Name Age PLEASE INDICATE YOUR PRIMARY PHYSICIAN (PCP): PHYSICIAN S NAME: OFFICE ADDRESS: SPECIALITY: PHONE #:
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1 Name Age PLEASE INDICATE YOUR PRIMARY PHYSICIAN (PCP): PHYSICIAN S NAME: OFFICE ADDRESS: SPECIALITY: PHONE #: PLEASE INDICATE ANY PHYSICIAN S THAT HAS TREATED YOUR CONDITION: EX: HOSPITAL, URGENT CARE, OR PAIN MANAGEMENT CLINIC PHSICIAN S NAME: PHYSICIAN S NAME: OFFICE NAME: OFFICE NAME: ADDRESS: ADDRESS: PHONE #: PHONE #: **IF YOU HAVE AN ATTORNEY YOU MUST COMPLETE THIS SECTION** 1. Have you been involved in a motor vehicle accident or a slip and fall? Yes or No If yes, please indicate which one. 2. Do you have Med-Pay? (Circle one) Yes or No If so, how much do you have available? $ 3. Do you have Workman s Compensation? (Circle one) Yes or No 4. Do you have an attorney? (If yes complete the information below.) Yes or No Attorney s name: Name of the Law Firm: Address: Phone #: Fax #: Case Manger Name: Case#: PLEASE BE PROACTIVE AND USE YOUR PHONE TO HELP GOOGLE THE INFORMATION THAT IS NEEDED. THIS HELPS TO SPEED UP THE PROCESSING OF YOUR INFORMATION AND HELPS TO REDUCE YOIUR WAIT TIME. WE APPRECIATE YOUR COOPERATION.
2 PATIENT INFORMATION: NAME: D.O.B SSN: - - MARITAL STAUS: S M W SEP D ADDRESS CELL NUMBER ( ) HOME ( ) SPOUSE S NAME: SPOUSE S ADDRESS (IF DIFFERENT) EMERGENCY CONTACT NAME: #: ( ) EMPLOYER INFORMATION: EMPLOYER S NAME: EMPLOYER S ADD.: PHONE NUMBER: Your position: NON-EMPLOYED PRIMARY HEALTHCARE INSURANCE: NAME OF INSURANCE: MEMBER ID #: PRIMARY SUBSCRIBER: # TO PROVIDER SERVICES (ON THE BK OF YOUR CARD): SECONDARY HEALTHCARE INSURANCE: NAME OF INSURANCE: MEMBER ID #: PRIMARY SUBSCRIBER: # TO PROVIDER SERVICES (ON THE BK OF YOUR CARD): HOW DID YOU HEAR ABOUT US? PHONE BOOK INTERNET PATIENT/FRIEND REFERRAL (FROM WHOM)
3 PERSONAL MEDICAL HISTORY: CIRCLE ALL THAT APPLY: CHEST PAIN/PRESSURE/LIGHTENING ASTHMA KIDNEY DISEASE HYPERTENSION DIZZY SPELLS SHORTNESS OF BREATH HEART ATTACK CANCER TB/LUNG DISORDER STROKE DIABETES ULCER HEADACHES ARTHRITIS SKIN DISORDER GLAUCOMA HEPATITIS DIFFICULTY HEARING ALLERGIES/EXCEMA CATARACTS DEPRESSION HEMORRHOIDS FREQUENT URINARY INFECTIONS OTHER GENERAL INFORMATION: REASON FOR TODAY S VISIT: PRESENT MEDICATION: ALLERGIES TO MEDICATION: ALLERGIES TO SPECIFIC LAUNDRY DETERGENT: LIST ANY SURGERIES OR HOSPITALIZATIONS (INCLUDE MISCARRIAGES/LIVE BIRTHS FEMALES: ARE YOUR PREGNANT OR PLANNING A PREGNANCY? (CIRCLE ONE) DO YOU SMOKE? (CIRCLE ONE) YES OR NO YES OR NO CIGARETTES PIPE CIGARS ILLEGAL SUBSTANCE
4 HOW MANY YEARS? HOW MUCH? DO YOU DRINK? YES OR NO DAILY (CUPS) OCCASSIONAL DO YOU REGULARLY DRINK COFFEE? (CIRCLE ONE) YES OR NO 1. IS THIS AN ON-THE-JOB INJURY? (CIRCLE ONE) YES OR NO 2. IS THIS AN AUTOMOBILE ACCIDENT? (CIRCLE ONE) YES OR NO 3. DOES THIS VISIT PERTAIN TO ACCIDENTAL INJURY? (CIRCLE ONE) YES OR NO IF YES, PLEASE COMPLETE THE FOLLOWING INFORMATION: DATE OF ACCIDENT: TIME DESCRIBE HOW IT HAPPENED: PATIENT COMFORT ASSESSMENT GUIDE: WHERE IS YOUR PAIN? PLEASE CIRCLE ALL THAT APPLY. SHOULDER (CIRCLE ONE) LEFT RIGHT BOTH ARM (CIRCLE ONE) LEFT RIGHT BOTH HAND (CIRCLE ONE) LEFT RIGHT BOTH LEG (CIRCLE ONE) LEFT RIGHT BOTH ANKLE (CIRCLE ONE) LEFT RIGHT BOTH KNEE (CIRCLE ONE) LEFT RIGHT BOTH BACK (CIRCLE ONE) UPPER LOWER MID FOOT (CIRCLE ONE) LEFT RIGHT BOTH ELBOW (CIRCLE ONE) LEFT RIGHT BOTH WRIST/HIP (CIRCLE ONE) LEFT RIGHT BOTH
