APPLICATION FOR CARE AT FAMILY FIRST WELLNESS CENTER Today s Date: PATIENT DEMOGRAPHICS (Please Print)
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1 APPLICATION FOR CARE AT FAMILY FIRST WELLNESS CENTER Today s Date: HRN: PATIENT DEMOGRAPHICS (Please Print) Name: Birth Date: - - Age: Male Female Address: City: State: Zip: Address: Phone Mobile: Phone H/ W: Marital Status: Single Married Do you have Insurance: No Yes Insurance Type: Employer: Occupation: Spouse s Name: Spouse s Employer: Height: Weight: Ethnicity: Hispanic or Latino / Not Hispanic or Latino / I Decline to answer Race: American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) / Native Hawaiian or Pacific Islander / Other / I Decline to Answer Preferred Language: English Spanish, French, Italian, Creole, Other: Emergency Contact Name: Phone Number: Relationship: Who referred you to this office? Are you here for wellness care? No Yes If yes, please skip to PAST HISTORY Complaint or Wellness on Page 2. Goals For My Care: People see health care practitioners for a variety of reasons. Some seek to correct whatever core malfunctions they may be experiencing, some for relief of pain or discomfort, and some to correct the cause of pain or discomfort. Dr. Haskel will weigh your needs and desires when recommending your program of care. Please check the type of care desired so that we can create a personalized program. Relief Care - Symptomatic relief of pain or discomfort Corrective Care - Correcting and relieving the cause of the problem as well as the symptoms Comprehensive Care - Address the entire system and bring whatever is malfunctioning in the body to the highest state of health possible. Other Goals - Weight Loss Increased Energy Hormone Balance Other On a scale of 1 to 10 with 10 being the worst discomfort and zero being no discomfort, rate your health concerns by circling the number: Primary or chief complaint is : When did the problem(s) begin? Is it the result of ANY type of accident or injury? Yes, No If so, please describe it: 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 Condition(s) ever been treated by anyone in the past? No Yes If yes, when? by whom? How long were you under care? What were the results? Name of Previous Chiropractor: N/A Page 1 of 6
2 Second complaint : Third complaint : Fourth complaint : *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? IDENTIFY ANY OTHER INJURY(S) TO YOUR SPINE, MINOR OR MAJOR, THAT THE DOCTOR SHOULD KNOW ABOUT: ACTIVITIES OF LIFE Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life: ACTIVITIES: EFFECT: Carrying Groceries No Effect Painful (can do) Painful (limits) Unable to Perform Sit to Stand No Effect Painful (can do) Painful (limits) Unable to Perform Climbing Stairs No Effect Painful (can do) Painful (limits) Unable to Perform Pet Care No Effect Painful (can do) Painful (limits) Unable to Perform Driving No Effect Painful (can do) Painful (limits) Unable to Perform Extended Computer Use No Effect Painful (can do) Painful (limits) Unable to Perform Household Chores No Effect Painful (can do) Painful (limits) Unable to Perform Lifting Children No Effect Painful (can do) Painful (limits) Unable to Perform Reading/Concentration No Effect Painful (can do) Painful (limits) Unable to Perform Bathing No Effect Painful (can do) Painful (limits) Unable to Perform Dressing No Effect Painful (can do) Painful (limits) Unable to Perform Shaving No Effect Painful (can do) Painful (limits) Unable to Perform Sexual Activities No Effect Painful (can do) Painful (limits) Unable to Perform Sleep No Effect Painful (can do) Painful (limits) Unable to Perform Static Sitting No Effect Painful (can do) Painful (limits) Unable to Perform Static Standing No Effect Painful (can do) Painful (limits) Unable to Perform Yard work No Effect Painful (can do) Painful (limits) Unable to Perform Walking No Effect Painful (can do) Painful (limits) Unable to Perform Sweeping/Vacuuming No Effect Painful (can do) Painful (limits) Unable to Perform Dishes No Effect Painful (can do) Painful (limits) Unable to Perform Laundry No Effect Painful (can do) Painful (limits) Unable to Perform Garbage No Effect Painful (can do) Painful (limits) Unable to Perform Lifting Groceries No Effect Painful (can do) Painful (limits) Unable to Perform Other: No Effect Painful (can do) Painful (limits) Unable to Perform 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? If any injury, how did it happen? (use back of sheet if needed ) 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 Page 2 of 6
3 PAST HISTORY Complaint or Wellness Please identify any and all types of jobs you have had in the past that have imposed any emotional, chemical, or 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: INJURIES SURGERIES CHILDHOOD DISEASES ADULT DISEASES HOW LONG AGO TYPE OF CARE RECEIVED BY WHOM 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 Disabilty Gall Bladder Trouble Numb/Tingling arms, hands, fingers ADD/ADH Eating Disorder Liver Trouble Numb/Tingling legs, feet, toes Allergies Trouble Sleeping Hepatitis (A,B,C) SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes How often? Daily Occasionally Never Former If you are a former smoker what was the date you started: Date Quit: 2. Alcoholic Beverage: How often? Daily Weekends Occasionally Never 3. Recreational Drug use: How often? Daily Weekends Occasionally Never 4. Does this condition affect or interfere with your: Work Leisure Sleep Sports/Exercise Hobbies Mental Attitude Other How so 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: LIST ALL PRESCRIPTION DRUGS, NON- PRESCRIPTION DRUGS AND ALL SUPPLEMENTS THAT YOU ARE CURRENTLY TAKING Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.) Page 3 of 6
4 LIST ALL MEDICATION ALLERGIES if none, please circle No Medication Name Reaction Onset Date Additional Comments QUADRUPLE VISUAL ANALOGUE SCALE HR# Patient Name Date Please read carefully: 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 score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: Headache Neck Low Back 1 What is your pain RIGHT NOW? 2 What is your TYPICAL or AVERAGE 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: ExamineReprinted from Spine, 18, Von Korff M, Deyo RA, Cherkin D, Barlow SF, Back pain in primary care: Outcomes at 1 year, , 1993, with permission from Elsevier Science. Page 4 of 6
5 I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as the result of the nature and frequency of chiropractic care.) I hereby authorize payment to be made directly to Family First Wellness Center 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 Family First Wellness Center for any and all services I receive at this office. Patient or Authorized Person s Signature Doctor s Signature / / Date Completed / / Date Form Reviewed INFORMED CONSENT TO CHIROPRACTIC TREATMENT The nature of chiropractic treatment: Chiropractic care seeks to restore health through natural means without the use of medicine, surgery or other invasive means. Chiropractic care is not a substitute for traditional medical care, nor is traditional medical care a substitute for chiropractic. The doctor will use his/her hands or a mechanical device in order to move your joints. Various ancillary procedures, such as Low Intensity Laser Therapy, therapeutic exercise, mechanical massage, hot or cold packs, electric muscle stimulation, therapeutic ultrasound or hydrotherapy may also be used. Possible risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Rare complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, stroke or injury to intervertebral discs, nerves or spinal cord. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications. Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as rare, about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered rare. Other treatment options which could be considered may include the following: Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases. Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases. Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases. Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases. Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult. I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and hereby give my full consent to treatment. I also have read and agree to the Consent for Use and Disclosure of Protected Health Information on File at Family First Wellness Center. Printed Name Signature Date Page 5 of 6
6 RECORD REQUEST AND FINANCIAL RESPONSIBILTY AGREEMENT Patient name: SSN: DOB: Billing address: Phone: This is to certify that the above named patient authorizes the request of any records pertinent to the health care of same individual from but not inclusive of any insurance carrier, adjustor, attorney, or other health care provider. This also authorizes this facility to release records, upon receipt of the above named patient's signature, or on an emergency basis, to, but not inclusive of, any insurance carrier, any attorney, health care provider, hospital or immediate family member. This also certifies that the above named individual agrees to pay in full for all professional services rendered at the time they are performed, unless other arrangements are made in advance of the set appointment. The below named guarantor understands a $25.00 returned check fee will be charged along with any appropriate collection or attorney's fee which may accrue upon collection of any outstanding balance. A photocopy of this agreement shall be considered as effective and valid as the original. Privacy: The Standards for Privacy of Individually Identifiable Health Information ( Privacy Rule ) establishes, for the first time, a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services issued the Privacy rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). A major goal of the Privacy Rule is to assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well-being. You can be assured that this facility takes your privacy seriously and is in compliance with all HIPAA guidelines. Your health information will not be disclosed without your permission or will your name, address or telephone number be disclosed to any third party. Print Name Policyholder/Guarantor's signature Date Page 6 of 6
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CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Insurance. Patient Family Information. Patient Condition
Welcome to Amarillo Family Wellness Group In order to serve you best we would like to know more about you and your health history. Please print clearly and fill this out completely prior to your appointment
Rupp Chiropractic FAMILY PHYSICIAN FEMALES: ARE YOU PREGNANT, OR A CHANCE YOU MIGHT BE PREGNANT? YES / NO HOW WERE YOU REFERRED TO OUR OFFICE?
