LIST YOUR HEALTH CONCERNS BELOW
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- Clement Doyle
- 5 years ago
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1 Name Date / / Age Male/Female Address City State Zip Phne: Hme Cell_ Date f Birth / / Address Fr cnfirming appintments, wuld yu prefer? r TEXT CELL PROVIDER IS Occupatin Emplyer s Name Single / Married / Divrced / Widwed Spuse s Name Number f Children Names, Ages & Gender Wh may we thank fr referring yu? LIST YOUR HEALTH CONCERNS BELOW Health Cncerns: List accrding t severity Rate f Severity 1 = mild 10 = unbearable When did this episde start? If yu had the cnditin befre, when? Did the prblem begin with an injury? Are symptms cnstant r intermittent? HAVE YOU EVER SEEN OTHER DOCTORS FOR THESE CONDITIONS? YES / NO CHIROPRACTOR? MEDICAL DOCTOR? OTHER WHO AND WHEN? CIRCLE ALL CURRENT PROBLEMS YOU HAVE: DIZZINESS THROAT ISSUES KIDNEY PROBLEMS LIVER DISEASE NERVOUSNESS HEADACHES THYROID PROBLEMS MID BACK PAIN SHOULDER PAIN EPILEPSY VERTIGO ASTHMA IRRITABLE BOWEL CHRONIC FATIGUE DISC PROBLEM EAR INFECTIONS ULCERS SCIATICA LUPUS INFERTILITY NAUSEA NUMBNESS IN ARMS NUMBNESS IN LEGS FIBROMYALGIA GASTRIC REFLUX TMJ NUMBNESS IN HANDS NUMBNESS IN FEET CHEST PAIN NECK PAIN MENSTRUAL DISORDER LOW BACK PAIN ARM PAIN OTHER MIGRAINES HEART DISORDERS HIP PAIN ADD/ADHD ANXIETY STOMACH DISORDERS LEG PAINS CHRONIC SINUS BLADDER PROBLEMS KNEE PAIN
2 CIRCLE ANY CONDITION YOU HAVE NOW/ HAVE HAD: STROKE CANCER HEART DISEASE SPINAL SURGERY SEIZURES SPINAL BONE FRACTURE SCOLIOSIS DIABETES LIST ALL SURGICAL OPERATIONS AND YEARS LIST ALL Over the Cunter & PRESCRIPTION MEDICATIONS YOU ARE ON: WHEN WAS YOUR LAST AUTO ACCIDENT HAVE YOU HAD PREVIOUS CHIROPRACTIC CARE? YES / NO IF YOU HAVE, DR. & HAVE YOU EVER BEEN KNOCKED UNCONCIOUS? YES / NO FRACTURED A BONE? YES / NO IF YES, PLEASE DESCRIBE OTHER TRAUMA: What are sme health gals that yu hpe t achieve under chirpractic care? IF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOW NAME OF PRACTICE MEMBER WHO IS A MINOR/CHILD I AUTHORIZE DR. JOSH ALBRECHT AND ANY AND ALL IGNITE CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD. AS OF THIS, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY IGNITE CHIROPRACTIC. WITNESS SIGNATURE _ GUARDIAN SIGNATURE GUARDIAN S RELATIONSHIP TO MINOR / CHILD
3 AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF YOUR X-RAYS IN OUR FILES. THE FEE FOR COPYING YOUR X-RAYS IS $ THIS FEE MUST BE PAID IN ADVANCE. DIGITAL X-RAYS ON CD WILL BE AVAILABLE WITHIN 72 HOURS OF PREPAYMENT ON ANY REGULAR PRACTICE HOURS DAY. PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF IGNITE CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE. BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS. PRINT YOUR NAME HERE SIGNATURE YOUR AGE FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT IGNITE CHIROPRACTIC. SIGNATURE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE DO NOT WRITE BELOW THIS LINE Sex: M F Lat Cervical Flex/Ext / / / / /15 40 MA 300 Size 8x10 APOM / / / / MA 300 Size 8x10 Lwer Cervical / / / / MA 300 Size 8x10 Other View CM Kvp MAS MA Size Ntes: Lateral Thracic / / / / / / / /2 150 MA 300 Size14x17 Lateral Lumbar / / / / / / / /2 2 MA 200 Size 14x17 CA Initials: A-P Thracic / / / / / / / /5 120 MA 300 Size14x17 A-P Lumbar / / / / / / / / / / /2 2 MA 300 Size 14x17
4 Practice Member Infrmatin (Must be Cmpleted Befre Services Can Be Rendered) NAME: FIRST MIDDLE LAST PHONE: Hme Cell Wrk SOCIAL SECURITY NUMBER: MARITIAL STATUS: OF BIRTH: CONTACT IN CASE OF EMERGENCY: Phne #: NAME OF PRIMARY INSURANCE CARRIER: Name f Insured Insured Date f Birth Insured Scial Security Number NAME OF SECONDARY INSURANCE CARRIER: Name f Insured Insured Date f Birth Insured Scial Security Number: Insurance Plicies and Fee Schedule Cnsultatin- includes practice member histry. This service is cmplimentary Assessment (new r established practice member)- includes ne r mre f the fllwing: thermgraphy, surface electrmygraphy, range f mtin, mtin and/r static palpatin, leg check $50-$80. Chirpractic Adjustment- The actual re-alignment f the vertebra dne by hand. Often a sund will be heard, but if there is n auditry result, it des nt mean that the adjustment has nt taken place. $40-$50. X-rays- Specific x-ray views taken f yur spine t determine a misalignment/subluxatin f yur vertebrae. These can als be used t indicate prgress after perid f care. $50 per view. Release f Authrizatin/Assignment f Benefits I authrize and request payment f insurance benefits directly t Jsh Albrecht DC. I agree that this authrizatin will cver all services rendered until I revke the authrizatin. I agree that a phtcpy f this frm may be used in place f the riginal. All prfessinal services rendered are charged t the patient. It is custmary t pay fr services when rendered unless ther arrangements have been made in advance. I understand that I am financially respnsible fr charges nt cvered by this assignment. Signed Date
5 In rder t prvide fr the mst effective healing envirnment, mst effective applicatin f chirpractic prcedures, and the strngest pssible dctr-patient relatinship, it is ur wish t prvide each patient with a set f parameters and declaratins that will facilitate the gal f ptimum health thrugh chirpractic. T that end, we ask that yu acknwledge the fllwing pint regarding chirpractic care and the services that are ffered thrugh this clinic: A. Chirpractic is a very specific science, authrized by law t address spinal health cncerns and needs. Chirpractic is a separate and distinct science, art and practice. It is nt the practice f medicine. B. Chirpractic seeks t maximize the inherent healing pwer f the human bdy by restring nrmal nerve functins thrugh the adjustment f spinal subluxatin(s). Subluxatins are deviatins frm nrmal spinal structures and cnfiguratins that interfere with nrmal nerve prcesses. C. The chirpractic adjustment prcess, as defined in the law f this jurisdictin, invlves the applicatin f a specific directinal thrust t a regin r regins f the spine with the specific intent f re-psitining misaligned spinal segments. This is a safe, effective prcedure applied ver ne millin times each day dctrs f chirpractic in the United States alne. D. A thrugh chirpractic examinatin and evaluatin is part f the standard chirpractic prcedure. The gal f this prcess is t identify any spinal health prblems and chirpractic needs. If during this prcess, any cnditin r questin utside the scpe f chirpractic is identified, yu will receive a prmpt referral t an apprpriate prvider r specialist, accrding t the initial indicatins f the need. E. Chirpractic des nt seek t replace r cmpete with yur medical, dental r ther type(s) f health prfessinals. They retain respnsibility fr care and management f medical cnditins. We d nt ffer advice regarding treatment prescribed by thers. F. Yur cmpliance with care plans, hme and self-care, etc., is essential t maximum healing and ptimal health thugh chirpractic G. We invite yu t speak frankly t the dctr n any matter related t yur care at this facility, its nature, duratin, r cst, in what we wrk t maintain as a supprting, pen envirnment. By my signature belw, I have read and fully understand the abve statements. All questins regarding the dctr s bjectives pertaining t my care in this ffice have been answered t my satisfactin. I therefre accept chirpractic care n this basis. _ (Signature) (Date) Ntice f Privacy Practices Acknwledgement I understand that I have certain rights f privacy regarding my prtected health infrmatin, under the Health Insurance Prtability & Accuntability Act f 1996 (HIPAA). I understand that this infrmatin can and will be used t: 1. Cnduct, plan and direct my treatment and fllw-up amng the multiple healthcare prviders wh may be invlved in that treatment directly and indirectly. 2. Obtain payment frm third-party payers. 3. Cnduct nrmal healthcare peratins, such as quality assessments and physicians certificatins. I acknwledge that I may request yur NOTICE OF PRIVACY PRATICES cntaining a mre cmplete descriptin f the uses and disclsures f my health infrmatin. I als understand that I may request, in writing, that yu restrict hw my private infrmatin is used t disclsed t carry ut treatment, payment, r healthcare peratin. I als understand yu are nt required t agree t my requested restrictins, but if yu agree, then yu are bund t abide by such restrictins. _ (Signature) (Date)
6 CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE. PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE. I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT. PRINT PRACTICE MEMBER S NAME HERE PRACTICE MEMBER S SIGNATURE IF PRACTICE MEMBER IS A MINOR/CHILD, PARENT OR GUARDIAN MUST SIGN BELOW. SIGNATURE OF PRACTICE MEMBER OR GUARDIAN RELATIONSHIP TO MINOR/CHILD WITNESS SIGNATURE (OFFICE STAFF)
7 THIS FORM IS TO ASSIST THE DOCTORS BY PROVIDING PAST HEALTH HISTORY INFORMATION FOR THEIR REVIEW. PLEASE PRINT YOUR NAME HERE CONDITION SPOUSE SON DAUGHTER MOTHER FATHER ARM PAIN ARTHRITIS ASTHMA ADD/ADHD ALLERGIES BACK TROUBLE BED WETTING CANCER CARPAL TUNNEL DECEASED DIABETES DIGESTIVE PROBLEMS DISC PROBLEMS EAR INFECTIONS FIBROMYALGIA HEADACHES HEARTBURN HIGH BLOOD PRESSURE HIP PAIN LEG PAIN MENSTRUAL DISORDER MIGRAINES NECK PAIN SCOLIOSIS SHOULDER PAIN SINUS TROUBLE TMJ
Reach Chiropractic Health Profile
Reach Chirpractic Health Prfile NameDate / / Age Male/Female Address City State Zip Phne: Hme Cell Cell Phne Prvider Date f Birth / / Email Address_ OccupatinEmplyer s Name Single/Married/Divrced/Widwed
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
Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)
Name_ Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon) For reminders do you prefer Phone Calls, Text Messages or Emails? CALL ME / TEXT ME / EMAIL ME Email Address
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
LIST YOUR HEALTH CONCERNS BELOW
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
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:
Etio Chiropractic Health Profile
Eti Chirpractic Health Prfile Persnal Infrmatin Name Street Address City State Zip Birth Date Date Primary Phne Secndary Phne Email Gender Marital Status Occupatin Family member name(s) and age(s): Hw
When&did&& this&episode&start?&
GreaterLifeChirpracticHealthPrfile NameDate / / Age Male/Female Address City State Zip Phne:Hme Cell CellPhnePrvider DatefBirth / / EmailAddress_ OccupatinEmplyer sname Single/Married/Divrced/Widwed Spuse
Current Health Information
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
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
LIST YOUR HEALTH CONCERNS BELOW
LOCATION COMING SOON Lakewood Ranch, FL 32402 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 Position Single
LIST YOUR HEALTH CONCERNS BELOW
T 1 2 3 ROOTS CHIROPRACTIC HEALTH PROFILE In Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Work Email Address Date of Birth / / Occupation Employer's Name Single / Married / Divorced
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
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
New Practice Member Paperwork
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Practice Member Profile
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LIST YOUR HEALTH CONCERNS BELOW
Date / / HEALTH PROFILE T C E X Name D.O.B. / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Carrier: Email Address Occupation Employer s Name _ Single / Married / Divorced / Widowed
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
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
Who 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 /
New 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 /
Revelation Chiropractic Health Profile
Revelation Chiropractic Health Profile Name Date / Age Male / Female Address Apt City Zip Phone Numbers: Home Cell Circle best number to reach you at: Home Cell Date of Birth / / Occupation Email Address
List the health concerns that brought you into this office
New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Email Address Occupatin Emplyer s Name Single / Married / Divrced / Widwed
Who may we thank for referring you? When did this episode start?
