In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines:
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- April Alyson Perry
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1 Arrival Policy nd Ave., Madison, MN In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines: Attend all scheduled therapy appointments and follow any home instructions. Notify the clinic 24 hours prior to your scheduled appointment if you are unable to attend Inform the front desk staff of upcoming physician appointments or any other scheduling conflicts In addition, patients may be subject to discharge from therapy services when they fail to arrive to three scheduled appointments. At times it may be necessary for Big Stone Therapies, Inc. to change or reschedule your therapy appointment(s). By signing this agreement I give consent to allow the staff at Big Stone Therapies, Inc. to contact me by phone, , at home or work regarding information about my therapy appointment(s) including leaving messages. Your compliance with this policy will ensure that we can provide you with the best therapy experience. We look forward to the opportunity to work with you and to help you heal. I understand and agree to the following policy as stated above. Patient Signature Date We will be communicating with your physician throughout the course of your treatment to keep him/her well informed of your treatment plan and your progress. We take pride in keeping a high level of communication with your health care provider to ensure the highest quality of care.
2 To better acquaint your therapist with your medical history, you have been asked to complete this health questionnaire. Your answers are strictly confidential and help your therapist perform a detailed evaluation. Name Height Weight Occupation Full Time or Part Time (circle) Work Restrictions? Yes/No (circle) What do you do for work activities? What do you do for hobby/leisure/sports activities? How would you rate your general health status? Excellent Good Fair Poor (circle one) During the past month, have you been bothered by feeling down, depressed, or hopeless? Yes/No (circle) During the past month, have you often been bothered by little interest or pleasure in doing things? Yes/No (circle) If yes, is this something with which you would like help? Yes/Yes, but not today/no (circle) Do you smoke or use tobacco? Yes/No (circle) Do you drink alcohol? Yes/No (circle) What is your stress level? Low Medium High (circle one) Would you be interested in learning about a Wellness or weight loss program? Yes/No (circle) Current Symptoms Please mark the area on the diagrams below where your symptoms are: Briefly describe current symptoms When and how (gradually or suddenly) did the symptoms start? Do your symptoms completely go away for any period to time? Yes / No (circle) Are your symptoms worse at any time of the day? Yes / No (circle) If Yes, then when? What makes your symptoms WORSE? (circle all that apply) Lying down Standing Walking Stress Sitting Other: What makes your symptoms BETTER? (circle all that apply) Lying down Standing Walking Stress Sitting Other: Currently are you receiving treatment from anyone else for your symptoms? Yes/No (circle) If yes, please list Have you previously received treatment for symptoms? Yes/No (circle) Please circle the number which best represents the severity of your At WORST the last 24 hours At BEST the last 24 hours AVERAGE over the last 24 hours
3 If yes, when and what providers Have you had an x-ray, MRI, or other imaging for this issue? Yes/No (circle) If yes, please explain Are the symptoms currently: Better Worse Same (circle one) Medical History Do you currently have, or have previously, been diagnosed with any of the following conditions? (circle all that apply) Cancer Heart Problems Lung Problems Neurologic Disorders Diabetes Osteoporosis Poor Balance Changes in Appetite Dizziness/Vertigo Arthritis Headaches Thyroid Disease Nausea/Vomiting Difficult swallowing Peripheral Artery Disease Unwanted Bowel or Bladder Loss Loss of Consciousness Sensitivity to Cold/Heat Night Sweats List all prescription and/or over the counter medications recently or currently taking. See attached prescription list. Did you have any previous surgical history? (circle and date all that apply) Hospitalizations Broken Bones Serious Illnesses Falls Surgeries Dislocations Sprains Other Do you have a family history of any of the following? (circle all that apply) Cancer Diabetes Heart Disease High Blood Pressure Arthritis/Osteoporosis Stroke Psychosocial Disorders Peripheral Artery Disease Other Currently I am experiencing (circle all that apply) Fever/Chills/Sweats Poor Balance (Falls) Unexplained Weight Loss Numbness or Tingling Changes in Appetite Depression Difficulty Swallowing Recent Bacterial Infection Shortness of Breath Dizziness Fatigue Changes in Bowel or Bladder Function Headaches Nausea/Vomiting Increased Pain at Night Recent Trauma or Accidents Numbness in area that covers a bicycle s eat Urine Retention Morning Stiffness Personal Information Do you have any barriers to learning? Yes/No (circle) If yes, please explain What methods of learning do you prefer? (circle all that apply) Handouts Demonstration Practice Verbal Instruction Written Instruction Identify up to three important functional activities that you are currently unable to do or are having difficulty with: Please list personal goal(s) for therapy
4 Patient Signature Date Parent/Guardian signature if patient is under 18 years of age
