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1 CHICAGO CENTER FOR MYOFASCIAL PAIN RELIEF Please fill this form out before you arrive for your first appointment, it will save time when you are with us. Contact Information TODAY S DATE: NAME ADDRESS: PHONE NUMBER: D.O.B Your Diagnosis: Who referred you to us? Name: SPECIALTY: Address: Phone: Please give us the Name and contact information for other Physicians / Therapists you work with: 1) Practitioner name: a. Name and type of Practice /clinic: b. Their phone number: 2) Practitioner name: a. Name and type of Practice /clinic: b. Their phone number: 3) Practitioner name: a. Name and type of Practice /clinic: b. Their phone number: Page 1 of 2
2 Your Name: Date: EMPLOYER INFORMATION COMPANY NAME ADDRESS: PHONE NUMBER: JOB TITLE: Carrier Name Insurance Information Member Number: Group Number: Co-Pay Amount: Insurance Phone #: Primary Care Doctor (omit if same as referral source on first page) Name: SPECIALTY: Address: Phone: Page 2 of 2
3 Dr. Renee S Hartz Pre-appointment History Please complete this form before your evaluation nd bring it with you to your appointment. Thank you. Name: Today s Date Address : Birthdate : : Employer : Cell ph #: Occupation : What is your Chief Complaint: (#1 problem) How long have you had this problem? List all injuries, accidents, procedures or surgeries, starting with the most recent and going back as far as you can remember. EVERYTHING matters, so please try be as thorough as possible. Approximate Date Description of Injuries/Accident/Surgery/ Procedure Chicago Center for Myofascial Pain Relief; Pre Appointment History Page 1 of 5
4 Have you been told by a physician that you have the following: Herniated or Bulging Disks Spinal Stenosis Scoliosis Fibromyalgia Carpal Tunnel Syndrome Diabetes Thyroid problems Auto-immune disorders Are you right-handed or left handed? Osteoporosis/Osteopenia Arthritis Hypermobility Disorders Heart Disease High Blood Pressure Kidney Disease Stroke Circulatory Problems Do you wear shoe orthotics?. If yes, how long? Do you now, or did you as a child, prefer to sit on one leg? Do you have any food sensitivities?. If yes, please list: Do you have any allergies?. If yes, please list: Are you pregnant? Yes/No. Have you been through menopause? Yes/ no When? List any medications you are currently taking: 1. additional list here: List any supplements or vitamins you are currently taking: List any medications you have tried in the past and the reason you stopped taking it: Please circle other current therapists/ therapies, and underline any past therapies you have tried: Chiropractic PT Tens Unit Ultrasound Cortisone Injections Acupuncture Massage Dry Needling Other: Chicago Center for Myofascial Pain Relief; Pre Appointment History Page 2 of 5
5 What is your occupation: Is your pain affecting your work performance? If yes, Describe: Are you immobile for long periods? If yes, describe: Does anything increase your pain? If yes, please explain. Does anything relieve your pain, e.g., medication, heat, cold? Is the pain associated with any movements you make? Jaw/Facial Pain (only complete this section if you have jaw/facial pain) Do you have TMJ? Do you have jaw pain associated with chewing or yawning? Do you clench or grind your teeth? Do you wear a night guard or mouth splint? When was your last dental appointment? When was your last eye exam? Do you wear bifocals/trifocals? Home Stress Do you have childcare or home-tasks? Are you immobile for long periods at home? Do you read while laying on a couch/bed (neck flexed forward)? How stressed are you from day to day (please circle)? High High-Medium Medium Medium-Low Low Sleep What position do you most often sleep in? Circle and give % of night in each. Back Side Stomach Arms Overhead Half-stomach/half side Fetal position Pets in bed Spooning with partner Chicago Center for Myofascial Pain Relief; Pre Appointment History Page 3 of 5
6 Do you use pillows under or between the knees or behind your back? How many hours of sleep do you typically get? Do you have difficulty falling asleep? Yes / no Do you wake up often in the middle of your sleep? Yes / no Do you wake up feeling tired? Yes / no Exercise Are you able to exercise? If yes, what type of exercises do you do and how frequently? Please be specific. If not, what are your reasons for not exercising? What kind of exercises do you think you would enjoy doing? Smoking/Alcohol/Caffeine/Sugar Do you smoke or use tobacco products? If yes, what kind and how much per day? Do you drink alcohol? If yes, what kind and how often? Do you drink caffeinated beverages? If yes, what kind and how often? How much water do you drink per day? What are your goals for treatment with us? Thank you for taking the time to complete this form. We look forward to working with you on your journey toward better health! Dr Renee Hartz and the Team at Chicago Trigger Point Center Please bring any test results/films/reports that may be relevant to your condition. Chicago Center for Myofascial Pain Relief; Pre Appointment History Page 4 of 5
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Clinic Staff: Mary Biancalana, Board Certified Myofascial Trigger Point Therapist Lisa Campana, Board Certified Myofascial Trigger Point Therapist
An Overview of Our Practice Model 1-773-628-7654 6304 N Nagle Ave Suite #3 Second Floor www.chicagotriggerpointcenter.com Clinic Staff: Mary Biancalana, Board Certified Myofascial Trigger Point Therapist
Personal Medical History. Please describe the condition you are seeking treatment for and give a brief history, including onset:
Personal Medical History Name: Date: / / Please describe the condition you are seeking treatment for and give a brief history, including onset: What are your goals for treatment? What other treatments
The UW Pain Treatment and Research Center takes a holistic approach to your pain care.
