APPLICATION FOR CARE
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- Shauna Garrett
- 5 years ago
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1 3023 Eastland Blvd. Suite 101 Clearwater, FL Ph: Fax: APPLICATION FOR CARE Date: Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Address: Birth Date: Age: SSN: Marital Status: S M D W Occupation: # of Children: Spouse s Name: Name & Number of Emergency Contact: Relationship: Do you have insurance? Yes No HISTORY OF COMPLAINT Please identify the condition(s) that brought you to this office (in order of severity), and circle your level of pain on a scale of 1 to 10 (zero = no pain; 10 = worst pain) 1. Pain Level: Pain Level: Pain Level: Pain Level: When did the problem(s) begin? When is the problem at its worst? early AM mid-morning mid-day early evening late evening How long does it last? constant throughout day I experience it on and off during the day it comes and goes throughout the week How did the injury happen? Is your problem the result of ANY type of accident? Yes No Has the condition(s) ever been treated by anyone in the past? Yes No If yes, when: and by whom? How long were you under care: What were the results: Name of previous chiropractor: N/A
2 PLEASE MARK the areas on the diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull T = Tingling A = Aching N = Numbness S = Sharp/Stabbing What relieves your symptoms? What makes them feel worse? Please list any restricted activities, your current activity level, and your usual activity level: RESTRICTED ACTIVITY CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL ex: walking ex: walk half mile 2x/week ex: walk one mile 4x/week Identify any other injuries to your spine, minor or major, that the doctor should know about: Please list all prescription medications (and their purpose) and non-prescription medications/vitamins/supplements you are currently taking: Females: Is there any chance that you are pregnant? Yes No
3 PAST HISTORY Have you suffered with any of this or a similar problem in the past? Yes No If yes, how many times? When was the last episode? How did the injury happen? Have you tried any other forms of treatment: Yes No 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, activities, or events you have experienced 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: P = in the Past C = Currently N = Never have had: broken bone disability cancer rheumatoid arthritis osteoarthritis diabetes cerebrovascular heart attack dislocations tumors thyroid disorder other: Please identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem: Condition How Long Ago Type of Care Received By Whom INJURIES SURGERIES CHILDHOOD DISEASES ADULT DISEASES SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes daily weekends occasionally never 2. Alcoholic beverage consumption: daily weekends occasionally never 3. Recreational drug use: daily weekends occasionally never 4. Hobbies/recreational activities/exercise/sports: FAMILY HISTORY 1. Does anyone in your family suffer with the same condition(s)? Yes No If yes whom: grandmother grandfather mother father sibling(s) son(s) daughter(s) Have they ever been treated for their condition? Yes No I don t know 2. Any other hereditary conditions the doctor should be aware of? No Yes:
4 Q V A S Instructions: Please circle the number that best describes the question being asked. Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the source for each complaint (see example below). Example: Headache Neck Low Back 1. What is your pain level right now? 2. What is your typical or average level of pain? 3. What is your pain level at its best (how close to 0 does your pain get at its best)? 4. What is your pain level at its worst (how close to 10 does your pain get at its worst)? Other Comments: OATS Score: %
5 ACTIVITIES OF DAILY LIVING Please identify how your current condition(s) is affecting your ability to carry out activities that are routinely part of your life. Reading/Concentrating N/A No Effect Painful (can do) Painful (limits) Unable to Perform Extended Computer Use N/A No Effect Painful (can do) Painful (limits) Unable to Perform Washing/Bathing N/A No Effect Painful (can do) Painful (limits) Unable to Perform Dressing N/A No Effect Painful (can do) Painful (limits) Unable to Perform Shaving N/A No Effect Painful (can do) Painful (limits) Unable to Perform Taking out Garbage N/A No Effect Painful (can do) Painful (limits) Unable to Perform Sleeping N/A No Effect Painful (can do) Painful (limits) Unable to Perform Rolling Over N/A No Effect Painful (can do) Painful (limits) Unable to Perform Carrying (groceries, children, etc.) N/A No Effect Painful (can do) Painful (limits) Unable to Perform Lifting (groceries, children, etc.) N/A No Effect Painful (can do) Painful (limits) Unable to Perform Yard Work N/A No Effect Painful (can do) Painful (limits) Unable to Perform Pet Care N/A No Effect Painful (can do) Painful (limits) Unable to Perform Driving N/A No Effect Painful (can do) Painful (limits) Unable to Perform Walking N/A No Effect Painful (can do) Painful (limits) Unable to Perform Bending N/A No Effect Painful (can do) Painful (limits) Unable to Perform Sitting N/A No Effect Painful (can do) Painful (limits) Unable to Perform Standing N/A No Effect Painful (can do) Painful (limits) Unable to Perform Sit to Stand Position N/A No Effect Painful (can do) Painful (limits) Unable to Perform Stand to Sit Position N/A No Effect Painful (can do) Painful (limits) Unable to Perform Climbing Stairs N/A No Effect Painful (can do) Painful (limits) Unable to Perform Household Chores N/A No Effect Painful (can do) Painful (limits) Unable to Perform Sweeping/Vacuuming N/A No Effect Painful (can do) Painful (limits) Unable to Perform Dishes N/A No Effect Painful (can do) Painful (limits) Unable to Perform Laundry N/A No Effect Painful (can do) Painful (limits) Unable to Perform Other: N/A No Effect Painful (can do) Painful (limits) Unable to Perform N/A No Effect Painful (can do) Painful (limits) Unable to Perform N/A No Effect Painful (can do) Painful (limits) Unable to Perform
6 Please mark the listed items below as: P (Past) C (Currently) N (Never) headache convulsions/epilepsy diarrhea/constipation neck pain tremors kidney trouble jaw pain, TMJ dizziness gallbladder trouble shoulder pain loss of balance liver trouble upper back pain fainting prostate problems mid back pain double vision impotence low back pain blurred vision menstrual problems hip pain ringing in ears PMS back curvature/scoliosis hearing loss menopausal problems numb/tingling arms asthma depression numb/tingling hands/fingers difficulty breathing irritable numb/tingling legs lung problems bed wetting numb/tingling feet/toes heart problems skin problems knee problems heartburn mood changes foot problems chest pain learning disability swollen/painful joints high blood pressure ADD/ADHD frequent colds/flu low blood pressure eating disorder pain w/ cough/sneeze ulcers trouble sleeping allergies digestive problems Hepatitis (A, B, C) sinus/drainage problem colon trouble other: I hereby authorize payment to be made directly to Risoldi Family Chiropractic 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 affecting 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 Risoldi Family Chiropractic for any and all services I receive at this office that are not covered under a healthcare plan. Signature of Patient or Authorized Person Date Signature of Doctor Date Notes:
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SPARROW FAMILY CHIROPRACTIC
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LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
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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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APPLICATION FOR CARE AT
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New Practice Member Application
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New Practice Member Application
i New Practice Member Application PATIENT DEMOGRAPHICS Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Would you like to receive text reminders for your appointments? Cellular
Who may we thank for referring you?
NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
New Practice Member Application
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Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
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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 #
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LIST YOUR HEALTH CONCERNS BELOW
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3. How Long Has This Been An Issue?
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Type of Patient and/or payment method (circle one)
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Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
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PATIENT INFORMATION HEALTH INFORMATION
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Chiropractic Case History/Patient Information
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PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
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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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LIST YOUR HEALTH CONCERNS BELOW
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PERSONAL INFORMATION Puritz Chiropractic Center Today's Date: File #: First Name: Middle Initial: Last Name: Preferred First Name / Nickname: Social Security #: - - Are you: right handed left handed ambidextrous
New Patient Form Date:
New Patient Form Date: Patient name: M F Date of Birth: / / SS# Address: City: State: Zip Code: Home Phone #: Cell #: Work #: Email: Emergency Contact: Emergency Phone #: Referred by: Primary Care Physician
Welcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
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
634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
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
RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
Peak Health 7555 W. 150 th street Phone (913) Overland Park, KS Fax (913)
1 7555 W. 150 th street Phone (913) 685-0950 Overland Park, KS 66223 Fax (913) 685-2941 Whom may we thank for referring you to? Patient Demographics : _ Date of Birth Age Male or Female (Circle) Address:
New Patient Information and History Form
New Patient Information and History Form John K. Dorman, M.D., FACS Diplomate of The American Board of Neurological Surgery 400 Rosalind Redfern Grover Parkway Suite 200 Midland, TX 79701 432 687-2350
Area of Complaint: Right Left Bilateral. When did your complaint begin? Unknown Work Accident Auto Accident Sports Injury Other:
Quality Chiropractic 6231 Leesburg Pike Suite 200 Falls Church VA 22044 (703) 237-0404 fax (703) 237-7828 Quality Chiropractic & Rehab 102 Elden Street Suite 12 Herndon VA 20170 (703)581-8999 fax (703)
Carriage House Chiropractic and Acupuncture
Chiropractic Patient History Questionnaire Date: Name: Date of birth: Address: City: St: Zip: Phone: (home) (cell) (work) May we send appointment reminders to you via text messages on your cell phone Email:
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Health History Name Address City State Zip Day Phone Evening Phone E-mail Address Employer Birth Date Age Gender Emergency
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
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
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
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.