Clinical Services Intake
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- August Dylan Preston
- 5 years ago
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1 Clinical Services Intake Name: Date: Address: City: State: Zip: rimary hone: Secondary hone: Birthdate: Status: Single Married Divorced Widowed Children: Yes No How Many: Are you considered a minor? Yes No If Yes, who is the responsible payer? Occupation: Employer: Family Doctor: Yes No Name of Doctor: hone: Emergency Contact: hone: How did you hear about our facility? ast Medical History For the conditions below, place a check in the past column if you have had the condition in the past. If you presently have any condition listed below, please place a check in the present column. Condition ast resent Condition ast resent Condition ast resent Headaches Neck ain Upper Back ain Mid Back ain Low Back ain Shoulder ain Elbow/Arm ain Wrist ain Hand ain Hip ain Upper Leg ain Knee ain Ankle/Foot ain Jaw ain Joint ain/ Stiffness Arthritis Rheumatoid Arthritis Cancer Tumor Asthma Chronic Sinusitis High Blood ressure High Cholesterol Heart Attack Stroke Angina Kidney Stones Kidney Disorders Bladder Infection Loss of Bladder Ctrl rostate roblems Abnormal Wt Loss/Gain Loss of Appetite Abdominal ain Ulcer Hepatitis Liver Disorder Gall Bladder Disorder General Fatigue Thyroid Disorder Muscular Incoordination Visual Disturbances Dizziness Diabetes Excessive Thirst Frequent Urination Addiction Drug/Alcohol Allergies Depression Systemic Lupus Fibromyalgia Epilepsy Skin Conditions HIV/AIDS For Women: Birth Control Hormone Replacement List ALL Medications you are Currently Taking: List any Allergies: (including food) List any Surgeries: Have you had any adverse reaction to massage creams, or massage oils? Yes No Do you have any contraindication to the use of Electrical Stimulation Rehab equipment? Yes No Family Medical History lease indicate if you have any immediate family members with the following conditions: Rheumatoid Arthritis Heart roblems Diabetes Cancer Lupus/Fibromyalgia Mulitple Sclerosis Other ertinent Family Medical history: Social History Do you smoke: Yes No How Much: Drink Alcohol: Yes No how much: For Women Only: regnant? Yes No How Long: Nursing? Yes No
2 Clinical Services Intake lease indicate on the drawing below where you are experiencing your symptoms 1) Where is your problem: When Did It Start: ain Level (0= No ain/10=highest ain) How often does it occur: Occasionally Intermittently Frequently Constantly (0-25% of the time) (26-50% of the time) (51-75% of the time) (76-100% of the time) lease describe your pain: Aching Burning Dull ulling Sharp Shooting Stabbing Stinging Throbbing Tight What aggravates your symptoms: Notes: 2) Where is your problem: When Did It Start: ain Level (0= No ain/10=highest ain) How often does it occur: Occasionally Intermittently Frequently Constantly (0-25% of the time) (26-50% of the time) (51-75% of the time) (76-100% of the time) lease describe your pain: Aching Burning Dull ulling Sharp Shooting Stabbing Stinging Throbbing Tight What aggravates your symptoms: Notes: 3) Where is your problem: When Did It Start: ain Level (0= No ain/10=highest ain) How often does it occur: Occasionally Intermittently Frequently Constantly (0-25% of the time) (26-50% of the time) (51-75% of the time) (76-100% of the time) lease describe your pain: Aching Burning Dull ulling Sharp Shooting Stabbing Stinging Throbbing Tight What aggravates your symptoms: Notes: Current Treatment of Symptoms Have you seen anyone else for these symptoms: Yes No Who: List any treatment given for these symptoms: List any medications given for these symptoms: atient Signature: Date:
3 Activity Release of Liability LEASE READ CAREFULLY, THIS AFFECTS YOUR LEGAL RIGHTS. In exchange for participation in the activity of any exercise and/or rehabilitation organized by Orlando Body and Movement Therapy, of 7345 West Sand Lake Rd., Orlando, FL and/or use of the property, facilities and services of Orlando Body and Movement Therapy, I agree for myself and (if applicable) for the members of my family, to the following: 1. I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Orlando Body and Movement Therapy, or the employees, representatives or agents of Orlando Body and Movement Therapy. 2. I recognize that there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, and further release and discharge Orlando Body and Movement Therapy, whether caused by the fault of myself, my family, Orlando Body and Movement Therapy, or other third parties. 3. I agree to indemnify and defend Orlando Body and Movement Therapy against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family s use of or presence upon the facilities or Orlando Body and Movement Therapy. 4. I agree to pay for all damages to the facilities of Orlando Body and Movement Therapy caused by my or my family s negligent, reckless, or willful actions. 5. Any legal or equitable claim that may arise from participation in the above shall be resolved under Florida law. I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY SIGNING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS. Signature Date rint Name Date of Birth Address City State Zip Code rimary hone Work/Secondary hone In case of emergency (Relationship) Emergency contact phone
4 INFORMED CONSENT OF MANIULATION WITHOUT DIAGNOSTIC IMAGING Orlando Body & Movement Therapy does not maintain an X-Ray unit at this facility. X-Ray and other diagnostic imaging studies (MRI, CT, etc.) are not absolutely necessary for spinal and/or joint manipulation to be performed, but can be helpful to better visualize a particular area. It is our policy that all clinic patients be examined to determine if X-Rays are necessary prior to any spinal and/or joint manipulation. If any further diagnostic studies (X-Ray, MRI, CT scan, etc.) are deemed necessary by the physician we will direct you to Sand Lake Imaging Center or another appropriate imaging center of your choosing. If you have any reservations regarding having X-Rays taken or any other imaging procedure please discuss this with the doctor on staff. Alternatively if you have any reservations regarding receiving spinal and/or joint manipulation without first having taken X-Rays of the area of concern please discuss this with the doctor on staff before signing this form. By signing this form below you are acknowledging that you have been informed of our policies regarding utilizing diagnostic imaging studies in this facility and your rights to accept or refuse any diagnostic imaging study as well as any spinal and/or joint manipulation. Furthermore you acknowledge that you accept any risks involved in having spinal and/or joint manipulation without having prior diagnostic imaging. You have the right to refuse individual procedures without the risk of hindering any further treatment. atient Signature rinted Name Date
5 Informed Consent Orlando Body & Movement Therapy is dedicated to helping you regain and maintain control of your health through a holistic approach combining fitness with sports therapy modalities. We will provide you with superior care without the use of drugs or surgery. Our methods are 100% percent natural and based on years of training and experience. We utilize several therapeutic modalities to achieve outstanding clinical outcomes and results. The therapeutic modalities used in your treatment may include one of more of the following; manual therapy techniques, Micro current oint Stimulation, Chiropractic manipulation, electrical stimulation, ultrasound, nutritional supplementation, and exercise therapy. Where conventional or allopathic medicine focuses on treating illness symptoms through surgery and pharmaceutical drugs, the goal of our facility s treatment is to optimize health with a non-invasive approach that does not use drugs or surgery. The primary avenue of care is manual therapy techniques and chiropractic manipulation of the spine to improve the framework of the body. In addition to adjustments, other treatments used by this facility include physical therapy (ice, heat, electrical stimulation, ultrasound,), nutritional recommendations and rehabilitative procedures. As is the case with all health care interventions, the benefits of care must be weighed against the inherent risks and limitations of receiving treatment. Due to reservations some patients may have regarding chiropractic treatment we feel the need to provide the following information. Chiropractic treatments are one of the safest interventions available to the public as evidenced by malpractice statistics. While there are risks involved with treatment, these are seldom great enough to contraindicate care. Nonetheless, they must be considered when making the decision on whether or not to receive chiropractic care. Listed below are summaries of some key research articles that have addressed both common and rare side effects/complications associated with chiropractic care. One research study indicated that with the first 2 months of care approximately half of patients report some reaction to chiropractic treatment. Of those who reported a reaction, the following were the most commonly reported reactions to initial chiropractic care: ~Local discomfort (53%) ~Tiredness (11%) ~Headache (12%) ~Radiating discomfort (10%) Most reactions appeared within 4 hours of treatment and resolved within 24 hours. Other rare, yet possible side effect/complications: ~ Rib fracture (when osteoporosis is apparent) ~Cauda Equina Syndrome ( 1 case per million adjustments) ~Compromise of the vertebrobasilar artery ( 1 case per approx.. 1 million cervical spine adjustments) References: Senstad O, et al. Frequency and characteristics of side effects of spinal manipulative therapy. Spine 1997; 22: Shekelle G, et al. Spinal manipulation for low back pain. Ann Intern Med 1992: 117(7):590-8 Haldeman S, etal. Risk factors and precipitating neck movements causing vertebrobasilary artery dissection after cervical trauma and spinal manipulation. Spine 1999; (24): Haldeman S, et al. Guidelines for chiropractic quality assurance and practice parameter. Aspen ublishers, 1997 In addition to national guidelines, our clinic has set criteria for how we manage our patients. Through questioning and examination, we will do our best to determine what risk, if any, chiropractic care may pose to you and advise you of those risks as well as the possible need for medical referral. We may also suggest alternate medical approaches if we detect absolute or relative contraindication to the standard therapeutic treatment. I have read the previous information regarding risks of chiropractic care and my doctor has explained my risks (if any) to me and suggested alternatives when those risks exist. I understand the purpose of my care and have been given an explanation of the treatment, the frequency of care, and alternatives to this care. All of my questions have been answered to my satisfaction. I agree to this plan of care understanding any perceived risk(s) and alternatives to this care. atient Signature atient rinted Name Date arent/guardian Signature arent/guardian rinted Name Date
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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
Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes
New Patient Intake Form. Patient s Full Name. Male Female Age: Date of Birth: / / Mailing Address: City: State: Zip:
New Patient Intake Form Date: / / Patient s Full Name E-Mail: Home Phone: Cell: Male Female Age: Date of Birth: / / Social Security # - - Mailing Address: City: State: Zip: Married Single Widowed Separated
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Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
CHIROCENTER. Home Address: City: State: Zip: I would like to receive notifications Please do not send notifications
CHIROCENTER PATIENT ADMITTANCE Name: (First) (Middle Int). (Last) Today s : Home City: State: Zip: Telephone: Work: Cell: of Birth: Sex: M or F Social Security#: (Month) (Day) (Year) Circle if you are:
Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
Patient Information Name: First Last M.I. Date: Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Email: Phone: Cell/Home/Work (please circle one) How did you hear about us? Door hanger, Fargo
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
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
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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
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*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) 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 #
Body Harmony Chiropractic 4051 Kirkpatrick Rd, Suite 300 Flower Mound, Tx PATIENT INTAKE FORM
Body Harmony Chiropractic 4051 Kirkpatrick Rd, Suite 300 Flower Mound, Tx 75028 940-594-0795 PATIENT INTAKE FORM Name Birthdate / / Age Today s date / / Address City State Zip Home # ( ) Work # ( ) Ext.
Family First Chiropractic
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Family First Chiropractic
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Family Chiropractic Care Patient Health Questionnaire. Patient Name: Date: What type of regular exercise do you perform? None Light Moderate Strenuous
Family Chiropractic Care Patient Health Questionnaire Patient Name: Date:_ What type of regular exercise do you perform? _None _Light_Moderate_Strenuous What is your height and weight? Height Weightlbs
Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other
Patient s Name Date: What is the reason for you visit today? Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone # (home)
CHIROPRACTIC REGISTRATION AND HISTORY
CHIROPRACTIC REGISTRATION AND HISTORY PATIENT INFORMATION Date SS/HIC/Patient ID# Patient Name Last name First name Middle Initial Address City State Zip Sex Male Female Age Birth date Married Single Divorced
Medical History Questionnaire
Date Medical History Questionnaire Name DOB Reason for visit When did symptoms first appear Is the condition getting worse? Please rate your pain 0 1 2 3 4 5 6 7 8 9 10 No Pain Extreme Pain Please circle
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Today s Date PATIENT INFORMATION Name Last First Middle Address Number Street Name Apt# City State Zip Home Phone Work Phone Cell Phone Date of Birth / / Age Sex: Male Female Employed Full-Time Student
Carriage House Chiropractic and Acupuncture
Chiropractic Patient History Questionnaire Date: Name: Date of birth: Address: City: St: Zip: Phone: (home) (cell) (work) May we send appointment reminders to you via text messages on your cell phone Email:
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
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
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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
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Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
Patient Intake Form Please Write Legibly
Chiropractic Wellness Center Date: Patient Intake Form Please Write Legibly Patient Legal Name: Male Female Preferred Name: Date of Birth: Age: Home Address: Apt#: City: State: Zip: Home Phone: Cell Phone:
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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 #
Revelation Chiropractic Health Profile
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New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
Name Date / / Age Male / Female Address City State Zip Phone: Home Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single / Married / Divorced / Widowed Spouse s Name
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska 99518 (907)563 7700 PATIENT DEMOGRAPHICS Today's Date: Name: Birth Date: Age: Male
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
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New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED Patient Information Name: DOB: / / Gender: M F Home Address: Home Phone: City, State, Zip: Work Phone: Email Address: Cell Phone: I do not want
Dr. Brett Whitekettle
Dr. Brett Whitekettle For Office Use Only: Patient ID #: 200 Cape Fear Circle Suite 2 Sneads Ferry, NC 28460 T: (910) 327-0022 F: (910) 327-0337 office@whitekettlechiropractic.com Patient Information Phone
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
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
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
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Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
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Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX
Liberty Chiropractic Clinic, -6154 Patient's Name Patient's Address City State Zip Code Age D.O.B. Single Married Divorced Widowed No. of children Occupation Employer Home Phone Work Phone Cell Phone Email
Name Date / / Age Male/ Female Address City State Zip
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New Patient Intake Form
New Patient Intake Form Please complete information below Name: DOB Age Male Female Referring Physician FAX Address Phone _ Primary Care Physician FAX Address Phone Is this a work related problem? If yes,
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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
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HEALTH QUESTIONNAIRE
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LIST YOUR HEALTH CONCERNS BELOW
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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
3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
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PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
Brisbin Family Chiropractic
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8209 Natures Way Unit 115 Lakewood Ranch, Florida 34202 (941) 877.1507 Name Date / / Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name
Regenerate Health, PLLC
Dear Patient: This office is a multidisciplinary doctor group. We have done this for various reasons, with the most important one being that our facility can enjoy a more comprehensive approach to your
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Physician's Spine and Rehab, LLC
ABOUT THE PATIENT Physician's Spine and Rehab, LLC Name Birth date AgeSS# Address City State Zip Home Phone Cell Phone Work Phone Gender M F Your Employer E-Mail Address Significant Other s Name Insured
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Initial Visit Forms. Life in Motion Chiropractic & Wellness 6139 Route 96 -Suite 1 Farmington, NY (585)
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New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone
1 New Client Intake Address City State Zipcode Date of Birth Home Phone Mobile Phone Emergency Contact: Relationship to you Phone Please explain the pain you are experiencing and its origin story: https://docs.google.com/document/d/1q0tns8lwtefzbbj1n9jyt2onopvy2abs9s1ofr07zai/edit
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Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
Marital Status: Single Married Other Spouse/Parent/Guardian Name: Birth Date: Phone: Referred By:
COON RAPIDS CHIROPRACTIC OFFICE File# Patient Intake Information Today's Date: Patient Title: Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name: MI: Last Name: Suffix: Nick Name: Birth Date: SSN Gender: Male
SPARROW FAMILY CHIROPRACTIC
Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address:
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
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
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
Insurance. Patient Family Information. Patient Condition
Welcome to Amarillo Family Wellness Group In order to serve you best we would like to know more about you and your health history. Please print clearly and fill this out completely prior to your appointment
RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
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:
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
ADIO CHIROPRACTIC HEALTH PROFILE
ADIO CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
Basic Information Full Name: Address: City: State: Zip: Cell: Home: Work: Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S Email: Occupation: Emergency Contact: Phone: Children: O No
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Informed Consent Form
Informed Consent Form The doctor of chiropractic evaluates the patient using standard examination and testing procedures. A chiropractic adjustment involves the application of a quick, precise force directed
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:
GENERAL INFORMATION HEALTH & LIFESTYLE PROFILE
GENERAL INFORMATION Name Today s Date // Address City/State/Zip Mobile Phone # _ Other Phone # Your Birthdate Occupation Employer Relationship: Single Married Partner Widow Children: Yes No How did you
Cascadia Chiropractic Centre
Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please