PATIENT REGISTRATION FORM
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- Vernon Robert Walker
- 5 years ago
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3 PATIENT REGISTRATION FORM NAME: D.O.B AGE: SEX: STREET: CITY: STATE: ZIP: SS #: ETHNICITY: RACE: LANGUAGE: PHONE # TO LEAVE A PERSONAL MESSAGE: HOME PHONE #: WORK #: CELL #: E MAIL ADDRESS: EMERGENCY CONTACT: RELATION: PHONE #: EMPLOYER NAME: ADDRESS: DATE OF INJURY: REASON FOR VISIT: REFERRED BY DOCTOR: PRIMARY DOCTOR: ADDRESS: ADDRESS: PHONE #: PHONE #: BILLING INFO: (CIRCLE ONE) WORKER S COMP AUTO PRIVATE HEALTH INSURANCE PRIMARY INSURANCE: SECONDARY INSURANCE: ADDRESS: ADDRESS: CL/I.D #: I.D.# GRP# ADJUSTER S NAME: SUBSCRIBER S NAME: PHONE #: SUBSCRIBER S DOB/RELATION: EFFECTIVE DATE: EFFECTIVE DATE: PLEASE LET US SCAN YOUR HEALTH INSURANCE CARD AND PHOTO ID, EVEN IF THIS IS THROUGH WORKMEN S COMP OR AUTO. THANK YOU. IF APPLICABLE, NAME AND ADDRESS OF ATTORNEY: PHONE #: FAX #: WE DO NOT BILL ATTORNEY S FOR SERVICES RENDERED, NOR DO WE ACCEPT LETTERS OF PROTECTION. I AUTHORIZE INSURANCE BENEFITS BE PAID DIRECTLY TO THE PHYSICIAN AND UNDERSTAND I AM RESPONSIBLE FOR NON COVERED SERVICES. I ALSO AUTHORIZE THE PHYSICIAN TO RELEASE ANY INFORMATION REQUIRED IN THE PROCESSING OF THE CLAIMS. PATIENT S SIGNATURE: DATE:
4 MAIN LINE SPINE: PAIN DIAGRAM NAME DOB DATE OF APPOINTMENT Please mark the diagram according to the symptoms you are currently experiencing. Indicate the location of your symptoms and the nature of your symptoms by using the markers shown here. BURNING X X X X X ACHE O O O O O STABBING / / / / / / NUMBNESS & * * * * * * TINGLING RIGHT LEFT LEFT RIGHT FRONT BACK
5 1. Is this a related to a: Work injury date of Injury: Auto accident date of accident: 2. Do you have (please circle all that apply): Neck Pain Arm Pain Mid Back Pain Low Back Pain Leg Pain Other: 3. When did your pain begin? 4. Did your pain result from (please circle one): a work related injury an auto accident a lifting event a fall without any precipitating event or trauma Other 5. Since your symptoms began your pain has (please circle one): worsened improved remained the same 6. Describe your pain (please circle all that apply): aching burning cramping dull fiery hot numbing pinching pressure like pulsing sharp shock like shooting spasms squeezing stabbing stinging tenderness tingling 7. Is the pain (please circle one): continuous intermittent 8. Is the pain worse (please circle one): in the morning in the evening no difference 9. Use the following guidelines to describe your pain: 1 No pain 2 3 Mild pain 4 5 Moderate pain 6 7 Pain limits ability to perform daily activities 8 9 Severe pain limits all activities 10 The worst pain you can imagine Must go to the hospital Based on the guidelines above, your pain on a scale of 1 10 is graded as: at best: (least) (severe) on average (least) (severe) at its worst: (least) (severe)
6 10. Describe your pain ratio: Please circle one: Please circle one: Neck Pain/Arm Pain % Low back Pain/ Leg Pain % 100% Neck/0% Arm 100% Back/0% Leg 90% Neck/10% Arm 90% Back/10% Leg 80% Neck/20% Arm 80% Back /20% Leg 70% Neck/30% Arm 70% Back /30% Leg 60% Neck/40% Arm 60% Back /40% Leg 50% Neck/50% Arm 50% Back /50% Leg 40% Neck/60% Arm 40% Back /60% Leg 30% Neck/70% Arm 30% Back /70% Leg 20% Neck/80% Arm 20% Back /80% Leg 10% Neck/90% Arm 10% Back /90% Leg 0% Neck/100%Arm 0% Back /100% Leg 11. Do you have any numbness? (please circle one): yes no If yes, where? 12. Do you have any weakness? (please circle one): yes no If yes, where? 13. Do you have any stiffness: (please circle one): yes no If yes, where? 14. Your pain is aggravated by (please circle all that apply): activity sitting standing walking driving coughing sneezing looking to the same side as the pain looking away from the side of the pain looking up looking down lifting everything nothing in particular lying down movement physical therapy position change work turning over steroid injections other 15. Your pain is improved by (please circle all that apply): rest medications sitting standing walking lying down position change physical therapy massage ice heat nothing in particular acupuncture activity chiropractics steroid injections TENS unit use other 16. I no longer have pain in (name of body part)
7 17. What is your tolerance (in minutes ) for : (example 30minute, 1 hour) a) Sitting: Standing: Walking: b) Are you functionally limited? YES / NO What is hard to do? c) Falls? YES / NO If so, when? Injury? d) Equipment used to help myself: 18. What imaging studies related to this condition have been performed? (please circle all that apply): ***PLEASE GIVE ALL FILMS/DISCS/REPORTS TO THE RECEPTIONIST*** MRI X Ray CT Scan Bone Scan Ultra Sound None Please list body part: 19. What medications have you used for this condition? (please circle all that apply): non steroidal anti inflammatories muscle relaxants nerve stabilization agents narcotics oral Prednisone taper patches/gel/pain cream other 20. What amount of relief do you receive from the medications? (please circle one): 10 20% 20 30% 30 40% 40 50% 50 60% 60 70% 70 80% 80 90% greater than 90% 100% no relief at all 21. What treatments have you received for this condition? (please circle all that apply): no specific treatment home exercise program physical therapy chiropractic therapy acupuncture epidural steroid injections trigger point injection shoulder injections knee joint injections hip joint injections facet injections Botox nerve condition/ electro diagnostic studies medications radiofrequency ablation sympathetic blocks spinal cord stimulator other 22. If you have received physical therapy, please list name of facility and dates you attended: Facility Name: From: To: 23. Do you have a structured home exercise program? Yes No (exercises given by a physical therapist or doctor)
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HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM
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Family First Chiropractic
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Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
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We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
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Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
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PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER
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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.
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Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
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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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Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
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Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
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History of Present Condition
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NEW PATIENTS' INFORMATION SHEET
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CORNERSTONE PAIN MANAGEMENT
SECONDARY INSURANCE PRIMARY INSURANCE CORNERSTONE PAIN MANAGEMENT PATIENT INFORMATION First Name: Dr. Mr. Mrs. Ms. Miss MI: Last Name: Social Security: Age: Date of Birth: Gender: Address: City: State:
It's your life... be there healthy. RIGHT LEFT RIGHT
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New Patient Form Date:
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Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
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Patient Name: Appointment Date: Appointment with: Dr. Jeffrey A. Kozak NON-INJURY QUESTIONNAIRE Why did you make an appointment to see the doctor? Evaluation Surgical Opinion Reassurance Other Specify:
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PLEASE BRING COMPLETED PACKET TO APPOINTMENT ALONG WITH YOUR FILMS
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Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other
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Patient Name Date of Birth / / Today s Date / /
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ASSIGNMENT OF BENEFITS
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Name (First, Middle initial, Last): Mailing Address: Home phone: Cell Gender identification: M F Birthdate: Age: Birthplace:
General Information Name (First, Middle initial, Last): Mailing Address: Home phone: Cell Email Gender identification: M F Birthdate: Age: Birthplace: Nationality: Religion: Marital Status: Ages of children
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(Please Print) New Patient Information Name Address City/State/Zip Cell: Home: email: Social Security # Birthdate Age Male Female Occupation Employed by Wk ph. # Address City/State/Zip Number of Children
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
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NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE Today s : Patient Name: DOB: Race White/Caucasian Black/African American Asian Native American Alaskan Native Native Hawaiian Pacific Islander Other: Preferred Language:
New Patient Intake Form. Patient s Full Name. Male Female Age: Date of Birth: / / Mailing Address: City: State: Zip:
New Patient Intake Form Date: / / Patient s Full Name E-Mail: Home Phone: Cell: Male Female Age: Date of Birth: / / Social Security # - - Mailing Address: City: State: Zip: Married Single Widowed Separated
989 Kenmore Avenue Kenmore, NY P: F: E:
Chiropractic Registration Form This information is needed so we can better serve you. Please fill in ALL portions of the form. If you need assistance, please ask our receptionist, and we will be happy
NEW PATIENT INFORMATION
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!"#$%#&'()*$+(,-'#$ 846 Laurel Avenue Saint Paul Minnesota Fax:
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PAIN MANAGEMENT IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or Cat scans. Patient s name:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM Last Name: First Name: Middle: Home Phone: Other Contact: Other Contact: DOB: Age: Sex: Name of Referring Physician: Phone: Fax: Address: City: State: Zip: Name
INITIAL PAIN EVALUTION QUESTIONNAIRE
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NEW PATIENT INFORMATION
NEW PATIENT INFORMATION PATIENT INFORMATION First Name: Middle Initial: Last Name: Sex Male Female Date of Birth: Age: SSN: Marital Status: Married Single Divorced Widowed Number of Children: Home Phone:
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
Patient Name: Cell Phone Home Phone Work Phone. Address City State Zip Address
Patient Name: Date Cell Phone Home Phone Work Phone Address City State Zip Email Address Sex M F Marital Status M S D W Date of Birth Age Social Security Number Occupation Employer Referred by Have you
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
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
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.
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Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
REFERRED BY PAINFUL SIDE: RIGHT, LEFT, CENTRAL, RIGHT MORE, LEFT MORE, EQUAL ON BOTH SIDES, OTHERS DAILY PAIN: HRS MIN TIMES DAYS, WEEK, MONTH
NAME ADDRESS PHONE AGE DOB / / HT WT RACE MALE FEMALE SSN DATE OF ACCIDENT: / / REFERRED BY DATE OF VISIT CIRCLE APPROPRIATE ANSWERS OR EXPLAIN: 1. TYPE OF INJURY AUTO WORK OTHER PLEASE GIVE DETAILED EXPLANATION