List the health concerns that brought you into this office
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- Lewis Morrison
- 5 years ago
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1 New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Address 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 the health cncerns that brught yu int this ffice Health Cncern: Rate f Severity When did Have yu had the Did the Are symptms List accrding 0 = n pain this prblem prblem befre? prblem begin cnstant (C) r t severity. 10 = unbearable start? If s, when? with an injury? intermittent (I)? A: B: C: D: Have yu ever seen ther dctrs fr these cnditins? Yes N If Yes: Chirpractr Medical dctr Other Wh? When? Results? Please Mark P Fr In The Past OR Mark C Fr Currently Have: Headaches Ear Infectins Sinus Issues Kidney Prblems Sexual Dysfunctin Migraines Hearing Lss Frequent Clds Bladder Prblems Sleep Prblems Jaw/TMJ Pain Ringing in the Ears Thyrid Issues Menstrual Prblems Tight/Sre Muscles Neck Pain Dizziness Asthma Prstate Prblems Sprts Injury Shulder Pain Lss f Energy Chest Pain Infertility Sciatica Arm Pain Nervusness Heart Prblems Fibrmyalgia Arthritis/Jint Pain Upper Back Pain Duble/Blurry Visin Nausea Epilepsy/Cnvulsins GERD/Gastric Reflux Mid Back Pain Anxiety Ulcers Tremrs Numb/Tingling in Arms/Hands Lwer Back Pain ADD/ADHD Digestive Issues Disc Prblems Numb/Tingling in Legs/Feet Hip/Leg Pain Lss f Balance Diarrhea Sclisis Stmach Prblems Knee Pain Depressin Cnstipatin Pr Psture High/Lw Bld Pressure Ft Pain Allergies Bed Wetting Skin Prblems Difficulty Breathing Other: Page 1
2 Please Mark P Fr In The Past OR C Fr Currently Have: Strke Cancer Heart attack Spinal Surgery Spinal Bne Fracture Sclisis Diabetes Arthritis Seizures Other Cnditins List all surgical peratins & years: List any ther injuries t yur spine, minr r majr, that the dctr shuld knw abut: List all ver the cunter & prescriptin medicatins yu are n, & the reasn fr each: Have yu ever been in an aut accident? List all: Have yu ever been kncked uncnscius? Yes N Explain Fractured A Bne? Yes N Explain: Other trauma: Scial Histry 1. Smking: Hw ften? Daily Weekends Occasinally Never 2. Alchl: Hw ften? Daily Weekends Occasinally Never 3. Exercise: Hw ften? Daily Weekends Occasinally Never 4. Have yu cnsumed any caffeine r prducts with caffeine in the past 48 hurs? Yes N Quadruple Visual Analgue Scale Please circle the number that best describes the questin asked. If yu have mre than ne cmplaint, please answer each questin fr each individual cmplaint listed n page ne and indicate the crrespnding letter abve EXAMPLE: N pain A B Wrst pssible pain 1. Hw wuld yu rate yur pain RIGHT NOW? 2. What is yur typical r AVERAGE pain? 3. What is yur pain level at its BEST? (Hw clse t 0 des yur pain ever get?) 4. What is yur pain level at its WORST? (Hw clse t 10 des yur pain get at its best?) Health Gals Please list yur tw main health gals that yu wuld like t achieve while under care in this ffice: Page 2
3 Family Health Histry This frm is t assist the dctrs by prviding past health histry infrmatin fr their review. CONDITION SPOUSE MOTHER FATHER SON DAUGHTER Headaches Neck Pain Jaw/TMJ Pain Shulder Pain Back Pain Hip/Leg Pain Arthritis/Jint Pain Ear Infectins Hearing Lss Dizziness Lss Of Energy Nervusness Blurred/Duble Visin Anxiety ADD/ADHD Depressin Allergies Sinus Issues Thyrid Prblems Asthma Breathing Prblems Heart Prblems High/Lw Bld Pressure Stmach Prblems Infertility Bed Wetting Sciatica Sleep Prblems Strke Fibrmyalgia Pr Psture Alzheimer s Diabetes Heart Disease Cancer Page 3
4 ACTIVITIES OF LIFE Please identify hw yur current cnditin is affecting yur ability t carry ut activities that are rutinely part f yur life: CIRCLE 3 activities that affect yu the mst n a day t day basis. Climb Stairs Walk Run Sleep Dress Carry Grceries Pet Care Drive Lift Extended Cmputer Use Husehld Chres Read/Cncentrate Shaving Sweep Vacuum Dishes Laundry Yard Wrk Static Standing Static Sitting Page 4
5 Practice Member Infrmatin (Must be Cmpleted Befre Services Can Be Rendered) 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: SOCIAL SECURITY NUMBER: CONTACT IN CASE OF EMERGENCY: Phne #: 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 $20-$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. $10-$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. $25 per view. Release f Authrizatin/Assignment f Benefits I authrize and request payment f insurance benefits directly t Juan Munz 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 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 (HIPPA). 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 physician s certificatins. I acknwledge that I may request yur NOTICE OF PRIVACY PRACTICES 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 disclse 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: Page 5
6 INFORMED CONSENT Yu have a right, as a patient, t be infrmed abut the cnditin f yur health and the recmmended care and treatment t be prvided t yu s that yu can make the decisin whether r nt t underg such care with full knwledge f the knwn risks. This infrmatin is intended t make yu better infrmed in rder that yu can knwledgeably give r withhld yur cnsent. THE NATURE AND PURPOSE OF CHIROPRACTIC Chirpractic is predicated n the science which cncerns itself with the relatinship between structures (primarily the spine) and functin (primarily f the nerve system) f the bdy and hw this relatinship can affect the restratin and preservatin f health. The fllwing infrmatin is rutinely furnished t all wh cnsider Chirpractic care and treatment in this clinic. Adjustments are made by Chirpractrs in rder t crrect spinal and extremity jint subluxatins. One f the mst cmmn disturbances t the nerve system is the vertebral subluxatin. This cnditin is where ne r mre vertebra in the spine is misaligned sufficiently t cause interference and/r irritatin t the nerve system. The primary gal in Chirpractic health care is the remval f nerve interference caused by subluxatin. A Chirpractic examinatin will be undergne which may include spinal and physical examinatin, rthpedic and neurlgical testing, palpatin, specialized instrumentatin, and radilgical examinatin (x-rays). The Chirpractic adjustment is the applicatin f a precise, high velcity mvement f the spine ver a very shrt distance. There are a number f different methds r techniques by which the Chirpractic adjustment is delivered. Chirpractic adjustments can be delivered by hand, but will be delivered using an instrument r ther specialized equipment at Inside-Out Family Chirpractic. CONSENT FOR CHIROPRACTIC CARE I have been infrmed f the nature and purpse f Chirpractic care, the pssible cnsequences f care, and the risks f care, including the risk that care may nt accmplish the desired bjective. I have been advised f the pssible cnsequences if n care is received. I acknwledge that n guarantees have been made t me cncerning the results f the care and treatment. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE INSIDE-OUT FAMILY CHIROPRACTIC TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT. PRINT NAME HERE SIGNATURE FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT INSIDE-OUT FAMILY CHIROPRACTIC. DATE SIGNATURE WITNESS SIGNATURE (OFFICE STAFF) DATE DATE If this health prfile is fr a minr/child, please fill ut and sign belw: Written Cnsent Fr A Child Name f practice member wh is a minr/child: I authrize Dr. Juan Munz and any and all Inside-Out Family Chirpractic staff t perfrm diagnstic prcedures, radigraphic evaluatins, render chirpractic care and perfrm chirpractic adjustments t my minr/child. As f this date, I have the legal right t select and authrize health care services fr my minr/child. If my authrity t select and authrize care is revked r altered, I will immediately ntify Navigate Chirpractic. Guardian Signature: Date: Relatinship t minr/child: Page 6
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phne: Hme Cell_ Date f Birth / / Email Address Fr cnfirming appintments, wuld yu prefer? EMAIL r TEXT CELL PROVIDER IS Occupatin Emplyer s Name Single
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
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
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 /
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
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
Health for Life Chiropractic At Cloverdale Mall Unit # The East Mall Etobicoke, ON, M9B 3Y
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Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn
Myrtle Grove Chiropractic & Acupuncture Center
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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
LIST YOUR HEALTH CONCERNS BELOW
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ADIO CHIROPRACTIC HEALTH PROFILE
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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:
Patient Name: Date: Address City/State Zip Code. Home. Phone Cell: Work.
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm Patient Name: Date: Address City/State Zip Cde Hme. Phne Cell: Wrk. Email Address: Sex: M F (Please circle) Date f Birth: Referred by:
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
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
Revelation Chiropractic Health Profile
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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
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
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LIST YOUR HEALTH CONCERNS BELOW
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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
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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
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
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Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Occupation Employer
Milham Family Chirpractic Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex M F Marital Status M S D W Date f Birth Age Occupatin Emplyer Referred by: Have yu ever received Chirpractic
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Personal Information Date:
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New Practice Member Application
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New Practice Member Application
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