Home Address: City: St: Zip: SSN: - - Date of Birth: / / Sex: M F. How did you learn about our clinic?
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1 New Patient Child Intake Pietila Chiropractic, LLC, River Ridge Blvd., Burnsville, MN (952) John R. Pietila, DC, DACNB, Jennifer L. Engesether, DC, DACNB, Nicholas C. Moe, DC, Michael P. Hennes, DC Name: Date: (First) (Middle) (Last) Home Address: City: St: Zip: HomePhone: WorkPhone: CellPhone: Student Status: FT PT Employment Status: FT PT NA SSN: - - Date of Birth: / / Sex: M F Parent s Names: Best Contact Number: Emergency Contact: Phone: How did you learn about our clinic? Were you referred by anyone? If so, please name: Address: May we send you clinic updates? (ie: upcoming seminars, newsletter) yes no Payment Information I will be paying today by: Cash Check Credit Card I authorize Pietila Chiropractic, LLC the release of any medical or other information necessary to process this claim. I request payment of medical benefits from either a government or non-government source to Pietila Chiropractic, LLC. I authorize Pietila Chiropractic, LLC to initiate a complaint to the Insurance Commissioner on my behalf. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I further understand that I will be legally responsible for all collection costs involved with the collection of this account including court costs, reasonable attorney fees and all other expenses incurred with collections, if I default on this agreement. In addition, if I issue a check that is returned by the bank for non-sufficient funds, I understand I will be charged $30.00 for each returned check. If I choose to use my non-contract insurance company I will be considered a cash patient by Pietila Chiropractic. Payment for professional services are due at the time of service. After paying in full I will receive a receipt with the appropriate billing and diagnosis codes to submit to my insurance company myself by following the directions on the back of my insurance card. My insurance company will reimburse me directly. I certify the information above is true and correct to the best of my knowledge. Parent Signature: Date:
2 CHIEF COMPLAINT Present Condition When did your complaints and/or symptoms begin? Describe your current injury or your current problem: Please mark your symptoms on the diagram. Aching XXX Burning - ### Numbness - /// Pins/Needles 000 Stabbing - Rate your pain right now (mark as N ); worst (mark as W ); best (mark as B ) no pain mild moderate severe very severe worst possible Please check all present symptoms related to your current condition: Head & Face base of skull side/temple nausea/vomiting ear pain throbbing migraine incapacitating front ringing in ears nose bleeds eyelids heavy top double vision pressure head feels heavy eye pain jaw pain flushing light sensitive blurry vision headache affects vision dizziness sinus problems Neck weakness spasms pain on motion limited motion pain swelling lumps throat tight radiating pain difficulty swallowing stiffness Shoulder, Arm & Hand Shoulder: local pain limited movement pain on movement pain from neck radiates down arm Arm & Hand: local pain pain on movement swelling cold hands weakness radiates from neck numbness/tingling cannot raise arm Mid-back & Low-back weakness pain spasms rib pain chest pain stiffness swelling pain on motion limited motion radiating pain Hips, Legs, Knees and Feet local pain radiating from back down leg swelling numbness tingling spasms cramping cold feet weakness pain on motion varicose veins Nerves burning numbness tingling tremor dizziness loss of balance loss of consciousness coordination twitching difficulty with memory seizures generalized weakness Sleep good fair poor poor due to pain deep burning pain difficulty falling asleep difficulty staying asleep wake often Fatigue must rest during day cannot get enough rest intermittent fatigue constant fatigue worse with exercise mental fatigue physical fatigue Current Diagnosis, if any Date given
3 Who gave the current diagnosis? Phone Criteria used for diagnosis Past/Present treatments used Does your child have medical records that have been created or has your child seen another doctor because of his/her current condition? Y / N If so, please list the doctors that have seen your child for his/her current complaint. 1. Name: Phone: 2. Name: Phone: 3. Name: Phone: Has your child had any diagnostic tests performed by the aforementioned doctors or any other doctors? Yes / No If so, please check the tests your child may have had performed. MRI X rays Lab Work Electrodiagnostics Functional Testing Psychological Testing Other: PREGNANCY AND DEVELOPMENT: Was the pregnancy normal/without complications? Yes / No Duration of the pregnancy Number of weeks early late Type of delivery: Vaginal Breech Cesarean Forceps/Extraction Complications during labor or delivery? Yes / No Newborn difficulties? Yes / No Please indicate the age at which your child achieved the following: Sat without support Spoke first words Crawled Put 2-3 words together Walked Spoke in sentences Toilet trained Concerns regarding your child s early development? Yes / No Current Grade Level Has your child had school-related problems in any of the following areas? Reading (phonics) Attention/Concentration Reading (comprehension) Behavior Spelling Social Skills Mathematics Emotions Handwriting
4 PAST HEALTH CARE HISTORY: Has your child had any previous care (DC, DDS, DO, DPT, MD, ND, OD, PhD)? Yes / No Please list where and when: Has your child ever been hospitalized? Yes / No If so, where and when? Has your child had any previous surgeries? Yes / No If so, please list the date, type, hospital, and result: Has your child ever had any major illnesses, injuries, or falls? Yes / No Review of Systems: Head, Ears, Eyes, Nose, and Throat Vision problems Eye pain Hearing difficulty Dental problems Headaches Ear ache/ infections Sore throat Ringing in ears Sinus congestion Cardiovascular and Respiratory Chest pain/tightness Fainting dizziness irregular/heartbeat Coldhands/feet light headed Gastrointestinal Nausea/Vomiting Diarrhea Constipation Gas/bloating Bloody stools esophageal reflux bowel incontinence Abdominal Pain/Cramps Genitourinary Pain with Urination Loss of bladder control Frequent urination Wake to Urinate Blood in Urine Urgency with Urination Musculoskeletal Joint pain Muscle pain difficulty w/limb movement joint stiffness muscle stiffness Nervous System nervousness/anxiety seizures/convulsions dizziness depression confusion/forgetfulness weakness General Weight loss/gain skin rash/sores night sweats excessive thirst chills fever insomnia fatigue Bruise/bleed easily Is your child taking any medications? Yes / No If yes, please fill complete the chart below. Medication Name Dosage (strength) How often taken How long have you been taking medication Who Prescribed this Medication For Doctor s Use Only Are there medications to which your child has had an allergic reaction or unpleasant side-effects? Yes No If yes, name. Medication Name Reaction
5 Has your child had an allergic reaction to any of the following? Latex and rubber Bee or wasp stings Adhesive tape Iodine or x-ray contrast Influenza vaccination Other: None Does your child have any food allergies? Yes / No If yes, please list Is your child currently taking any Supplements? Yes / No If yes, please list: Cancer Heart Disease Diabetes Eczema/Psoriasis Migraine Headache Seizure Disorder Stroke/TIA Abnormal Bleeding Anemia Alcohol /Drug Abuse Depression Other Psych. /Mental Illness Suicide (or attempted suicide) Genetic Disorder FAMILY HEALTH HISTORY Patient Mother Father Brothers Sisters Grandparents None If any family member is deceased due to any of the conditions listed above, please list who and of what condition What are your expectations or hopes regarding the treatment outcomes? Do you have any special concerns regarding treatment procedures? Upon signature of this document I am certifying that all the information provided is true, correct and complete. If more information about my illness becomes known I will tell the doctor when possible so that it can be added to my record. I also understand that I have read the separate informed consent sheet. Parent or Guardian Signature Date
Home Address: City: St: Zip: SSN: - - Date of Birth: / / Sex: M F. How did you learn about our clinic?
New Patient Application Pietila Chiropractic, LLC, 12358 River Ridge Blvd., Burnsville, MN 55337 (952) 681-7746 John R. Pietila, DC, DACNB, Jennifer L. Engesether, DC, DACNB, Nicholas C. Moe, DC, Michael
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
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)
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: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
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CHIROPRACTIC INTAKE FORM
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New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Reason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
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CHIROPRACTIC ASSOCIATES CLINIC
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DATE: / / 7509 E. Main Street Reynoldsburg, Ohio Telephone: (614) Fax: (614)
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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
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
Dawn Smallwood, DC, NTP PATIENT INFORMATION
Dawn Smallwood, DC, NTP 120 East 1st Street Cle Elum, WA 98922 509.674.4448 CleElumchiropractic.com PATIENT INFORMATION Name: Date: (Last) (M.I.) (First) Sex: M F Marital status: (circle) single married
New Patient Specialty Intake Form Department of Surgery
This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
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
It's your life... be there healthy. RIGHT LEFT RIGHT
Dr. Sara Weigel Dr. Douglas Ness Active Life It's your life... be there healthy. Chiropractic Patient Information Major Complaint Information Date First Name: Last Name: Initial What is your major complaint(s)?
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 Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
PLEASE NOTE: This file must be saved to your desktop before and after completing!
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
Please print carefully and answer all questions Date MAILING ADDRESS CITY ST ZIP PHYSICAL ADDRESS CITY ST ZIP
Clinic Patient Information Please print carefully and answer all questions Date Patient legal name LAST FIRST MIDDLE Sex: M / F MAILING ADDRESS CITY ST ZIP PHYSICAL ADDRESS CITY ST ZIP HOME PHONE # CELL
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
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
Acknowledgement of receipt of notice of privacy practices
Acknowledgement of receipt of notice of privacy practices NOTICE OF PRIVACY PRACTICES I acknowledge that I have received a Notice of Privacy Practices from Kettering Physician Network (dba Kettering Cancer