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1 Vitality Chiropractic & Wellness Center 3348 Tyrone Blvd. St. Petersburg, FL Phone (727) Fax (727) Welcome to our office! Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don t hesitate to ask one of our qualified Chiropractic Assistants. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care.
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3 HEALTH CONCERNS: Please list your top health concerns in order of priority. 1) 2) 3) 4) TREATMENT: What type of treatment are you looking for? I am looking for the most minimal amount of care to patch up the symptoms of my problem. I am looking to resolve my symptoms and then go on to fix the cause of my problem. I am looking to take care of my problem and then go on to achieve optimal health and wellness. Please mark on the diagram to the right the following symbols as they relate to the patients symptoms: SS = spasms DP = dull pain SH = shooting pain NU = numbness ST = stiffness SP = sharp pain TI = tingling O = Other COMPLAINT/PROBLEM: In relation to your primary complaint: When did you first seek treatment for this problem? Has another doctor(s) treated you for this condition: Y N Whom? MD DO DC DDS Other: Name of primary doctor? Treatment(s) Tried: Medication Surgery Lifestyle change Chiropractic other Have you had any intolerance or reactions to treatments? Y N Describe: When did the problem start?: How did it originally occur? Has it become worse recently? Y N Same Better Gradually worse How frequent is the condition? Constant Daily Intermittent How long does it last? All day Few hours Minutes Is this condition interfering with your? Work Sleep Daily routine Recreation Does anything relieve the symptom(s)? Y N Medication(prescription or OTC) Rest Exercise/Stretch Other: If no, what have you tried? Medication (prescription or OTC) Rest Exercise/Stretch Surgery Is there anything that you can do to relieve the symptom? Y N Medication(prescription or OTC) Rest Exercise/Stretch Other: If no, what have you tried to do that has not helped? Medication (prescription or OTC) Rest Exercise/Stretch Surgery Chiropractic Other: How long has it been since you really felt good? Days Weeks Months Years >10 years Describe the pain/problem: Sharp Dull Numbness Tingling Aching Burning Stabbing Other: What makes the problem worse? Standing Sitting Lying Bending Lifting Twisting Other: What do you believe is cause of the problem? Are there any other conditions or symptoms that may be related to your major symptom? Y N If yes, what? Please check all of the symptoms that apply. (P=Past / C= Current) P / C P / C P / C P / C P / C Headache High Blood Pressure Tingling in Feet Facial Pain ` Low Blood Pressure Walking Problems Eye Pain Abdominal Pains Sore Muscles Blurred Vision Nausea/Vomiting Weak Muscles Dizziness Poor Appetite Paralysis Earache Fullness of Bladder Shakiness Forgetfulness Urination Difficulty Sweating Confusion Frequent Urination Insomnia Sinusitis Constipation Fainting Teeth Grinding Hemorrhoids Convulsions Dry Mouth Decreased Sex Drive Irritability Excessive Thirst Menstrual Irregularities Impatience Unpleasant Taste Elbow / Hand Pain Fatigue Neck Pain Tingling in Hands Feel Loss of Control Sore Throat Clammy Hands Lump in Throat Low Back Pain Swallowing Pain Hip Pain Unsteady Voice Knee Pain Shoulder Pain Poor Circulation Persistent Coughing Swollen Joints Chest Pressure Joint Stiffness Slow Heart Rate Swollen Ankles Rapid Heart Rate Ankle / Foot Pain Other:
4 ALLERGIES/Sensitivities: Please check and list all allergies. Food: Dairy Wheat Corn Soy Seafood Gluten Peanuts Fruits Other: Medications: Penicillin Sulfa Drugs Iodine Insulin Antibiotics Other: Seasonal/Other: Pollen Dust Hay Mold Chemical(s) Smoke Animals Insects Other: MEDICATIONS: Please check and list all medications that you are currently taking with the date you began taking them. Medication Name Date Started Antacids Antibiotics Antidepressants Anti-Diabetics Anti-Inflammatory Blood Pressure Lowering Meds. Cholesterol Lowering Meds. Hormone Replacements (HRT) Oral Contraceptives OTC (over the counter) Other SUPPLEMENTS: Do you take Vitamins/Supplements or Herbs? Y N If yes, who recommended them? SCARS / SURGICAL PROCEDURES: Have you had any surgical procedures? YES NO Any Scars? YES NO SPINE: Cervical Thoracic Lumbar EXTREMITIES: Shoulder/Elbow/Hand/Wrist R L Hip/Knee/Ankle/Foot R L ABDOMINAL/CHEST: Appendix Colon Gall Bladder Heart Lungs Breast Other: HABITS: Heavy Moderate Light None 5-7x/wk 3-5x/wk 1-3x/wk None Type Alcohol Exercise Aerobic Weights. Coffee 8+ hrs 7-8 hrs 6-7 hrs 5-6 hrs <5 hrs Soda / Diet Soda Sleep. Tobacco Drugs Meals / day. Stress Level 64+ oz oz oz <8 oz Water / day WORK ACTIVITY: Heavy Labor Light Labor Mostly Sitting Mostly Standing Walking / Moving Driving FAMILY HISTORY: Identify any conditions that you, or any of your family members have now or have had in the past: (F = Family, P = Personal History) Alcoholism Eczema Miscarriage(s) Tumor(s) Anemia Emphysema Mumps Ulcer(s) Cancer Epilepsy Pleurisy Other: Cold sores Goiter Pneumonia Deep vein thrombosis Gout Polio Detached retina Heart disease Rheumatic fever Diabetes HIV / AIDS Stroke Patient s Printed Name Patient s Signature Date Reviewed By: Date:
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New Patient Information
New Patient Information : / / WELCOME! PLEASE TELL US ABOUT YOURSELF: Full Name: Gender: M F Age: Birth : / / Address: City: State: Zip: Home phone: ( ) E-mail: Work phone: ( ) Cell Phone: ( ) Social Security
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
California Chiropractic Boshears, Inc. 35191 Yucaipa Blvd., Yucaipa Ca. 92399 Phone: (909) 790-5005 Fax : (909) 790-5009 Patient Information Date: Name: Address: Home Phone: Work Phone: Sex: Male or Female
Gentle Chiropractic, LLC Dr. Amy Richard 7919 Big Bend Blvd. Suite B Webster Groves, MO Phone: Patient Data Sheet:
Gentle Chiropractic, LLC Dr. Amy Richard 7919 Big Bend Blvd. Suite B Webster Groves, MO. 63119 Phone: 314-537-1461 Patient Data Sheet: Date Name: Address: City: State: Zip: Social Security Number: - -
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
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
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Name Phone ( ) Age Birth Date Sex S.S.N. Employer Address Did you report this to YOUR Car Insurance? Yes No (Circle One) Your Car Insurance Co. is Claim # Claims Adjuster
Chiropractic Registration and History
Chiropractic Registration and History 1. Patient Information Name: Birthdate: SS/HIC/Patient ID #: Address: City: State: Zip: Phone: Cell: E-Mail: Sex: M F (Circle) Minor Single Married Divorced Separated
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
Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:
Leader Heights Spine, Joint & Nerve Associates Date: Chart # DC # Patient Information: Please print clearly and complete all sections. Please Circle : Mr. Mrs. Ms. Miss Dr. Rev. Marital Status : Single
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
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
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
PERSONAL HISTORY. Describe your pain or complaint:
PERSONAL HISTORY Dear Patient, welcome to our clinic, this form is designed to help us get to the cause of your current health problem as quickly as possible. The more detailed and accurate you are, the
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 Which Chiropractor are
Last First MI. Full Mailing Address:
BridgeMill Family Healthcare, LLC Date Patient Information Name: Full Mailing Address: Last First MI Phone# (Mobile) (Home) (Work) Email Address Date of Birth: Sex: Male Female SS#: Marital Status: Single
Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program
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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)
PATIENT HEALTH QUESTIONNAIRE
PATIENT HEALTH QUESTIONNAIRE Name Date Please check all answers and fill in the blanks where appropriate. In the space below, please describe the major complaint which brought you to this office for care.
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
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.
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
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:
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it
AUTOMOBILE ACCIDENT HISTORY
AUTOMOBILE ACCIDENT HISTORY Todays of Injury Was the accident on the job? Yes No Where were you seated in the vehicle? Name of person driving the vehicle Your Vehicle (year, make, model) Your estimated
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
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Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
NEW PATIENT QUESTIONNAIRE
Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
PATIENT INTRODUCTION
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Initial Patient Health Assessment Form
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New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
CONSULTATION ADMITTANCE FORM
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
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
Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:
Name Age Date Please list All your current health complaints, including the reason that brought you to our office: List any other doctors see for current problems and list treatment received and results:
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
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:
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
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Rockwood Natural Medicine Clinic
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ACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date:
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Pain Relief Recover from Injury Chiropractic Therapeutic Laser Therapy. Release & Balance Method Nutritional Counseling Laboratory Testing & Analysis
Health Solutions Center John Gangemi Chiropractic Physician Date Date of Birth Name Mailing Address Home Phone Cell Occupation Email How Did You Hear About Our Office Whom May We Thank For Referring You
Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
PLEASE NOTE: This file must be saved to your desktop before and after completing! PATIENT INFORMATION Date First Name SSN Sex Marital Status Middle Name Birth Date Last Name Height Spouse Name Address
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
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 #
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
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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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Client Registration Form
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AHI - New Patient Information
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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
NEW PATIENT INFORMATION
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Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
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CONSULTATION ADMITTANCE FORM
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Medical Information. (office use) MRN: CMRN: Last Name: First Name: Middle Initial: Date of birth: Age: Sex: M F Height: Weight:
1835 W. County Rd C, Suite 80, Roseville, MN 55113 P: 651-797-6880 F: 651-797-6881 info@spartzvein.com spartzvein.com Medical Information Date of consultation: (office use) MRN: CMRN: Last Name: First
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Address Street Address City State Zip Code. Address Street Address City State Zip Code
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PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
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INSURANCE... ACCIDENT INFORMATION PATIENT CONDITION _.
WELCOME 3 LOCATIONS TO SERVE YOU BETTER! PINES WEST CHIROPRACTIC EAST SIDE CHIROPRACTIC MARTINEZ CHIROPRACTIC 18501 Pines Blvd., Suite 104 8228 Biscayne Blvd. 12595 S.W. 137 Ave., Ste 108 Miami, FL 33029
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
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
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
MacKay Chiropractic, LTD., 7450 W. Cheyenne Ave. #114 Las Vegas, NV (702)
Personal History Date Patient # Name: Address: City: State: Postal Code: Birth date: Age: Sex: M F Home Phone: _ Cell Phone: Social Security #: Type of Work Email (for appt/e-news letter): Business/Employer:
Patient Information. Name: Last First MI. Address: Street City State Zip
Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
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DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
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BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
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My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one) Date of
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Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
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