5 DESCRIBE YOUR PAIN. CIRCLE ALL THAT APPLY. ACHING SHOOTING SHARP PENETRATING THROBBING TENDER NAGGING BURNING RADIATING NUMB STABBING EXHAUSTING MISERABLE GNAWING TIRING UNBERABLE OCCASSIONAL CONTINUOUS RATE YOUR LEVEL OF PAIN. PAIN SCALE: 1 LEAST AMOUNT OF PAIN/10 WORST AMOUTN OF PAIN 1. PAIN AT ITS WORST IN THE LAST MONTH PAIN AT ITS LEAST IN THE LAST MONTH PAIN AT ITS AVERAGE IN THE LAST MONTH PAIN RIGHT NOW IN THE LAST MONTH WHAT INCREASES THE PAIN? 6. WHAT DECREASES THE PAIN? WHAT TREATMENTS OF MEDICINES ARE YOU RECEIVING FOR YOUR PAIN? A) NO COMPLETE COMPLETE RELIEF TREATMENT/MEDICINE/DOSAGE B) NO COMPLETE COMPLETE RELIEF TREATMENT/MEDICINE/DOSAGE C) NO COMPLETE COMPLETE RELIEF TREATMENT/MEDICINE/DOSAGE D) NO COMPLETE COMPLETE RELIEF TREATMENT/MEDICINE/DOSAGE
6 PLEASE CIRCLE YOUR POINTS OF PAIN
7 NARCOTICS CONTRACT NARCOTICS CONTRACT (PLEASE REVIEW THE INFORMATION AND SIGN AT THE BOTTOM) CONTROLLED SUBSTANCE MEDICATIONS (NARCOTICS, TRANQUILLIZERS, AND BARBITUATES) ARE VERY USEFUL, BUT HAVW HIGH POTENTIAL FOR MISUSE AND ARE, THEREFORE, CLOSELY CONTROLLED BY LOCAL, STATE, AND FEDERAL GOV T. THEY ARE INTENDED TO RELIEVE PAIN TO IMPROVE FUNCTION AND/OR ABILITYTO WORK, NOT TO SIMPLY FEEL GOOD. BECAUSE MY PHYSICIAN IS PRESCRIBING SUCH MEDICATION FOR ME, I AGREE TO THE FOLLOWING CONDITIONS: 1. I WILL DISCLOSE AL CURRENT DOCTOR RELATIONSHIPS AND OBTAIN AND ALL PAIN MEDICATIONS SUCH AS NARCOTICS OR OTHER CONTROLLED SUSBSTANCE MEDICATIONS ( NERVE MEDICATIONS, ANXIETY MEDICATIONS, SEDATIVES, SLEEPING PILLS, OR MUSCLE RELAXANTS) ONLY FROM SPINE AND ORTHOPEDICS CENTER. I UNDERSTAND THESE DRUGS HAVE AN ABUSE POTENTIAL BECAUSE THE CAN PRODUCE PHYSICAL AND PSYCHOLOGICAL DEPENDANCE. 2. I WILL NOT REQUEST OR EXCEPT CONTROLLED SUBSTANCE MEDICATIONS FROM ANY OTHER PHYSICIAN OR INDIVIDUALS WHILLE I AM RECEIVING SUCH MEDICATIONS FROM SPINE & ORTHOPEDIC CENTER. BESIDES BEING ILLEGAL TO DO SO, IT MAY ENDANGER MY LIFE. 3. REFILLS OF CONTROLLED SUBSTANCE MEDICATIONS: A) ARE COMPLETED ONLY ON MONDAYS, TUESDAYS, AND FRIDAYS ONLY B) WILL NOT BE MADE IF I RUN OUT EARLY YOU ARE RESPONSIBLE FOR TAKING YOUR MEDICATIONS IN THE DOSE IT IS PRESCRIBED C) WILL NOT BE MADE IF LOST OR STOLEN. YOU ARE RESPONSIBLE FOR YOUR MEDICATION. PHARMACY NAME TELEPHONE:
8 WAYS TO STAY COMPLIANT CONTRACT REFRAIN FROM GOING TO THE ER AND SEEKING PAIN MEDICATIONS EXCEPT FOR AN ACUTE EMERGENCY. ADVISE SPINE & ORTHOPEDIC CENTER IN ADVANCE IF ANY ACUTE SITUATIONS ARISE THAT REQUIRE OTHER PHYSICIANS TO PRESCRIBE PAIN OR CONTROLLED MEDICATIONS. COOPERATE WITH URINE DRUG SCREENS OR FAMILY CONFERENCES WHEN ASKED TO DO SO. I UNDERSTAND THIS MAY BE NEEDED TO FURTHER EVALUATE MY MEDICAL CONDITION AND RESPONSE TO THESE DRUGS. REFRAIN FROM USING ILLEGAL DRUGS/SUBSTANCES COMPLY WITH YOUR RECOMMENDED TREATMENT PLAN ******IF YOU DON T AGREE WITH YOUR TREATMENT PLAN IT MUST BE DISCUSSED WITH THE TREATING PHYSICIAN. ATTEND ALL APPOINTMENTS (PRESCRIPTION REFILL, INJECTIONS, AND THERAPY) AS SCHEDULED, ALL SAME DAY CANCELLATIONS FOR FOLLOW-UP AND THERAPY ARE $35.00 AND ALL PROCEDURES ARE $ ~NO EXCEPTIONS~ I UNDERSTAND THAT IF I VIOLATE ANY OF THE ABOVE INFORMATION MY TREATMENT AT SPINE & ORTHOPEDIC CENTER MAY BE ENDED IMMEDIATELY. REFRAIN FROM BEING DISRESPECTFUL TO STAFF PAY YOUR COPAY, DEDUCTIBLES, AND BALANCES AT THE TIME SERVICES ARE RENDERED. I HAVE READ THE NARCOTICS CONTRACT AND WAYS TO STAY COMPLIANT CONTRACT AND I FULLY UNDERSTAND THE CONSEQUESNCES OF VIOLATING ANY OF THE INFORMATION LISTED. PATIENT S SIGNATURE/DATE PHYSICIAN S SIGNATURE/DATE