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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,
Primary (First) Complaint and Location
Name: : File #: Case Type: Sex: Birth : Age: Social Security #: Address: Residence and Mailing City State Zip Code Home Phone: Mobile Phone: Email: Occupation: Employer: Work Phone: Marital Status: S M
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
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 HEALTH HISTORY
Southern Oregon Physical Therapy Associates, Inc. 924 S. Riverside Ave. Medford OR 97501 541.773.7678 Fax 541.773.5517 Email: sopta@integra.net website: southernoregonphysicaltherapy.com Health History-1
Sleep Disorders Diagnostic Center 9733 Healthway Drive, Berlin, MD , ext. 5118
Sleep Questionnaire *Please complete the following as accurate as possible. Please bring your completed questionnaire, insurance card, photo ID, Pre-Authorization and/or Insurance referral form, and all
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
Subjective Medical History Information
Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
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Address, including apt # City State Zip. Do you have an address? We do not share addresses with anyone. Home: ( ) Work: ( ) Cell: ( )
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Sleep History Questionnaire B/P / Pulse: Neck Circum Wgt: Pulse Ox
2700 Campus Drive, Ste 100 2412 E 117 th Street Plymouth, MN 55441 Burnsville, MN 55337 P 763.519.0634 F 763.519.0636 P 952.431.5011 F 952.431.5013 www.whitneysleepcenter.com Sleep History Questionnaire
Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
Name Social Security No. Last First MI Address Phone No. ( ) City State Zip Secondary No. ( ) Date of Birth Sex (M/F) Race Email County Primary Care Marital Status Single Divorced Married Widowed Employer
A B O U T Y O U D E N T A L I N F O R M A T I O N
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Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)
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Comprehensive History, Consult, and Evaluation Form
1 Comprehensive History, Consult, and Evaluation Form 1.Patient Information: Today s Date: Mr. Ms. Miss Mrs. Dr. Name Age: Date of Birth: Male Female Address: City/State/Zip: Home Phone: Work Phone: Cell
What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux)
What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux) What previous methods have you tried to alleviate your discomfort
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
Melatonin replacement and sleep program
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Facial Problem(s) Questionnaire
Facial Problem(s) Questionnaire Full Legal Name: _ Birth Date: Referred by: Referring Dr s Phone#: Referring Dr s Email address: _ Christopher M. Anderson, DMD 1225 Johnson Ferry Road Suite 660 Marietta,
SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
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
General Questionnaire
General Questionnaire Name: Date: Address:_ Home Phone: Alternate number: Occupation: Age: Height: Weight: Weight 6 months ago: At age 20: At your heaviest: Referring Physician: Family Physician: 1. In
Patient Information. Name: Date of Birth: Address: Number & Street City State Zip Code. Home Number: ( ) Cell Number: ( )
Patient Information Name: Date of Birth: Age: Address: Number & Street City State Zip Code Home Number: ( ) Cell Number: ( ) Social Security Number: Marital Status: Religion: Race: Height: Weight: Sex:
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:
Application for Patient
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PULMONARY & CRITICAL CARE CONSULTANTS OF AUSTIN 1305 West 34 th Street, Suite 400, Austin, TX Phone: Fax:
Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: 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.
