Case Number: (For Office Use Only) Social Security #: - - Birthday: - - Social Security#: - - Birthday: - - How did you hear about us?
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- Esmond Chapman
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1 Date: Name: Case Number: (For Office Use Only) Nickname: Address: City: State: Zip: Social Security #: - - Birthday: - - Spouse s Name: Social Security#: - - Birthday: - - Contact Information Home: - - Work: - - Cell: - - Mobile Provider Emergency Contact: (relationship) Emergency Contact s Number: - - How did you hear about us? Please help us work to improve the quality of health care. Your responses to these questions help us ensure quality care for all groups of people. Please circle the appropriate response: Race: African American American/Black Indian or Alaska American Native Asian Indian Black Asian or African White/Caucasian American Native Hawaiian/Other Hawaiin or Pacific Islander White Other Other Ethnicity: Hispanic/Latino Not Hispanic/Not Latino Undefined Preferred Language:
2 PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRIMARY COMPLAINT Area of Complaint: Right Left Bilateral When did your complaint begin? How did your complaints begin? Unknown Suddenly Gradually What happened to cause or re-aggravate your complaint? Not Known Work Accident Auto Accident Home Accident Sports Injury Other, explain: Has this complaint existed in the past? Yes, how long ago No Have you received any recent treatment for this complaint? Yes No If yes, please list dates, treatment type and doctor Have you experienced a change in any of the following since your symptoms began? Bowel Function Bladder Function Sexual Function None Is your condition: Improving Worsening Not Changing What is the rate of change: Slowly Gradually Quickly Has change occurred since: Last Month Last Week Other: What is the quality of your pain: Stiff Dull Achy Sharp Shooting Burning Tingling Throbbing Other: Is your pain: Mild Moderate Severe Is the pain Constant Frequent Intermittent Occasional Does the pain radiate? Y N To where: What aggravates your pain? What alleviates your pain? Is there numbness? Y N Where: Is there spasm? Y N Where: Is there swelling? Y N Where: If your complaint involves headaches, please complete the following: What is the location of your headaches: Front Side Back Sinus (Of Head) How often do they occur: times per: Hour Day Week Month What is the duration of your headaches: Minutes Hours Constant
3 PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR SECONDARY COMPLAINT Area of Complaint: Right Left Bilateral When did your complaint begin? How did your complaints begin? Unknown Suddenly Gradually What happened to cause or re-aggravate your complaint? Not Known Work Accident Auto Accident Home Accident Sports Injury Other, explain: Has this complaint existed in the past? Yes, how long ago No Have you received any recent treatment for this complaint? Yes No If yes, please list dates, treatment type and doctor Have you experienced a change in any of the following since your symptoms began? Bowel Function Bladder Function Sexual Function None Is your condition: Improving Worsening Not Changing What is the rate of change: Slowly Gradually Quickly Has change occurred since: Last Month Last Week Other: What is the quality of your pain: Stiff Dull Achy Sharp Shooting Burning Tingling Throbbing Other: Is your pain: Mild Moderate Severe Is the pain Constant Frequent Intermittent Occasional Does the pain radiate? Y N To where: What aggravates your pain? What alleviates your pain? Is there numbness? Y N Where: Is there spasm? Y N Where: Is there swelling? Y N Where: If your complaint involves headaches, please complete the following: What is the location of your headaches: Front Side Back Sinus (Of Head) How often do they occur: times per: Hour Day Week Month What is the duration of your headaches: Minutes Hours Constant
4 HISTORY With whom do you currently live: Alone Spouse Spouse/Children (# ) Other Smoking Status: Current Former Never Alcohol Intake: None Casual Moderate Severe Caffeine Intake: None < 3/day 3 to 6/day >6/day Recreational Drugs: None Recreational User Addict Exercise Frequency: Never Daily (3-7x/week) Weekly Exercise Type: What is your Occupation? Are you currently: In School Employed Unemployed Retired How long have you been at your current job? What is your: Height: Weight: Female Patients, to the best of your knowledge are you pregnant? Y N Do you currently have a Primary Care Physician? Y N Doctor s Name: Have you been to a chiropractor prior to today s visit? Y N Please complete the following regarding medications you are currently taking: DATE STARTED DRUG NAME PRESCRIBED BY Allergy Please list any allergies: Reaction
5 Date (Approximate) Please list any surgeries: Surgery Please list hospitalizations (you can exclude surgery related if listed above): Date (Approximate) Reason Hospital Please list any major illnesses: Date (Approximate) Illness Please list any pertinent family history: Relationship History Deceased Y/N Father Mother Brothers Sisters Children Paternal Grandparent Maternal Grandparent Cause of Death To the best of my knowledge, all of the information completed above is correct. Signature: Date:
Area of Complaint: Right Left Bilateral. When did your complaint begin? Unknown Work Accident Auto Accident Sports Injury Other:
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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 #
New Practice Member Application
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 /
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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
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Version 7/2/2015 Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Private Health Patient Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
PATIENT APPLICATION FORM
2105 E. Clairemont Ave., Eau Claire, WI 54701 Phone (715)835-9514 Fax (715)835-2602 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level
Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?
Gregory H. Tchejeyan, M.D., Inc. Please fill out this form in its entirety. Please complete every line item, as it is necessitated by regulations from the government (Health Care Finance Administration