PATIENT INFORMATION NAME DATE ADDRESS CITY STATE ZIP HOME # CELL # WORK # E MAIL ADDRESS SOCIAL SECURITY # I WOULD LIKE TO RECEIVE EMAIL APPOINTMENT REMINDERS [YES] [NO] RACE: AMERICAN INDIAN ALASKA NATIVE
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:
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
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
Lake Marion Chiropractic Center nd St W, Suite 203 Lakeville, MN
Lake Marion Chiropractic Center 9202 202 nd St W, Suite 203 Lakeville, MN 55044 952-469-8385 Patient Health History Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr.
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA PATIENT INTAKE - update
LUCAS CHIROPRACTIC 903 Howard St. Walla Walla WA 99362 PATIENT INTAKE - update Name Today s Date / / Date of Birth / / Address City State Zip Please check box for preferred communication means E-Mail Home
Dr. Brett Whitekettle
Dr. Brett Whitekettle For Office Use Only: Patient ID #: 200 Cape Fear Circle Suite 2 Sneads Ferry, NC 28460 T: (910) 327-0022 F: (910) 327-0337 office@whitekettlechiropractic.com Patient Information Phone
PERSONAL INJURY VERIFICATION
PERSONAL INJURY VERIFICATION Name Email Home Phone Cell Phone Address City Zip Code Birth Date Age Marital Status Employer Occupation Name of Spouse In case of emergency, please notify Phone MED-PAY 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
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:
Revelation Chiropractic Health Profile
Revelation Chiropractic Health Profile Name Date / Age Male / Female Address Apt City Zip Phone Numbers: Home Cell Circle best number to reach you at: Home Cell Date of Birth / / Occupation Email Address
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
LIST YOUR HEALTH CONCERNS BELOW
8209 Natures Way Unit 115 Lakewood Ranch, Florida 34202 (941) 877.1507 Name Date / / Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name
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
Brewster Chiropractic Michael B. Singleton DC, MS, CNS, CSCS
Michael B. Singleton DC, MS, CNS, CSCS How did you hear about this office? Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Preferred to be called
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Race: Marital: M S W D Occupation: Office Phone:
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
New Practice Member Forms
New Practice Member Forms Name Date Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider E-mail SSN Birthday Date of Occupation Employer s Name Single Married Divorced Widowed Spouse
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
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
Client Intake Form Therapeutic Massage
Personal Information: Client Intake Form Therapeutic Massage Name Phone (Day) Phone (Eve) Address City/State/Zip email Date of Birth Occupation Emergency Contact Phone The following information will be
PEDIATRIC HISTORY FORM
PEDIATRIC HISTORY FORM CHILD S NAME: NICKNAME: SSN: BIRTHDAY: AGE: MALE FEMALE NAME OF PARENTS/GUARDIANS: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL/WORK PHONE: EMAIL: HOW DID YOU FIRST HEAR OF CORRECTIVE
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
Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
Patient s Name: Date: What is the reason for your visit today? Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone #
Acknowledgment of Clinic Terms
Acknowledgment of Clinic Terms Our GOAL The goal of CHIRO-FIT, Inc. is to detect and correct subluxations of the spine and body. We do not focus on the treatment of pain and disease, instead aim to help
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
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:
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
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability.
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability. Patient Information Title: Mr. Mrs. Miss Ms. Dr. (circle one)
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.
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at