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's
GENERAL QUESTIONS CONTACT INFORMATION
GENERAL QUESTIONS Purpose of this visit: Today s date: Are you currently experiencing any dental pain? Date of last dental visit: Date of most recent dental x-rays: CONTACT INFORMATION Last Name: Telephone
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:
Kingsland Family Dental Registration and Medical History
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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:
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
SLEEP QUESTIONNAIRE. Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone:
SLEEP QUESTIONNAIRE Name: Sex: Age: Date: DOB: / / SSN: - - Address: Referring Physician: Family Physician: Height: Weight: Neck Size: Phone: Please fill in the blanks, and check appropriate areas on the
(Must be completed with blue ink pen) Last Name First Name Date / / Address City Zip. Home Phone Cell Phone. Social Security# Driver s License # State
(Must be completed with blue ink pen) (MR #: ) Last Name First Name Date / / Address City Zip Home Phone Cell Phone Email Birthday / / Sex: M F Social Security# Driver s License # State Occupation Employer
Initial Visit Forms. Life in Motion Chiropractic & Wellness 6139 Route 96 -Suite 1 Farmington, NY (585)
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KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings
Family First Chiropractic
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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
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Patient History Form
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PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
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Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
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Denver, CO Welcome Packet
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Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
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New Practice Member Paperwork
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CHIROPRACTIC CENTER OF ANNAPOLIS 108 Old Solomons Island Rd., Bldg. 2 Annapolis, MD (410) Dr. William J. Boro Dr. Mary X.
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STEPHEN C. SNITZER, D.D.S.,
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Welcome to the Minnesota Craniofacial Center for TMJ & Sleep Treatment!
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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 Health & Wellness
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
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk PATIENT QUESTIONNAIRE
THE SLEEP DISORDERS CLINIC Medical Director: Dr Raymond Gottschalk 55 Frid Street, Unit 7, Hamilton, Ontario L8P 4M3 Phone:905-529-2259 Fax: 905-529-2262 282 Linwell Road, Suite 118, St. Catharines, Ontario
Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:
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PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
Molland Spinal Care, LLC 124 Hwy 35 South Red Bank, NJ Phone:
Molland Spinal Care, LLC 124 Hwy 35 South Red Bank, NJ 07701 Phone: 908-601-5600 Welcome to Molland Spinal Care, LLC. Enclosed please find the patient health questionnaire. Please fill out the parts that
Date. Patient General Information
Date John D. Belde, DC Jonas T. Johnson, DC Kelley McGowan, PT 211 Hwy 25, P.O. Box 717 Monticello, MN 55362 763.295.4105 Patient General Information Name Date of Birth Gender Address Social Security No.
Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
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
Chiropractic Case History/Patient Information
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Nashoba Valley Chiropractic (978)
(978) 448-2800 Last Name: First Name: MI: Mailing Address: City: State: Zip: O.K. to call home? Yes No Home Phone: O.K. to call cell? Yes No: Cell Phone: Sex M F Birthdate: Age: Marital Status: Single
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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:
New Practice Member Application
T 1 2 3 Date / / New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Cellular Provider Email Address Occupation Employer s Name Single / Married
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)
PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring
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CHIROPRACTIC PLUS Phone: (616) 791-9702 Dr. Daniel Ohlman Fax: (616)-791-4661 Applied Kinesiology 0-699 Tallmadge Woods Dr. N.W. Grand Rapids, Mi 49534 Date: Name: Date of Birth: Age: Preferred Name to
Emergency Contact Information Name: Phone: Address: Employer Information Employer Name: Address/Street: City: Zip: Phone: Fax:
SUNSET SLEEP LABS PATIENT INFORMATION FORM Patient Information Name: Sex: M F Date of Birth: Address/Street: City: Zip: Phone: Alt Phone: Parent/Guardian: Phone: Social Security Number: Drivers License:
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SIENA PROACTIVE INTERNAL MEDICINE DR. DEBORAH BLENNER 45 Terry Road, Suite B Smithtown, NY 11787 www.sienaproactive.com Phone: (631) 656-8171 Fax: (631) 656-8173 PATIENT INFORMATION Last Name: First Name:
APPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
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
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
Associated Neurological Specialties and Sleep Disorder Center
Sleep Center Questionnaire Name: Sex: Age: Date: Date of Birth: Height: Weight: Neck Size: Primary Care Physician: Referring Physician: Main Sleep Issues/Complaints Trouble falling asleep Trouble staying
NEUROPATHY CLIENT HISTORY AND LIFESTYLE INTAKE
NEUROPATHY CLIENT HISTORY AND LIFESTYLE INTAKE In order for us to completely evaluate your health status, please fill out the following pages. Be as thorough as possible. This allows us to assess your
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: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State: