Please complete this profile, the answers will help determine if Chiropractic can help your child. Child s Name: Parent 1 Name: Parent 2 Name:
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- Adrian Parsons
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1 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 2 Name: Alberta Health Care #: Phone: Address: Postal Code Age: Weight: Height: Birth date: Birth Place: School/daycare: Family MD/Pediatrician: Referred to this office by: Current Health Condition Purpose of appointment/current complaint: Previous treatment for this condition: When did this condition begin: Did a fall/injury/trauma contribute to the current complaint: *Is this (circle): new/recurring *Did it come on (circle): suddenly/gradually/comes & goes Is your child presently taking and medication or under any other medical care: For what conditions:
2 Past Health History Birth History: Length of Pregnancy: full term (weeks) Any issues during the pregnancy for mom/baby: (position of baby, blood pressure, etc); Location of birth: Home/Hospital/Birthing Center Delivery: Vaginal/ Breech/ Cesarean/ Epidural/ Forceps/ Vacuum Any Postpartum complications: Length of labour: Normal/difficult Birth Weight: Birth Length: APGAR scores: Any Congenital anomalies: Infancy History: Feeding: (circle) Breast/ Bottle/ Formula Latching well: Y/N Breast preference: Y/N/right/left Sleep Quality: good/fair/poor Average hours total/night: Hours in a row: Trouble settling/ falling asleep: (circle) always/occasional/never General Health History Any known health conditions/allergies: Illness/Falls/Injuries: Hospitalizations/ Surgeries/ Stitches/ X-rays Treatment for any health conditions in the past year : Previous Chiropractic Care/Craniosacral : Date: Vaccination history Last doctors/ pediatrician appointment: any concerns: Lifestyle Activities: Computer/desk time: hours/day Appetite/eating habits: good/fair/poor Toddler/childhood sleep quality: good/fair/poor
3 Please check any of the following conditions that are currently a problem; and underline any that were a problem in the past: MUSCLE & JOINT GENERAL INFANCY sore muscles fatigue Colic sore joints allergies tilting head to one side growing pains difficulty sleeping difficulty nursing muscle cramps Dizziness/fainting preferred side nursing muscle jerking earaches/infections slow weight gain back problems nose bleeds fussing in specific positions neck problems sore throat/ frequent colds/flu Screaming/crying painful tailbone asthma pain between shoulders chronic cough ORGANS spinal curvature enlarged glands bedwetting arthritis loss of weight constipation/diarrhea difficulty chewing poor exercise/appetite anemia clicking in jaw nervousness Thyroid issues general stiffness depression/confusion vomiting walking problems Vision/dental/hearing problems skin eruptions/eczema feet turn in/out hyperactivity coordination problems behavioral problems OTHER CONCERNS: headaches Epilepsy/seizures pain in ankles/knees/hips rheumatic fever stomach aches I have rights for this child and by signing below authorize chiropractic care for him/her. Signature: Print name: Date: *please also see informed consent
4 CONSENT TO CHIROPRACTIC TREATMENT FORM L 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. o 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 preexisting 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.
5 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. 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. DO NOT SIGN THIS FORM UNTIL YOU MEET WITH THE CHIROPRACTOR 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. Date: 20. Name (Please Print) Date: 20. Signature of patient (or legal guardian) Date: 20 Signature of Chiropractor
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:
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
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
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
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
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
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
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
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 #
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 #
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
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
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
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
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
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:
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
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)
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
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
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
What is your occupation? Company Name Do you have extended healthcare benefits? Yes No Benefits are personal or from work
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
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
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WELCOME TO The Chiropractors at Commerce Place
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Have you ever had any falls, accidents, or injuries? (Y or N) When? If yes, please explain
Pregnant Patient Intake & Assessment Form PERSONAL Name: Mrs Ms Miss Dr (Please circle) (Last) (First) (Middle) Address: Postal Code: Telephone Numbers: ( ) (Home) ( ) (Cell) Email: Permission to send
Brisbin Family Chiropractic
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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
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GENERAL PATIENT INFORMATION
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Patient Introduction
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CHIROPRACTIC ASSOCIATES CLINIC
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CHIROPRACTIC ASSOCIATES CLINIC
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ACTIVE EDGE CHIROPRACTIC
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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
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HEALTH INFORMATION FORM
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KEY TO LIFE CHIROPRACTIC
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SURNAME: FIRST NAME: Address: Who Is your GP and where do they practice? Friend: Please Name
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Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:
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Back In Balance Chiropractic, LLC
Back In Balance Chiropractic, LLC Date Name What do you prefer to be called Address City State Zip Code Birth Date: / / Social Security Number: - - Height: Weight: E-mail Home Phone ( ) - Cell ( ) - Contact
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
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:
PLEASE NOTE: This file must be saved to your desktop before and after completing!
PATIENT INFORMATION PLEASE NOTE: This file must be saved to your desktop before and after completing! Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number
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
WELCOME TO FALLS CHIROPRACTIC AND INJURY!
WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
It's your life... be there healthy. RIGHT LEFT RIGHT
Dr. Sara Weigel Dr. Douglas Ness Active Life It's your life... be there healthy. Chiropractic Patient Information Major Complaint Information Date First Name: Last Name: Initial What is your major complaint(s)?
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
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
PATIENT INFORMATION HEALTH INFORMATION
PATIENT INFORMATION PLEASE PRINT PATIENTS LAST NAME FIRST NICKNAME STREET ADDRESS APT # TODAYS DATE / / CITY STATE ZIP E-MAIL SEX M F MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DOB / / AGE SPOUSES
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
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
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You
PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
PATIENT REGISTRATION
PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single