Welcome to our office!
|
|
- Jessica Fowler
- 5 years ago
- Views:
Transcription
1 Welcome to our office! In just a short time from now, I ll get to meet you and discover how we may be able to help you with safe and natural NUCCA chiropractic care Until then, by completing the paperwork that follows, I ll be able to learn what has brought you to our office and how I might be able to help you Since I m going to ask you some personal information, it s only fair that I share some information about myself! I was introduced to chiropractic in 1994 after I was in a serious snowboarding accident I had tried traditional approaches to resolve the difficulty I had with my knee and walking but it wasn t until I visited a chiropractor that I got relief That inspired me to change my career path and become a chiropractor Just as I was making this life changing decision, I met the most wonderful woman in the world, Marie, and we got married in 1999 We started our family three years later and we ve been blessed with four active children; two outrageously smart and busy boys, Caden and Kaleb who keep us moving at all times, and two sweet princesses, Makaela and Kiara, who both have contagious smiles that welcome everyone they meet We want the best for them and cherish them more than anything in the world In the summer, you almost always will find me mountain biking somewhere In the winter, I m usually on my snowboard And on the off days, I love to hang out at the gym with my wife My family loves to join me as well and we have a lot of fun being active together It s one of my greatest joys! I love to be active and thanks to a healthy spine, I can enjoy the things I love to do! With all of the various physical, chemical, and psychological stressors present these days, my family and I see a chiropractor on a regular basis It keeps our nervous systems interference-free, our immune systems PRECISIONSPINALCARE life improved strong, and helps us do our best in all aspects of our lives I guess you could say it helps us live a life improved I want you and your family to experience the same Thank you for your trust and confidence I look forward to personally meeting you and seeing how we can help you achieve your individual health goals Yours in health, Dr Ryan Dr Ryan Brown p e d i a t r i c a d m i s s i o n f o r m! 1 of 2! # Sunpark Drive SE Calgary, AB T2X 3V info@precisionspinalcareca wwwprecisionspinalcareca TELEPHONE FACSIMILE WEBSITE
2 # Sunpark Drive SE Calgary, AB T2X 3V4 t Clinic Director ID# P Today s Date: M M / D D / Y E A R recision Spinal Care seeks to provide the highest quality chiropractic care available in an inviting and healing atmosphere, instilling the concept of true health and wellness We are committed to the health and wellness of your entire family Our practice members receive the highest quality of chiropractic care, following the Upper Cervical System approach of NUCCA protocol and procedures We hold ourselves to an exceptional level of care to those we take care of We provide a warm, nurturing environment for our members to begin their healing process, and to continue their journey of lifetime wellness care to experience true health through upper cervical chiropractic If we do not sincerely believe you will respond satisfactorily, we will not accept your case but will work to refer you to the appropriate health care provider GENERALINFORMATION Name Sex M F Address City Province Postal Code Whom may we thank for referring your child to us? Home Phone _ Date of Birth (mm-dd-yy) Age Parent/Guardian Phone Present Weight Present Height/Length Parent/Guardian Business Phone Parent/Guardian Name(s) Pediatrician/Doctor Date of Last Visit Reason Names of Siblings 1 Age 2 Age Parent/Guardian Address Would you like us to send reminders to you at the address above before your appointments? yes no If yes, how many days in advance? 1 2 Emergency Contact Name Emergency Contact Phone 3 Age 4 Age p e d i a t r i c a d m i s s i o n f o r m! 2 of 2!
3 L ife is a miracle and so are you You deserve to be healthy The human body is designed to be healthy When you were created, you were given all the blueprints, intelligence, tools, and systems to live an active and healthy life Unfortunately, throughout your life, your health can be interfered with through accidents and events that cause a disruption to your health expression With your commitment to improve your health and adopt chiropractic into your lifestyle, we will work to remove these interferences to your natural health expression so that you can live the quality of life you want and deserve CONDITIONPROFILE What is the primary reason for your child consulting our office? The child has no complaints, he/she is here for a wellness check-up 1 For how long? What are your expectations for your child receiving care in this clinic? What phrase most accurately reflects the reason for seeking care for your child? wellness prevention feel good symptom relief Have your child had similar problems in the past? no yes When? Does anything initiate the condition? Does anything aggravate the condition? Does anything relieve the condition? Is it worse in the morning or the night? morning night no change Is it constant? yes no Is this condition getting progressively worse? yes no it comes and goes Onset of problem was: sudden gradual associate with an event Explain Duration of problem: minutes hours days months years Other health concerns _ Has your child ever been to a chiropractor before? no yes When was the last visit? Reason for visit Doctor s name Please list other doctors that your child has consulted for these conditions Doctor s name Diagnosis Doctor s name Diagnosis Please list any prescription medications your child is currently taking for? for? for? for? Please list any antibiotics your child is currently taking or has previously taken never had antibiotics none at this time for? for? for? Please list any vaccinations your child has had and at what age Were there any negative no yes Explain reactions? Reason for vaccinations Please list any surgeries, hospitalizations, and/or broken bones your child has had for? for? for? for? Has your child ever been in an auto accident? never past year past 5 years over 5 years PRECISIONSPINALCARE p e d i a t r i c a d m i s s i o n f o r m! 1 of 3!
4 General History HEALTHPROFILE Childhood Illnesses Yes No? Yes No? Age Ear infections Chicken pox Asthma/allergies Rubella Colic Croup Scoliosis Digestive Fifth disease Thrush problems Bed wetting Measles ADHD Mumps Chronic colds Whooping cough Recurring fevers Scarlet fever Temper Other tantrums Headaches Seizures Birth History Pregnancy duration weeks Location of birth hospital birthing centre home midwife Assisted birth? no yes If yes - c-section induced labor forceps vacuum other Were medications given to mother during birth? no yes If yes, Duration of birth Complications at birth? what? no _ yes Explain Ultrasounds during yes no Was delivery normal? yes no Explain pregnancy? APGAR score don t know Birth weight Birth length Growth & Development Was the infant alert and responsive within 12 hours of yes no Explain delivery? At what age was your child able respond to sounds follow an object hold head up sit up alone to: crawl stand walk vocalize Do your child s sleeping patterns seem normal to you? yes no Explain STRESSPROFILE Since problems that Chiropractors concern themselves with can be related to many types of stresses, the following is very important to us: Chemical Stresses Was (is) the child breast-fed? no yes How long? Was formula no yes At what age? Type of formula used introduced? Introduced to cow s milk? no yes At what age? Introduced solids? no yes At what age? Food/Juice intolerance? no yes Type During the pregnancy, did the yes no Drink alcohol? yes no mother Did the mother have any illnesses during Smoke? the pregnancy? yes no Any pets at home? yes no Any smokers at home? yes no Psychosocial Stresses Any difficulties with yes no Any problems with bonding? yes no lactation? Any behavioral problems? yes no Onset Do you feel that your child s social and emotional development is normal for their age? yes no Explain Any of the following? night terrors? sleep walking? difficulty sleeping? other? Traumatic Stresses Any trauma during pregnancy (fall, accidents)? no yes Explain Was there any evidence of birth trauma to the child? Check all that apply: bruising stuck in birth canal odd shaped head respiratory depression fast birth excessively long birth cord around neck other Any falls from - couches beds change tables other Any trauma with - bruising cuts stitches fractures other _ Sports played and age started Is a school backpack used? no yes weight - heavy light don t know PRECISIONSPINALCARE p e d i a t r i c a d m i s s i o n f o r m! 2 of 3!
