton, WI Dr. James M. Benzschawel
DATE: CASE HISTORY SEX: M / F LAST NAME: FIRST: M: DOB: ADDRESS: CITY: STATE: ZIP: APT OR UNIT #: HOME#: CELL#: SS #: - - MARITAL? M S W D # OF CHILDREN? SPOUSE NAME?: SPOUSE DOB?: OCCUPATION: EMPLOYER:
Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:
Leader Heights Spine, Joint & Nerve Associates Date: Chart # DC # Patient Information: Please print clearly and complete all sections. Please Circle : Mr. Mrs. Ms. Miss Dr. Rev. Marital Status : Single
PATIENT INTAKE SHEET 2016
PATIENT INTAKE SHEET 2016 Patient Name: Last First Middle D.O.B.: Sex: M F Year Month Day Address: Street Address City May we leave a detailed message? Postal Code Phone : Residence Yes [ ] No [ ] Work
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
Patient Name (last, first) Sex: Male / Female
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
Symptom Review (page 1) Name Date
v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
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
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
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