5 Neck Disability Index Patient Name Date This questionnaire is designed to help us better understand how your neck pain affects your ability to manage everyday life activities. Please mark in each section the one box that applies to you. Although you may consider that two of the statements in any one section relate to you, please mark the box that most closely describes your present day situation. Section 1: Pain Intensity I have no neck pain at the moment The pain is very mild at the moment The pain is moderate at the moment The pain is fairly severe at the moment The pain is very severe at the moment The pain is the worst imaginable at the moment Section 2: Personal Care I can look after myself normally without causing extra neck I can look after myself normally, but it causes extra neck It is painful to look after myself, and I am slow and careful. I need some help but manage most of my personal care. I need help every day in most aspects of self-care. I do not get dressed. I wash with difficulty and stay in bed. Section 3: Lifting I can lift heavy weights without causing extra neck I can lift heavy weights, but it gives me extra neck Neck pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, i.e. on a table. Neck pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned. I can lift only very light weights. I cannot lift or carry anything at all. Section 4: Work I can do as much work as I want. I can only do my usual work, but no more. I can do most of my usual work, but no more. I can t do my usual work. I can hardly do any work at all. I can t do any work at all. Section 5: Headaches I have no headaches at all. I have slight headaches that come infrequently. I have moderate headaches that come infrequently. I have moderate headaches that come frequently. I have severe headaches that come frequently. I have headaches almost all the time. Section 6: Concentration I can concentrate fully without difficulty. I can concentrate fully with slight difficulty. I have a fair degree of difficulty concentrating. I have a lot of difficulty concentrating. I have a great deal of difficulty concentrating. I can t concentrate at all. Section 7: Sleeping I have no trouble sleeping. My sleep is slightly disturbed for less than 1 hour. My sleep is mildly disturbed for up to 1-2 hours. My sleep is moderately disturbed for up to 2-3 hours. My sleep is greatly disturbed for up to 3-5 hours. My sleep is completely disturbed for up to 5-7 hours. Section 8: Driving I can drive my car without neck I can drive my car with only slight neck I can drive as long as I want with moderate neck I can t drive as long as I want because of moderate neck I can hardly drive at all because of severe neck I can t drive my car at all because of neck Section 9: Reading I can read as much as I want with no neck I can read as much as I want with slight neck I can read as much as I want with moderate neck I can t read as much as I want because of moderate neck I can t read as much as I want because of severe neck I can t read at all. Section 10: Recreation I have no neck pain during all recreational activities. I have some neck pain with all recreational activities. I have some neck pain with a few recreational activities. I have neck pain with most recreational activities. I can hardly do recreational activities due to neck I can t do any recreational activities due to neck Score [50] Source: Vernon H & Hagino C, 1991 hvernon@cmcc.ca
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#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:
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N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
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Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
NEW PATIENT INFORMATION
OrthoNeuro For every motion in life. NEW PATIENT INFORMATION NAME: AGE: DATE: REFERRING DOCTOR/THERAPIST: SELF REFERRAL (if so, circle) Are you: Male Female Right handed Left handed Ambidextrous CHIEF
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
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:
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 #
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
Home Phone # Cell Phone # Address. Occupation Employer. Work Address Work Phone # Person to Contact in an emergency Phone #
MOTOR VEHICLE ACCIDENT HISTORY (please print) Patient Information Dr./Mr./Mrs./Ms./Miss (circle one) Marital Status (circle one) M S W D Last Name First Name Middle Name Address City Province Postal Code
Last Name Middle Name Suffix
Patient Information Advantage Chiropractic & Wellness Dr. Chantel L. Moran, DC 5797 State Route 31 Ste #1 ~ Cicero, NY 13039 Phone: (315) 699-4533 ~ Fax: (315) 699-4534 www.mychiroadvantage.com Today s
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
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
Occupation: Leisure Activities: ALLERGIES Are you latex-sensitive? Y N List any medication(s) you are allergic to:
Hello and thank you for choosing Fusion Physical Therapy as the provider for your current healthcare need(s)! We look forward to working with you to help make your day a little easier! To ensure you receive
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:
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 of Birth Today s Date
SWEDISH PAIN SERVICES: Initial Visit Questionnaire Name Date of Birth Today s Date We realize that some of the questions might not address your exact situation but please answer them to your best ability.
Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.
203-610-2681 New Patient Intake Form Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information. Name: Last Name First Name Today s date: Address:
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM First Name MI Last Preferred Name Date of Birth / / Age Gender Patient/Guarantor SS# - - Email Address Martial Status Single Married Other Street Address City State Zip Code Profession
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit)
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit) Last name: First Name: Title: Mr. Mrs. Dr. Appt Date: Refer by: (Please provide name