NEW PRACTICE MEMBER APPLICATION 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
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Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
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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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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
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Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Describe the pain and it s location:
WELCOME TO ZIVKOVIC CHIROPRACTIC CENTER DATE: Please print clearly and fill in completely. ABOUT YOU: Patient Name:_ What do you prefer to be called:_ SS# Street Address City State Zip Date of Birth: Age:
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
When!did!! this!episode!start?!
New Hope ChiropracticHealthProfile Name Date / / Age Male/Female Address City State Zip Phone:Home Cell CellPhoneProvider DateofBirth / / EmailAddress_ OccupationEmployer sname Single/Married/Divorced/Widowed
Luker Chiropractic Health Questionnaire
Luker Chiropractic Health Questionnaire Name: D.O.B.: Address: City: State: Zip: Home Phone: Cell: Email: Male/Female Marital Status: M W D S Age: SS# Occupation: Employer: Spouse Name: # of Children:
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Race: Marital: M S W D Occupation: Office Phone:
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
APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
Today s Date: APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC PATIENT DEMOGRAPHICS Name: Birth Date: / / Age: Male Female Address: City: State: Zip: E-mail Address: Home Phone: Cell Phone: Martial
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:
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s
PATIENT 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
Chiropractic Health Dr. Art Vanderhoef
Patient Information Form Chiropractic Health Dr. Art Vanderhoef File # Name Address City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Email Address How do you prefer to be contacted? Mail Home
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
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
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.
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
EAST VALLEY DERMATOLOGY CENTER
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PERSONAL INFORMATION. First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip:
ADULT INTAKE FORM Date: PERSONAL INFORMATION First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip: Cell Phone: ( ) Alternate Phone: ( Text Reminders: Y N Before
New Practice Member Application
i New Practice Member Application PATIENT DEMOGRAPHICS Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Would you like to receive text reminders for your appointments? Cellular
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:
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
Family First Chiropractic
Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female
Child s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT
Date f Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Prtable Medical Summary Name: Date Updated: / / Address: Phne: Mbile: E-mail: DOB: SSN: - - Allergies: Pertinent Persnal Characteristics: What
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
Ages 6 to E. Lohman Ave Ste 22 Las Cruces, NM (575) Today's Date: Date of Birth: Phone Number with Area Code:
3961 E. Lohman Ave Ste 22 Las Cruces, NM 88011 (575) 652-3358 Ages 6 to 18 Today's Date: Name: Date of Birth: Sex: Male Female Mailing Address: Parent/Guardian Names & Phone Numbers: Phone Number with
Welcome To Corporate Chiropractic Works!
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PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*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
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
7035 Beracasa Way, Suite 103 Boca Raton Florida, 33433 Phone# (561)674-1217 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name middle Address City State Zip Date of Birth Age Social Security
Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Tassin Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Welcome to our Family Chiropractic Office
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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,
Assessment Field Activity Collaborative Assessment, Planning, and Support: Safety and Risk in Teams
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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
Welcome 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
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
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
Patient Name Date of Birth. Address. City State Zip. Cell Phone Work Phone Home Phone . SSN Employer Name Employer Number.
Waldrf Peridntics & Implants Amal Rastgi, DMD, MSD, PhD Cary Bly, DDS, MSD Bard Certified Specialists in Peridntlgy 11855 Hlly Lane #106 Waldrf, MD 20601 301-645-3100 (F) 301-885-0600 waldrfperidntics@yah.cm