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- Joan Casey
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1 Page1 Adult Intake Name: DOB: Today s Date: Your purpose today for visiting this office today is: Temporary pain reduction Corrective care Wellness care Bio Energetic Synchronization (B.E.S.T.) Nutrition Response Therapy (NRT) KST Manual Chiropractic adjustments Activator ArthroStim Other: Chief complaint information- Room for only two, if there is more, we ll go in to more details 1- Primary complaint / issue? 2- Have you experience this before? Yes No 3- How did it start? Sudden Gradual Other: 4- When did it start? 5- What makes it worse? 6- What makes it better? Primary chief complaint one issue at the time please. 7- Have you seen anyone else for this? Yes No 7a- If yes, who and was it helpful? 8- Any radiation of symptoms? Yes No 8a- If yes, to where? 9- Is it: Achy Sharp Numb / Tingling Deep Burning Other: 10- Is this worst at: Morning Noon Afternoon Evening Night Other: 11- The symptom effected when you: Sit Sleep Walk Standup Bend Move Other: 12- How often? Daily Weekly Monthly Constant Other: 13- % of time you experience this? %10 %20 %30 %40 %50 %60 %70 %80 %90 % Have you tried: Hot Cold Meds Nothing Other 14a- If using meds, please list 15-Do you consider this to be serious? Yes No Please mark the location of discomfort on the left. Please put a number from (no pain) - ( most imaginable pain) next to the location of discomfort. Front Back
2 Page2 Secondary complaint one issue at the time please. 1-Secondary complaint / issue? 2- Have you experience this before? Yes No 3- How did it start? Sudden Gradual Other: 4- When did it start? 5- What makes it worse? 6- What makes it better? 7- Have you seen anyone else for this? Yes No 7a- If yes, who and was it helpful? 8- Any radiation of symptoms? Yes No 8a- If yes, to where? 9- Is it: Achy Sharp Numb / Tingling Deep Burning Other: 10- Is this worst at: Morning Noon Afternoon Evening Night Other: 11- The symptom effected when you: Sit Sleep Walk Standup Bend Move Other: 12- How often? Daily Weekly Monthly Constant Other: 13- % of time you experience this? %10 %20 %30 %40 %50 %60 %70 %80 %90 % Have you tried: Hot Cold Meds Nothing Other 14a- If using meds, please list 15-Do you consider this to be serious? Yes No Please mark the location of discomfort on the left. Please put a number from (no pain) - ( most imaginable pain) next to the location of discomfort. Front Back If there are more issues you would like addressed, please write here:
3 Page3 Lifestyle questions You may be brief we ll go into more details if necessary 1-Were you on any medication for a prolonged amount of time? 1a If yes, what, why and for how long? 3-Are you currently taking medication(s)? 3a - If yes, what and for what purpose? 4-Do you take: Vitamin D? Probiotics? Fish oil? Multivitamin? 5- List any other supplements if any: 6-Have you ever been hospitalized? 6a-If yes, why? 7-Have you ever surgeries? 7a-If yes where on your body and why? 8-Have you had any major accidents/falls? Yes No 8a-If yes, please explain; 9-Do / did you have any fractures? 9a-If yes, where? 10-Do you have any scars? 10a-If yes, where? 11-Do you have any Mercury fillings? 13-Are you vegetarian? 12-Do you have any root canals? 14-Are you vegan? 15-How often do you consume; - Fruit? Never Once in a while Weekly Daily Multiple times per day - Vegetables? Never Once in a while Weekly Daily Multiple times per day - Protein? Never Once in a while Weekly Daily Multiple times per day - Dairy? Never Once in a while Weekly Daily Multiple times per day - Soda? Never Once in a while Weekly Daily Multiple times per day - Coffee /caffeine? Never Once in a while Weekly Daily Multiple times per day - Alcohol? In the past Never Once in a while Weekly Daily Multiple times per day - Cigarettes? In the past Never Once in a while Weekly Daily Multiple times per day - Rec. drugs? In the past Never Once in a while Weekly Daily Multiple times per day
4 Page4 Lifestyle questions You may be brief we ll go into more details if necessary 16- How often do you exercise? Never Once in a while Weekly Daily Multiple times per day 17- How much water do you consume on average, daily? Glasses Ounces 18- Are you healthier now than you were 5 years ago? 19- When do you generally feel your best? AM PM 20- When do you generally feel your worst? AM PM 21- How committed to your health are you? Not at all Extremely 22- How important is your health to you? Not at all Extremely 23- Do you think your health is: Challenged Fair Good Very Good Excellent 24- Would you like your health to be Challenged Fair Good Very Good Excellent Systems Review- check P for past and C for current, where applicable, use R for right and L for left or circle where appropriate 1- Have you had or do you now have any of the following pulmonary (lung related) issues? 1a- Asthma: P C 1b- Difficulty breathing: P C 1c- COPD: P C 1d- Emphysema: P C 1e- None: 1f- Other: 2- Have you had or do you now have any of the following related cardio vascular (heart) issues? 2a- Heart surgery: P C 2b- Congestive heart filature: P C 2c-Heart attacks: P C 2d- Atrial fibrillation: P C 2e-Angina / chest pain: P C 2f- Irregular heart beat: P C 2g- Pacemaker: P C 2h- Hyper tension: P C 2i- Stroke: P C 2j- Blood thick / thin: P C 2k- None: 2l- Other: 3- Have you had or do you now have any of the following neurologic (nerve related) issues? 3a- Visual changes / loss of vision: P C 3b- Seizures: P C 3c- One sided weakness of face: P C 3d- One sided weakness of body: P C 3e- One sided decrease of sensation in face: P C 3f- One sided decrease of sensation in body: P C 3g- Headaches: P C 3h- Memory loss: P C 3i- Tremors: P C 3j- Loss of sense of smell: P C 3k- Stroke: P C 3l- Vertigo: P C 3m- None: 3n- Other:
5 Page5 Systems Review- check P for past and C for current, where applicable, use R for right and L for left or circle where appropriate 4- Have you had or do you now have any of the following endocrine (glandular / hormonal related) issues or procedure? 4a- Thyroid disease: P C 4b- Hormone replacement therapy: P C 4c- Inject-able steroid replacement: P C 4d- Gland removal: 4e- Diabetes type I: P C 4f- Diabetes type II: P C 4g- None: 4h- Other: 5- Have you had or do you now have any of the following renal (kidney related) issues? 5a- Incontinences ( can t control) : P C 5b- Renal / calculi stones: P C 5c- Hematuria (blood in urine) : P C 5d- Hematochezia (blood through rectum) : P C 5e- Bladder infection: P C 5f- Difficulty urinating: P C 5g- Kidney disease: P C 5h- Dialyses: P C 5i- None: 5j- Other: 6- Have you had or do you now have any of the following gastro intestinal (stomach / digestion related) issues? 6a- Nausea: P C 6b- Difficulty swallowing: P C 6c- Ulcerative colitis: P C 6d- Frequent abdominal pain: P C 6e- Hiatal hernia: P C 6f- Constipation: P C 6g- Diarrhea: P C 6h- Pancreatic disease: P C 6i- Irritable bowel / colitis: P C 6j- Hepatitis / liver disease: P C 6k- Vomiting blood: P C 6l- Black or tarry stool: P C 6m- Bowel incontinent: P C 6n- Gastroesophageal reflux / heart burn: P C 6o- None: 6p- Other: 7- Have you had or do you now have any of the following dermatological (skin related) issues? 7a- Significant burns: P C 7b- Significant rashes: P C 7c- Significant Acne: P C 7d- Psoriatic disorder: P C 7e- Eczema: P C 7f- Melanoma: P C 7g- Excessive moles: P C 7h- Excessive skin tags: P C 7i- None: 7j- Other: 8- Have you had or do you now have any musculoskeletal (bone / muscle related) issues? 8a- Rheumatoid arthritis: P C 8b- Gout: P C 8c- Osteoarthritis: P C 8d- Spinal fracture: P C 8e- Excessive Arthritis ( unknown type): P C 8f- Spinal surgery: P C 8g- Scoliosis: P C 8h- Metal implants: P C 8i- None: 8j- Other:
6 Page6 Systems Review- check P for past and C for current, where applicable, use R for right and L for left or circle where appropriate 9- Have you had or do you now have any of the following psychological issues? 9a- Psychiatric diagnosis: P C 9b- Depression: P C 9c- Suicidal ideation: P C 9d- Bipolar disorder: P C 9e- Homicidal ideation: P C 9f- Schizophrenia: P C 9g- Psychiatric hospitalization: P C 9h- Anxiety: P C 9i- None: 9j- Other: 10- Have you had or do you have any of the following symptoms / pain / discomfort? 10a- Head ache: P C - R L 10b- Face: P C - R L 10c- Sinus issues: P C - R L 10d- Jaw: P C - R L 10e- Neck: P C - R L 10f- Throat: P C - R L 10g- Upper back: P C - R L 10h- Middle back : P C - R L 10i- Lower back: P C - R L 10j- Sacrum: P C - R L 10k- Coccyx: P C - R L 10l- Pubic symphysis: P C - R L 10m- Hip: P C - R L 10n- Knee: P C - R L 10o- Ankle: P C - R L 10p- Foot: P C - R L 10q-Shoulder: P C - R L 10r- Elbow: P C - R L 10s-Wrist: P C - R L 10t- Hand: P C - R L 10u-Rib: P C - R L 10v- Clavicle / Sternum: P C - R L 10w- None: 10x- Other: Circle M for mother and / or F for father where / if applicable. Diabetes: Mother Father Sibling Heart Disease: Mother Father Sibling High Blood Pressure: Mother Father Sibling Rheumatoid Arthritis: Mother Father Sibling Lupus : Mother Father Sibling Cancer: Mother Father Sibling Other: Mother Father Sibling Other: Mother Father Sibling Previous Chiropractic Experience Have you ever been to a Chiropractor before? If yes, what was the reason for your visit? You previous experience was; Excellent Good Beneficial Bad Other: When was your last physical? When was your last X-ray? Positive findings?
7 Page7 FEMALE ONLY! PLEASE Are you currently pregnant? If yes, how far along? What method of birth control do you use? Abstinence Pill IUD Patch Other: Do you have any biological children? Were they; Vaginal C-section Do you have episiotomy scars? Are your cycles regular? Please check yes or no or use your own words Do you have confidence and a compassionate view of yourself? Are you open to new ideas? Do you like what you do for a living? Do you enjoy a sense of purpose and peace in your life? Are addictions a challenge for you? Are you teachable? Do you invite constant and never ending improvement in your life? Do you sleep well at night and awake rested? Do you awake frequently at night to urinate? Do you have a sustained energy throughout the day? What emotion(s) best describes you? Is there anything else you would like to comment on today? What goals would you like to achieve while under care in this office? Signature and name: Date: Your health is your greatest asset. Thank you for the opportunity to serve you! PT: DR EX AM AN G/WF: OFFICE USE ONLY VO: TPR CC WC
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New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #
Patient Information: Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Email: Home # Cell # Work # Text Appointment Reminders: Yes No
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
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
PAIN QUESTIONNAIRE. Patient Name: Patient Date of Birth: Appointment Date:
Patient Name: Patient Date of Birth: Appointment Date: Please mark and/or notate the areas of your body which are affected by pain. RIGHT RIGHT LEFT LEFT RIGHT LEFT RIGHT RIGHT LEFT LEFT RIGHT LEFT For
ACTIVE 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
Sydney 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
Consent to Treat a Minor
1. Fill out the application for treatment sheets, two of them, and sign both of them accordingly. 2. If the appointment is for a minor, please read the Consent to Treat a Minor carefully and sign accordingly.
PATIENT 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
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Email Address: Birthday: Marital Status: Married
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form
1607 Visa Dr, Ste 1A 408 E College Ave, Ste C Normal, IL Normal, IL 61761
Normal, IL 61761 Normal, IL 61761 Full Name Address City State Zip Home Phone Cell Email How do you prefer to be contacted? Text Home, Cell, or Work Phone Email Text Reminders Yes No Who can we thank for
Child 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.
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Intensity: 0-10 (10 is the worse pain you have ever experienced in your life that you would want to jump from a building, 0 is no pain)
Patient Questionnaire: Name: Date: Occupation: Date of Birth: Age: Sex: Male Female Referring Physician: Chief Complaint: Describe your Pain: sudden onset gradual constant intermittent worsening improving
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
2. Previous interventions, treatments, medications, surgery, or care you ve sought for your complaint(s):
Address City State Zip Code H. Phone W. Phone Cell Phone Email Address: Sex M F Marital Status M S D W Date of Birth Age_ Social Security # Occupation Employer Referred by: Have you ever received Chiropractic
The failure to bring this information with you may result in the rescheduling of your appointment.
Alan Koester, MD Steven Novotny, MD John Jasko, MD Viorel Raducan, MD Brock Niceler, MD Thomas Reinsel, MD Chad Lavender, MD Thank you for choosing Marshall Orthopaedics! We will make every effort to ensure
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C
The Advanced Spine Center Jason E. Lowenstein, MD Jamie L. DiGraziano, PA-C ADULT SPINE HISTORY For Office Use Only: HR: BP: / Name of Patient: Date: Date of Birth: Age: Height: ft in Weight: lbs Form
Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:
Patient Medical Information Name: First Middle Last Sex: M / F Age: Date of Birth: Social Security # Driver s License # Home Address: City: State: Zip Code: Home Phone: Occupation: Cell: Employer: Business
Last Name First Name Middle Name MRN
Dr. Byers Dr. Su Dr. Sponzilli Lisa Elvin, NP Spine Center New Patient Form Last Name First Name Middle Name MRN This form is used to gather information so that my doctor can maximize the time used to
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.