5 INFORMED CONSENT Our sole objective is to locate, analyze, and correct interference to the nervous system There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic In particular you should note: a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures; b) There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stoke Recent studies suggest that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke In essence, there is a stroke already in progress However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death The possibility of such injuries occurring in association with upper cervical adjustment is extremely remote; c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this Consent I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments I intend this consent to apply to all my present and future chiropractic care TO BE COMPLETED BY THE PRACTICE MEMBER/PARENT: Practice Member Signature X Date M M / D D / Y E A R Witness Signature X PREGNANCY RELEASE: This is to certify that to the best of my knowledge I am not pregnant and that I give permission to the doctors and/or licensed staff at PRECISIONSPINALCARE to perform an x-ray evaluation (if needed) I understand that x-rays pose a serious potential risk to the health and welfare of a developing child Signature X PRECISIONSPINALCARE life improved PRECISIONSPINALCARE p e d i a t r i c a d m i s s i o n f o r m! 3 of 3!
6 Directions to Our Office Sunpark Drive SE South on Deerfoot Trail Take the BOW BOTTOM TR SOUTH/ANDERSON RD WEST exit (exit 243) Take the ANDERSON RD WEST ramp Merge onto MACLEOD TRAIL SOUTH via the ramp on the LEFT Turn LEFT onto SUN VALLEY BLVD Take 2nd RIGHT onto SUNPARK DRIVE (right after Petro Canada gas station) Continue 1 block Building is on the RIGHT hand side Entrance is in the back of the building Office is on the main floor to the right as you enter the building South on Macleod Trail Turn LEFT onto SUN VALLEY BLVD Take 2nd RIGHT onto SUNPARK DRIVE (right after Petro Canada gas station) Continue 1 block Building is on the RIGHT hand side Entrance is in the back of the building Office is on the main floor to the right as you enter the building North on Highway #2 Turn RIGHT onto SUN VALLEY BLVD Take 2nd RIGHT onto SUNPARK DRIVE (right after Petro Canada gas station) Continue 1 block Building is on the RIGHT hand side Entrance is in the back of the building Office is on the main floor to the right as you enter the building PRECISIONSPINALCARE life improved
Child s Name Date Parent(s) Name Siblings Names(Ages) Address City Prov. Postal Code Home Phone( ) Bus Phone( ) Date of Birth Age Referred by
Please complete the following as completely as possible. If you need assistance, please ask the front desk staff and they will be glad to assist you. Child s Name Date Parent(s) Name Siblings Names(Ages)
More informationAnderson Chiropractic Group 300 Lakeshore Drive, Suite 102, Barrie, Ontario, L4N 0B4 (705)
Child s Health History Form Child s Name Date_ File# Parent(s) Name_ Siblings Names (Ages) Address City: _ Postal Code Phone: (H) (W): _ (C): _ Date of Birth_ Age Referred by Has your child ever received
More informationWelcome to our office!
Welcome to our office! In just a short time from now, I ll get to meet you and discover how we may be able to help you with safe and natural NUCCA chiropractic care Until then, by completing the paperwork
More informationPEDIATRIC HISTORY FORM
PEDIATRIC HISTORY FORM Today s Date: MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code:
More informationPediatric Health Story Form
Pediatric Health Story Form Child s Personal Information Name Age Date of Birth Gender: M F Home Address City State Zip Names and Ages of Siblings Parent A Name Home phone ( ) Cell phone ( ) Employer E-mail
More informationHEALTH 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:
More informationPatient Health Record
Name: Date: AHC #: Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email for appointment reminders and information regarding your
More informationPEDIATRIC PRE-EXAM INFORMATION
PEDIATRIC PRE-EXAM INFORMATION Name: Date of Birth dd /mm /YY Sex: M F Age Address Postal Code Mother s Name Home Phone: Occupation : Work Phone: Father s name Home Phone: Occupation: Work Phone: Siblings
More informationPediatric Chiropractic Intake Form (Children under 13) State: Zip Code:
Sunset Hills Family Chiropractic Dr. Brittany Warren, DC Dr. Robyn Kuhn, DC Dr. Nathan Free, DC 4600 S. Lindbergh Blvd., Suite 3. Saint Louis, MO 63127 Phone: 314-729-0027 / Fax: 314-729-1015 Pediatric
More informationChild History Form. Personal Information. Legal Guardian & Occupation: Home Phone: Alternate Phone: Provincial Health Care Plan
Child History Form (Ages 6-12) The data on this form is essential if we are to render the best professional care. We appreciate your cooperation in filling it out so that we will have accurate records.
More informationYour Goals and Expectations:
New Member Information: Aligned Health Chiropractic Dr. Jennifer Carauddo, D.C. 987 University Avenue, Suite 28 Los Gatos, CA 95032 (408) 371-6003 Fax (408) 371-6009 Today s Date / / Name Birth Date /
More informationDynamic Balance Chiropractic Adult New Patient Questionnaire
1. Please fill in the following Patient Information: Dynamic Balance Chiropractic Adult New Patient Questionnaire Patient Name Date Male Female Age D.O.B. Address City Province Postal Code Home Phone Work/Cell
More informationAdult Health Questionnaire
Health for Life Chiropractic At Cloverdale Mall Unit #143-250 The East Mall Etobicoke, ON, M9B 3Y8 416-232-1822 416-232-0060 Dr. Chrystopher Sly B.Sc, D.C. Dr. Jesse Cracknell B.A., D.C. Adult Health Questionnaire
More informationPEDIATRIC HISTORY FORM
PEDIATRIC HISTORY FORM CHILD S NAME: NICKNAME: SSN: BIRTHDAY: AGE: MALE FEMALE NAME OF PARENTS/GUARDIANS: ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL/WORK PHONE: EMAIL: HOW DID YOU FIRST HEAR OF CORRECTIVE
More informationThrive Family Chiropractic
Thrive Family Chiropractic Dr. Kaitlin Parker, DC 1121 S. Bowman, Suite C-3 Little Rock, AR 72211 501.712.1022 Pediatric Vitality Questionnaire Name: Date: Birth Date: Gender: Male Female Parent s phone
More informationSEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY
SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY Welcome! PLEASE PRINT CLEARLY PERSONAL DATA Today s Date First name MI: Last name: Nickname Gender M F Age Date of Birth SS# (optional) Current address
More informationPatient 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
More informationBrisbin 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
More informationH e a l t h S t o r y : I n f a n t / C h i l d P r a c t i c e M e m b e r. Vital Information
Vital Information Name Date / / Prefers to be called Birthday / / Age Gender F M Address City State Zip Parent(s)/Guardian(s) Names & Relationships Home # - - Work # - - Cell # - - Preferred contact #
More informationINNOVA Medical and Rehab Dr. Farhad Babakhani. BSc, DC, FCCRS, RAc # Elgin Mills Road East Richmond Hill, ON L4S 0B2
INNOVA Medical and Rehab Dr. Farhad Babakhani. BSc, DC, FCCRS, RAc #111-1650 Elgin Mills Road East Richmond Hill, ON L4S 0B2 Tel: (905) 884-2121 Fax: (905) 884-8845 PATIENT INFORMATION: Name: Address:
More informationCOMPREHENSIVE 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
More informationHEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT healinghandsdc.com
HEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT 06492 203-626-9994 healinghandsdc.com Child Intake Form PERSONAL INFORMATION Date Child s Name: Address Gender M F Age Birthdate City State Zip
More informationACTIVE 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
More informationCHIROPRACTIC 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
More informationWelcome to. Active Health Chiropractic
Dr. Darrell Voll, DC CACCP Welcome to Active Health Chiropractic Thank you for choosing our office. We are committed to providing you and your family with the highest quality of chiropractic care available
More informationWe look so forward to seeing you at your first visit! If you have any questions, don t hesitate to call us at (705)
Welcome to StoneTree, and to the first steps on your way to feeling better! Thank you for choosing us as a part of your health care team. Your Forms and Health History Your new patient intake forms are
More informationHamilton Back Clinic
Hamilton Back Clinic Intake Form Name: City: Address: Postal Code: Phone: Sex: M F Date of Birth: Month/Day/Year E mail: Emergency Contact: Name/Phone: Name of Family Physician (MD): Employer: Employer
More informationWELCOME 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
More informationDr. 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
More informationPEDIATRIC PATIENT QUESTIONNAIRE
2Dr. Stephanie Spiers DC, CACCP 9402 Towne Square Ave. Suite E Cincinnati, OH 45242 513-792-9111 www.brightfuturesfamilychiro.com PEDIATRIC PATIENT QUESTIONNAIRE Child s Name: Nickname: Date: Parent(s)
More informationWe Believe that you are Designed to be Extraordinary. (Office Use) Care Provider: Name: Date of birth (MM/DD/YY): Apt# City: Prov: PC:
(Office Use) Care Provider: Name: Date of birth (MM/DD/YY): Mailing address: Apt# City: Prov: PC: Phone: h) c) Email: Do we have your permission to send you our weekly health newsletter? Y N **You can
More information634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
More informationHome 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 #
More informationPERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
Patient# WELCOME Today s Date / / Please fill out this form as completely as possible. Please print. PERSONAL INFORMATION Name What you prefer to be called Age Date of Birth / / Sex SS# E-Mail Home Address
More informationName First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
More informationChild (0-17) New Patient Intake Form. Child s Health Summary
Child (0-17) New Patient Intake Form Child s Name Age Birth Date / / Soc. Sec. # - - Parent/Guardian Name: Address: City: State: Zip: Parent/Guardian Email: Parent/Guardian Phone: Whom may we thank for
More informationPatient Health Record
Patient Name: Date: AHC #: (required by the Alberta College of Chiropractors) Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email
More informationMVA Patient Health Record
Name: Date: AHC #: Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email for appointment reminders and information regarding your
More informationChild Intake Form. In case of emergency, contact: Relationship: Phone:
Personal Information Date: Child Intake Form Name of child: Sex: M F Age: Birth Date: Name of parent/guardian: Address: City: Province Postal code: Telephone (Home): (Work): (Cell): Email: Preferred contact
More informationBalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Health History Name Address City State Zip Day Phone Evening Phone E-mail Address Employer Birth Date Age Gender Emergency
More informationSincerely, Dr. Justin & Woodbury Spine Staff
Welcome to our office! We are sure that you will be provided the most appropriate and professional chiropractic care possible. Our most important goal is the constant improvement and maintenance of your
More informationRise Chiropractic 239 S. French Broad Ave Asheville, NC
Rise Chiropractic 239 S. French Broad Ave Asheville, NC 28801 828.989.8369 1 Name: of Birth: Age: Sex: M F Address: City/State: Zip: Phone: (H) (W) (C) SS# Email: Occupation: Employer: Marital Status:
More informationCONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
More informationPatient Intake Form - Child. Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling out this form? (name, relationhip):
Patient Intake Form - Child Dr. Daria Novy, ND 2-228 Second St. West Cornwall, ON K6J 1G7 T: 613 938-9500 F: 855 820-1240 Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling
More informationWelcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
More informationWelcome to Manna Family Chiropractic!
Welcome to Manna Family Chiropractic! Today s date Who should we thank for referring you here? Is your visit today regarding you, or your whole family? Family Just Me Your name Date of Birth Street Address
More informationHead to Heal Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian s Occupation:
More informationThis article attempts to answer the questions asked by many parents about their children s spinal health. Appearing in Issue #18. Order A Copy Today
Chiropractors have been caring for children for more than a 100 years. Many common childhood ailments will respond to this safe, natural form of health care. More and more parents especially those who
More informationCARY HOLISTIC HEALTH, LLC. Thank you for scheduling an appointment with Cary Holistic Health. Maggie Thibodeau, ND
Maggie Thibodeau, ND CARY HOLISTIC HEALTH, LLC 222 Ashville Avenue, Suite 10 / Cary, NC 27518 (919) 858-1004 / CaryHolisticHealth.com Thank you for scheduling an appointment with. We are located at 222
More informationPatient Introduction (age 13-21)
#204, 1740 Gordon Drive Kelowna, BC V1Y 3H2 250-868-4880 www.lifeworkschiropractic.ca wecare@lifeworkschiropractic.ca Patient Introduction (age 13-21) Personal History: Your Name: First (Nick-name) Last
More information! Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian
More informationDr. 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
More informationAUERBACH CHIROPRACTIC
AUERBACH CHIROPRACTIC ARTS AND SCIENCE Dr. Gary Auerbach 2730 N. Pantano Road Tucson, AZ 85715 Phone: 520-721-7177 Welcome to the office of Auerbach Chiropractic Arts and Science. In order to better serve
More information(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
More informationCOMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:
More informationFeil & Oppenheimer Psychological Services
Feil & Oppenheimer Psychological Services 260 Waseca Ave. Barrington, RI 02806 401-245-4040 Fax: 401-245-1240 feiloppenheimer@gmail.com Adult Patient Questionnaire Name: Today's Date: Address: Home Phone:
More informationCHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET ADDRESS: PROVINCE: HOME PHONE: (CHECK WHICH PREFERRED) WORK PHONE: EMAIL ADDRESS: NEW LEGISLATION REQUIRES THAT WE OBTAIN CONSENT PRIOR TO SENDING EMAILS TO
More informationCascadia Chiropractic Centre
Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital
More informationAdult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
More informationChild Intake Form (To be completed by the parent or guardian and returned to the clinic) Phone: Select.
NORTHEASTERN UNIVERSITY Speech, Language, and Hearing Center 30 Leon Street 503 Behrakis Health Science Center Boston, MA 02115 Ph: (617) 373-2492 Fx: (617) 373-8756 1 TODAY S DATE: Child Intake Form (To
More informationPATIENT ENTRANCE FORM
PATIENT ENTRANCE FORM Name _ Date Address City/ Province Postal Code Home Telephone Work Telephone Email Address Would like email reminders for appointments? Yes No Date of Birth (Day/Month/Year) Age Marital
More informationCHIROPRACTIC, PLLC. & Wellness Center. Terms of Acceptance
CHIROPRACTIC, PLLC & Wellness Center Terms of Acceptance When a member of Vital Chiropractic Center seeks chiropractic health care and we accept a member for such care, it is essential for both to be working
More informationAdult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
More informationCONSULTATION 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
More informationPatient Introduction Child (to age 12)
#204, 1740 Gordon Drive Kelowna, BC V1Y 3H2 250-868-4880 www.lifeworkschiropractic.ca wecare@lifeworkschiropractic.ca Patient Introduction Child (to age 12) Personal History: Your Name: First (Nick-name)
More informationNew 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.
More informationWELCOME TO The Chiropractors at Commerce Place
WELCOME TO The Chiropractors at Commerce Place For Office Use Only live well adjusted Doctor: Date: _ Referred by: MVA WCB Date of injury: Previous Chiro Care: Y / N Previous Chiro: _ Last adj date: Spine
More informationPERSONAL INFORMATION WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE PERSONAL INFORMATION We appreciate the opportunity to serve you. As we endeavour to ensure that your health outcomes are met, we ask you to assist us by completing the following information.
More informationCHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
More informationWELCOME TO OUR FAMILY!
WELCOME TO OUR FAMILY! We know you have many options for your wellbeing, and truly embrace that you have chosen us to take care of you and any other of your family members. Our goal is to provide you with
More informationToday 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
More informationRosewood Family Healing Center. New Patient Intake Form
Rosewood Family Healing Center New Patient Intake Form Print Name Date Email Date of Birth Age Phone Number Marital Status- M D S W Occupation # of hours/day at a desk Repetitive movements Who may we thank
More informationAn Interview with a Chiropractor
An Interview with a Chiropractor Doctor Scott Warner took the time out of his busy schedule to talk to us about chiropractic medicine what it is, what it isn t, and why he chose it as a profession. What
More informationCHILD INTAKE (Please Print Clearly)
Jeremy Hayman, ND CHILD INTAKE (Please Print Clearly) Doctor of Naturopathic Medicine Child s name (First/Last) Date of birth (M/D/Y) Sex M F Referred by Who is filling out this form (name and relation)?
More informationAvicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s email address: Date of Birth: Gender: How did you hear about this clinic?
More informationNPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address: Gender: Date of Birth: Occupation: Best Time to Contact: Number of
More informationWritten by Tricia Arndt, DC, DACCP Thursday, 01 March :00 - Last Updated Wednesday, 19 March :00
Ouch! My legs hurt, Mommy! Have you ever had your child wake up in the middle of the night complaining of leg pains? Do you remember having them as a child? These are commonly referred to as growing pains
More informationNPM INTAKE FORM. INFORMATION: Name: Age: Date: Home Phone No.: Work Phone No: Cell Phone: Address:: Gender: Date of Birth:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
More informationChiropractic 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
More informationNPM INTAKE FORM INFORMATION: Name: Age: Date:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
More informationPEDIATRIC Patient Intake Form
PEDIATRIC Patient Intake Form Dr. Amy Henehan, BA, ND Naturopathic Doctor Newcastle Family Chiropractic 10 King Ave. East, Newcastle, ON L1B 1H6 Last Name First Name Middle Name Date Date of Birth M/D/Y
More informationPlease complete this profile, the answers will help determine if Chiropractic can help your child. Child s Name: Parent 1 Name: Parent 2 Name:
Pediatric Patient Profile Dear Parent: Please complete this profile, the answers will help determine if Chiropractic can help your child. Personal Information Date: Child s Name: Parent 1 Name: Parent
More informationPATIENT INFORMATION HEALTH INFORMATION
PATIENT INFORMATION PLEASE PRINT PATIENTS LAST NAME FIRST NICKNAME STREET ADDRESS APT # TODAYS DATE / / CITY STATE ZIP E-MAIL SEX M F MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DOB / / AGE SPOUSES
More information3. 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:
More informationPavilion Pediatrics at Green Spring Station, P.A Falls Road, Suite 260 Lutherville, Maryland Phone (410) Fax (410)
Date Provider Patient Name: Pavilion Pediatrics at Green Spring Station, P.A. 10755 Falls Road, Suite 260 Lutherville, Maryland 21093 Phone (410)583-2955 Fax (410)583-2962 Patient Questionnaire Sex: Date
More informationInsurance. 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
More informationADOLESCENT FLUENCY CASE HISTORY
COLLEGE OF ARTS & SCIENCES Department of Communication Sciences and Disorders Speech-Language-Hearing Clinic 3750 Lindell Blvd., Suite 32 St. Louis, MO 63108 Ph 314-977-3365 F 314-977-1615 ADOLESCENT FLUENCY
More informationNew Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
More informationHEALTH 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:
More informationWho? 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
More informationCHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
More informationPATIENT 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
More informationNew Pediatric Patient Information
Arden Yingling, L.Ac., MAcOM (TX #AC01588) 9300 US 290, Austin TX 78736 512.640.9778 arden@songbirdacupuncture.com songbirdacupuncture.com New Pediatric Patient Information Child's Name Today s Date Birth
More informationSydney 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
More informationBalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Chiropractic Intake Form Name Date Address City State Date of Birth Age Phone Email Address Employer Emergency Contact Phone
More informationPediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
www.monctonnaturopathic.com 12 Fifth Street, Moncton, NB, E1E 3G9 Ph: 506-382-1329 Fax: 506-382-1828 Pediatric Intake Form (6-12 years) Name: Date: Age: Date of Birth: / / Gender (circle one): female or
More informationDate of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
More informationWelcome to our Family Chiropractic Office
Welcome to our Family Chiropractic Office Thank you for choosing our office for chiropractic care. We are committed to providing your family with the highest quality of corrective and wellness chiropractic
More informationWho may we thank for referring you?
NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
More informationBody 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.
More information