\ NSMI. The National Sports Medicine InstJtute
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1 ~ \ NSMI The National Sports Medicine InstJtute Deerfield Avenue Su ite 3 12 Lansdowne, Virgin ia 20 I Stone Spring Blvd, Suite 250, Dulles, Virginia Patient Information: Last Name: First Name: Middle Initial: Home Address: City: State: Zip Code: " Home #: Cell #: Work #: Date of Birth: _1_1_ Age: _ Height Weight Address: Primary Physician: Phone: Referring Physician: Phone: Emergency Contact: Phone # Insurance Information: Primary Insurance: Phone# Policy ID# Group# Primary Insured Name: Date Of Birth: Social Security # - Effected Date: Name ofemployer: ~ Secondary Insurance: Phone# Policy ID# Group# Primary Insured Name: Date Of Birth: Social Security # - Effected Date: Name of Employer:
2 Hand Dominance: Left Right_ Ambidextrous Please list all sports and physical activities that you participate in: Are you in seasonal competition? _ Yes _ No Which Sport/s? History of Present Problem: Is this a work injury:? Date Symptoms Started: 1 1 What is the present problem? Please describe how the injury occurred (be specific): _ Location of Pain: Please mark on figures below: How often do you have pain? _ Constantly _ Intermittently Please describe the on set? Sudden Gradual 2
3 What is the quality of pain? _ Aching _ Throbbing _ Sharp _ Shooting _ Burning Please rate your pain score (using a scale of 0 to 10, 0= no pain and 10 =unbearable pain) _Without Activity _ With Activity What makes the pain better? (e.g. heat, cold, sitting, laying down, meds) _ What makes the pain worse? (e.g. bending, lifting, standing) Have you taken part in any conservative treatment? (e.g. physical therapy, chiropractor, meds) Have you had any injections or procedures for the current problem? Please list any health care professionals who have treated you for this specific problem in the past Past Medical History: Arthritis Asthma Back Pain _Bleeding Disorders Bronchitis Crohn'sl Ulcerative Colitis CHF _Blood Clots (DYT) _ Depression Diabetes Diverticu losis _Emphysema (COPD) _Fibromyalgia HIY Heart Attack Heart Murmur _Hepatitis _Hypertension _Kidney Disease Psoriasis Liver Disease _Lyme Disease Neck Pain _ Osteoporosis Gout Reflux Rheumatoid Arthritis Seizures _Sleep Apnea Stomach U leers Stroke Tutmors/Cancers _Joint Replacement Others, please explain: Past Sports related Injuries: _ Prior Hospitalizations (past 2 years): Past Surgical History (all body parts): 3
4 Medications (dose and frequency): A Ilergies: Social History: Marital Status: Single Married Divorced Widowed Do you smoke or use smokeless tobacco? _Yes No; How many daily? _ #ofyears? _ Do you consume alcohol? Yes No; How many daily? _ #ofyears?_ Have you ever abused alcohol? _ Yes No Do you use illicit drugs? _Yes No Have you abused illicit drugs in the past? Yes _ No Currently are you involved in any litigation/lawsuits relating to your injury? _ Yes No Family History: Arthritis Emphysema (COPD) Neck Pain Asthma Fibromyalgia Osteoporosis Back Pain HIV Pancreatitis Bleeding Disorders Heart Attack Reflux Bronchitis Heart Murmur Rheumatoid Arthritis Crohn's/ Ulcerative Colitis Hepatitis Seizures CHF Hypertension Sleep Apnea Blood Clots (DVT) Kidney Disease Stomach Ulcers _ Depression Kidney Stones Stroke Diabetes Liver Disease Tumors/Cancers Diverticulosis Lyme Disease Tubercu losis Others, please explain: ". 'r, 4
5 Review of Systems: Your current Height: and Weight: General: _ Changes in Weight _ Changes in Appetite _ Changes in Sleep _ Changes in Taste/Smell Fatigue _Fever _Other Skin: _ Rash _ Itching HeadlNeck: _ Hearing Impairment _ Dizziness _ Balance Problems _ Vision Problems _ Nose Bleed _ Hoarseness _ Mouth Sores _ Difficulty Swallowing Lungs: _ Chronic Cough _ Emphysema _ Tuberculosis _ Bronchitis Cardiovascular: _ High Blood Pressure _ Chest Pain _ Heart Attack _ _ Murmurs _ Congestive Heart Failure _ Blood Clot (DVT) _ High Cholesterol Shortness of Breath Gastrointestinal: Stomach Ulcers Heartburn Rectal Bleed Hernia Pancreatitis _ Diarrhea _ Constipation Urinary Tract: _ Kidney Stones _ Kidney Infections _ Painful Urination _ Incontinence _ Bleeding Reproductive: _ Sexually Transmitted Diseases _ Bleeding _ Impotence Endocrine: _ Thyroid Disease _ Pituitary/Hormonal Disease Blood/Lymphatic: _ HIV/AID _ Lymphoma _ Bleeding Problems _Sickle Cell Anemia Musculoskeletal: Osteoarthritis Rheumatoid Althritis Joint Pain I. Muscle Disorder Nervous: _ Fainting _ Headache _ Seizures _ Memory Loss _ Dizziness _ Numbness Psychiatric History: _ Depression _ Anxiety _ Psychosis 5
6 Authorization for Treatment and Payment I hereby request treatment by The National SPOl1S Medicine Institute and consent to care and treatment as ordered by my physician(s). I authorize the release of information related to my treatment to my referring physician(s). I authorize The National Sports Medicine Institute to submit this claim on my behalf for the medical services provided. I hereby authorize my health insurance company to make payment(s) directly to The National Sports Medicine Institute, for any benefits that I may receive. I understand that I am financially responsible for all charges made to my account whether or not an insurance company, attorney, or third party payer is involved with payment. I am responsible for all co-payment and co-insurance amounts, noncovered supplies and services along with yearly deductibles. Payment for services is expected at the time services are rendered. I authorize the release of any information necessary to process my insurance claims and facilitate payment of my account by a third party. Signature of Patient/Guardian Date Cancellation Policy If you are unable to keep your scheduled appointment with The National Sports Medicine Institute and, or The National Sports Medicine Physical Therapy Ceiiter we required 24 hours,. notice to avoid a no show/cancellation fee. This allows us the ability to see another patient in need of care. Failure to provide the appropriate cancellation notice will result in a $50.00 fee. This fee must be paid prior to scheduling another appointment. Please be advised that the $50.00 fee may not be submitted to your insurance carrier for payment, this remains the responsibility of the patient. Appointments may be cancelled or rescheduled Monday through Friday 8:30 am to 4:30 pm. During normal business hours, you may reach our office by phoning: Any mem ber of our staff wi II be happy to assist you. Signature of Patient/G uardian Date HIPAA Policy: I have read and received a copy of the Health Insurance Portability and Accountability Act (HIPAA). Signature of PatientlG uardian -----'- Date 6
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PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
Avery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
ADULT INFORMATION SHEET
DATE: DOCTOR TIME ADULT INFORMATION SHEET FULL NAME NICKNAME: SEX: BIRTHDATE: AGE: SOCIAL SECURITY #: HOME PHONE #: CELL PHONE #: MAILING ADDRESS: STREET CITY: STATE: ZIP: PLACE OF EMPLOYMENT: E-MAIL ADDRESS:
PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
NORTHERN VIRGINIA CENTER FOR ARTHRITIS PLEASE PRINT PATIENT REGISTRATION Patient s Name: DOB: Sex: Address: PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER Home#( ) [
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
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-
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
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
DEAN S CHIROPRACTIC CENTER
PATIENT INFORMATION Welcome to Our Office Patient Name of Birth SS# Address City ST Zip Home Phone Cell Work Phone Male Female Email Address Single Married Divorced Widowed Employer Name Occupation Spouse
Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right
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 Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Email: Daytime Phone Number: Date of Birth: / / Age: How did you hear
Mudit Sharma, MD, FAANS, FACS Board Certified Neurosurgeon
PATIENT REGISTRATION & CONSENT PATIENT INFORMATION: Name: DOB: Age: Male: Female: Single: Married: Divorced: Widow: Address: Home #: Mobile #: SSN: Email Address: Race: Ethnicity: Language: EMPLOYMENT
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies: