What is your present motivation for consulting our office? Vital Information (Adult)
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- May Manning
- 5 years ago
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1 What is your present motivation for consulting our office? Heal disease, symptoms and infirmities (ill-health) Preventing disease, symptoms and infirmities (ill-health) Improving family and/or community health Maximizing personal health potential Vital Information (Adult) Date First Name Last Name Address City Province Postal Code address Mobile Phone Home Phone Business Phone ext Date of Birth: D /M /Y Age: Height: Feet Inches Weight: lbs Who is your current employer? Occupation? Marital Status: Married Common Law Single Widowed Divorced Which best describes your current feeling about yourself and your situation? (circle) a) I feel helpless, it seems little or nothing works. b) This feels terrible, I am scared and hope you can fix it for me. c) I feel stuck, and can t help myself right now d) I deserve more than I have been experiencing with my body and would like you to assist me in my healing. e) Anything else?
2 Name: DOB: Date: Medical History Name of Medical Doctor: MD s phone number: Date and reason for last visit to medical doctor: (symptoms, diagnosis, treatment, outcome) Do you have any other medical conditions that you are under a doctor s care for? Please list any medications that you are currently taking (reason & duration) Please list any medications used in the past for more than three months and their purpose Please list any procedures or treatments received at a hospital Family Health Spouse s Name: Age: Occupation: Spouse s ongoing Health Problems: If deceased, cause: Date: Mother Age Health Problems If deceased, Cause Age of Death Father Brothers & Sisters Children Have you ever had cancer? Yes No What kind? When? Did you have radiation or chemotherapy? Yes No Current Status: With any of your medical conditions, have you ever been told not to eat certain foods or vitamins? Yes No Please List Do you work with any chemicals? Yes No Do you have any allergies? Yes No What kind?
3 Health Concerns Check any of the following symptoms you have experienced in the past 6 months: Low back pain Neck pain Difficulty sleeping/non restorative sleep Tension/Migraine headaches Fallen arches (flat feet) Tension across top of shoulders Asthma Pain between shoulder blades Arthritis Numbness/tingling in arms/hands High Cholesterol Numbness/tingling in legs or feet High blood pressure Anxiety/depression Frequent colds/flus Difficulty with stress Poor mental focus/concentration Digestive problems (gas, bloating, heartburn, indigestion) Low energy/tired/fatigue Weight trouble Nervousness/excessive worry/fear Elimination problems (<2 bowel movements/day) Ringing in ears What concerns do you have about your health and well being? Please list in order of importance. Please answer the following questions with respect to your most important concern: In what part of your body do you experience your concern (symptoms)? Does your symptom travel to anywhere else in your body? Y N If Yes, where? What does this symptom feel like? Please check any that apply: Sharp Stabbing Dull Achy Numb Tingling Burning Cold Pins & Needles Electricity Other (specify): When did this symptom begin? What happened? How has this symptom changed over time? Worse Better No Change How often does this symptom occur? When your symptom is present, how long does it last? On the scale below, please mark the level of severity you most consistently feel, 0 = no symptoms 10 = the worst you can imagine What makes this symptom better? What makes this symptom worse?
4 Why do you think you are experiencing this symptom? If you didn t have this symptom what would be different in your life? Are there any other related or associated concerns? Have you ever experienced this symptom or something similar in the past? Y N If Yes, please describe Have you sought advice or treatment from a health professional? Y N If Yes, what were you told? What was done? Did it seem to work? Y N Initial Nervous System Profile Do you have any concerns about your Nerve System and Spine that we should know about? When was your most recent auto accident? What speed was the collision? Type of impact: Front Impact / Side Impact / Rear Impact Was treatment received? Please describe When was your most recent strain/stress at work? Please describe the manner of the injury Was treatment received? Please describe Does your job require you remain in long-term stressful postures? (i.e. all day seating, repeated lifting, long-term computer use) Spinal traumas in the past? Collision, quick burst, or repetitive motion sports: hockey, football, wrestling, basketball, baseball, soccer, tennis, golf, track and field Trauma as a child! i.e. fall on your head, impact to your head, concussion, fall onto your back or tailbone, biking accident Health and Lifestyle How many hours of sleep do you get? What is the quality? Low Med High Please rate your: Great OK Dissatisfied Ability to Fall Asleep Ability to Stay Asleep Restorative quality of sleep Ability to Relax Balance in Life Alertness and Clarity Level of Energy `
5 Are you pregnant or nursing? Yes No Are you trying to get pregnant? Yes No On a scale of 1 (Low) to 10 (High), please rate the following: Current Life Stress Level of Health Overall Life Happiness Birth History Home Hospital Forceps or suction Caesarean section Breech Drug induced Prolonged Other Trauma: Your Needs and Hopes for Care In a published study of over 2,800 participants in Network Spinal Analysis, the participants reported an overall improvement in several categories of health and wellness listed below. Please indicate how you hope to benefit from care in this office: Improvement of physical symptoms Improvement of emotional/mental symptoms Improvement of my ability to react/respond to stress Improvement in enjoyment of life/ Ability to make constructive choices Overall improved quality of life Definitely Would be Nice Unimportant What is your commitment to yourself, your life and well-being on a scale of 1 to 10, where 1 is no commitment and 10 is will do whatever it takes? Are there particular factors or elements about your life, experiences, family, work, recreation, past injuries, genetics, dietary programs, exercises, outlook etc. that you feel may impair your opportunity for full vitality and health? Are there any factors and elements mentioned above that you feel give you an edge or add to your health? Is there anything else that may help in understanding you, your history or your professional needs which have not been discussed on this survey?
6 Finances Payment in full is expected on all FIRST VISIT services (whether you have insurance coverage or not.) All other fees are to be paid at time of service until other arrangements have been made and agreed upon in writing. Please indicate your method of payment. Cash Debit Card First Visit Fees: Comprehensive Exam: $100 X-Rays (if necessary): $30 Doctor s Report (Second Visit): $50 Adjustments/Entrainments: $47
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
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634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
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APPLICATION FOR CARE AT
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PATIENT INFORMATION HEALTH INFORMATION
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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
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
3. How Long Has This Been An Issue?
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Dr. Beth Kozak Welcome! New Patient Information Form Please provide us with the following information: Patient First Name: Last Name: Street Address: City: State: Zip Code Mobile Phone: Home Phone: Work
New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
Welcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA (570)
PATIENT Dr. Fawn Shaffer, DC 565 McElhattan Drive Lock Haven, PA 17745 (570) 748-3590 PERSONAL INFORMATION: Please Circle: Mr. Mrs. Ms. Miss Dr. Male Female Name: Nickname: Age: DOB: Address: City/State/
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You
NPM 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
NPM 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
Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
Last Name First Name MI: Address City State Zip. Referring Provider. Employer Address. Emergency Contact Relationship Phone. ID # Group # ID # Group #
Patient Demographic o New Patient o Return Patient o Update Account #: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
COMPREHENSIVE 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
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to