ASSIGNMENT OF BENEFITS
ASSIGNMENT OF BENEFITS PATIENT NAME: First Middle Last PHONE NUMBER: Home: Work: HOME ADDRESS: City ZIP AGE: DOB: SSN: Status EMAIL ADDRESS: PATIENT EMPLOYER: How long? Occupation SPOUSE S EMPLOYER: Spouse
Type of Patient and/or payment method (circle one)
Please print # Date: Last Name: First Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email address: Date of Birth: Sex: M F Social Security #: Employer name: Occupation: (if a minor,
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History of Present Condition
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Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
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.
*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
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DATE: Dear Mr./Mrs./Ms., location.
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PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!
Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C. 2407 Lenora Church Road / Snellville, Georgia 30078-6916 / 770-979-2731 Welcome to our office! Today's Date: / / Your Name: [ ] Male [ ] Female What
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
New Patient Paperwork
Name (Last, First, M.I.): M F Email Address: Primary Phone: Race: Today's Date: DOB: Alternate Emergency Phone: Contact: American Indian/Alaska Native Asian African American Caucasian Nat Hawaiian/Pacific
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
INFORMATION SHEET FOR THE DEPARTMENT OF PAIN AND PALLIATIVE CARE
INFORMATION SHEET FOR THE DEPARTMENT OF PAIN AND PALLIATIVE CARE Please review the following instructions as it contains important information regarding the management of your pain. Once reviewed, our
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 #
PATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
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
Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
PATIENT SIGNATURE: DOB: Date:
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice
PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
Patient Information Form
Patient Information Form Patient Name: (Last) (First) (MI) Name you prefer to be called: Mailing address: City: State: Zip: Best daytime phone: May we leave a message there? Yes No Alternate phone number:
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 #
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
History & Review of Systems Screening. Medical History
History & Review of Systems Screening Patient name: Date: / / Pharmacy name:_ Primary Care Physician: Referring Physician: Height: Weight: R or L handed Medical History Please tell the doctor if you have
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:
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 /
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
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: DOB: Age: Male Female Address: City: State: Zip: E-mail: Home
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
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 /
PATIENT HISTORY FORM
PATIENT HISTORY FORM NAME: DATE: DATE OF BIRTH/AGE: Name of the physician who referred you to see a neurosurgeon: City and State of referring physician: Is your referring physician a chiropractor? Yes
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate