WELCOME! Dr. Robert Wright, DC, CBCN Doctor of Chiropractic Clinical Nutritionist Applied Kinesiologist
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1 Dr. Robert Wright, DC, CBCN Doctor of Chiropractic Clinical Nutritionist Applied Kinesiologist WELCOME! You have made a wise health choice in choosing our holistic and natural healthcare office. This is the office where people gain control of their health. Here, they will heal, strengthen, and then learn how to keep control of their health through manageable steps, and learning. NUTRITIONAL PROGRAMS FEE SCHEDULE 01/21/15 Phone Consultation Initial Visit - NEW PATIENT - Thorough Examination - 45 minutes No Charge $ Initial Visit - CROSSOVER PATIENT (crossover from Chiropractic, Acupuncture or Massage) - Thorough Examination - 45 Minutes Follow-Up Visit In Office minutes Follow-Up Visit via Phone Consult minutes $85.00 $55.00 $35.00 PATIENT: PLEASE RETAIN PAGES 1 & 2 FOR YOUR RECORDS 1
2 Page 2 HealthSource Nutritional Fees & Policies Financial: Payment is due at each visit Methods of payment are: Cash, Personal Check, Credit Card or *CareCredit * CareCredit: A revolving open line of credit for health/dental/vision/veterinary care (Inquire at Front Desk on 3, 6 & 9 month 0%) This facility applies a $35.00 fee to any checks returned as NSF (Non-Sufficient Funds.) This facility allows a maximum family balance of $ Should a personal balance meet or exceed this maximum allowed, it is required that payment arrangements be discussed with the Office Financial Department. Patient/Guardian understands that once a financial agreement has been put into place on his/her behalf, missed payments or failure to comply with this said agreement, patient/guardian will immediately be considered in breach of this agreement and the said account is subject to alternative collection efforts Appointments Keeping your scheduled appointments are extremely important to the success of your care. Each visit builds upon the prior one. Dr. Wright s treatment recommendations are based on success with previous patients who have experienced similar conditions, so your compliance is absolutely important to your success. Should our facility need to contact you regarding appointment times or treatment, we will do so by calling the contact numbers you have provided. If necessary, a voice message will be left at these locations unless you provide written instructions otherwise. Cancellations Please allow 24-hour notice for Appointment Cancellations. Please notify us at (708) so we can fill the appointment with our Wait List Patients. A Missed Appointment charge equivalent to the visit fee will be billed if the minimal 24 hour advance cancellation notice is not provided. Returned Products - Pre-approval is required by Dr. Wright on all returns - Refrigerated items CANNOT be returned - No supplement returns will be accepted after 30 days on all regularly stocked items - Special orders CANNOT be returned - Prepaid labs can be returned for credit within one month of purchase Lab Tests - All labs are self-pay. A Lab Superbill will be provided in order for patients to submit to their insurance for possible reimbursement. A Superbill will be provided only if Lab is paid in full. - If Lab Tests have been ordered, the results of your lab test(s) will be sent directly to Dr. Wright. If your Lab Results ARE NOT back in time for your next scheduled appointment, our office will call and reschedule your appointment. 2
3 Dear New Patient: After you have read the above, please sign and return this page to our Front Desk. Thank you I have read and understand HealthSource s Nutritional Medicine Program Fee Schedule and Policies dated January 21, 2015 Printed Name: Signature Date Guardian for: 3
4 NEW PATIENT HEALTH QUESTIONNAIRE Name: Date: Address: City: State: Zip Code: Phone Home: Cell: NOTE: used for internal communications ONLY How did you find us / hear about us? Age: Birth date: Sex: M F Status: M S W D No. Children: Occupation: Employer: Years Employed: Person responsible for this account: What is your MAJOR Complaint: Secondary, etc. Complaints: What are your overall health goals once your complaints are resolved? How long has it been since you really felt good? How much change are you willing to/able to make at this time to improve your health? (Please circle) Minimal Some Complete I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. I authorize HealthSource to release my personal medical information to me. Patient s Signature: Date:. 4
5 PATIENT NAME: PLEASE ANSWER ALL QUESTIONS FRANKLY & TO THE BEST OF YOUR KNOWLEDGE 1. If you are taking any medications and/or nutritional supplements, please list: 2. List Surgeries, starting with most recent: 3. List Hospitalizations: 4. If you have fillings, are they: Amalgam (metals) Composite Combination of Both 5. In the past, have you used Antibiotics? for how long: Birth control pills for how long: 6. Do you presently, or have you ever had any of these conditions? C = Currently PP = Present in Past Anemia Depression / Anxiety Hypoglycemia Arthritis Diabetes Kidney Problems Asthma Chest Pains Chronic Colds / Flu Frequent Headaches/Migraines Heartburn / Reflux High Blood Pressure Liver Problems Osteoporosis Skin Conditions 5 Thyroid Condition Unexplained Weight Change
6 . 7. How much sleep do you get each night on average? Hours b) Do you regularly wakeup during the night? If so, roughly what time : 8. Do you have any food allergies, sensitivities or restrictions? 9. Do you SMOKE: If Yes, how much: DRINK ALCOHOL : How much: DRINK CAFFEINATED BEVERAGES: (coffee / energy drinks): How much: What type? USE RECREATIONAL DRUGS: What type / How Often / For How Long? 10. Please list foods you tend to overeat or crave (Sweets, breads, fatty foods, meats, milk, etc.): 9. Are there foods that you eat on a daily basis? 9a. Do you miss /crave these foods if you do not eat them? YES NO 10. Write briefly about your weight gain/loss history: a. What do you feel triggers your weight fluctuation? (circle) heredity stress eating habits boredom b. Is your weight gain/loss: (circle) sudden gradual problem since childhood 11. What methods have you tried to lose/gain weight? 6
7 12. Please list close relatives that have diabetes, heart disease or obesity: 13. How is your energy level? (0 = no energy 10 = high energy) a. Are there times in the day that you feel best? worst? 14. Are you happy in your life right now? YES NO 15. What are your main sources of stress? 16. How do you deal with your stress? 17. Please answer the following questions Yes or No: YES NO N/A If I m feeling down a snack makes me feel better I sometimes have a hard time going to sleep without a bedtime snack I get tired and / or hungry in the mid-afternoon Which? I get a sleepy, almost drugged feeling after eating a meal containing bread, pasta or dessert. Now & then I think I am a secret eater At a restaurant, I almost always eat too much bread before the meal I have difficulty concentrating or frequent fuzzy or spacey thinking patterns I experience cravings for sugar, breads, pasta and baked goods I feel shaky if I don t eat on time or if I don t snack I often find myself irritable or angry 7
8 18. Check off ( ) any of the following that have applied to you within the last 30 days: Do you feel nauseous? Do you have abdominal/intestinal pain? Do you have bloating? Do you get bloated after meals? Do you get heartburn? Do you have diarrhea? Do you have constipation? Do you travel outside of the U.S.? Do you have gas? Are your stools compact/hard to pass? Do you belch following meals? Do you have gurgles in your stomach? Do your bowel movements alternate between constipation and diarrhea? 19. In your estimation, how physically fit are you right now? (circle one) Unfit Below average Average Above average Very fit 20. How often do you exercise? a. What is your exercise regime? 21. If you do not currently exercise, what types of exercise have you enjoyed doing in the past? 22. What are your fitness goals? (Check all that apply) General fitness endurance Weight loss/maintain weight Osteoporosis prevention Specific sport enhancement Flexibility Muscle toning Muscle strengthening Muscular coordination/balance Other 8
9 23. Briefly describe where you have lived since childhood: 24. What is your heritage? (Polish, African American, Latin, etc.) 25. Circle NOW or PAST for only those items with which you identify. Ignore anything that does not apply to you. Right now, Is your life: Do you often: Satisfactory Now Past Feel depressed Now Past Boring Now Past Have anxiety Now Past Demanding Now Past Have irrational fears Now Past Unsatisfactory Now Past Do you worry over: Home life Now Past Feel Upset Now Past Feel things go wrong Marriage Now Past often Now Past Children Now Past Feel Shy Now Past Job Now Past Cry Now Past Income Now Past Feel Inferior Now Past Have you: Money problems Now Past Seriously considered suicide? Now Past NOT NECESSARY, BUT IF YOU CAN: Please fax / mail back these completed forms for Dr. Wright s review prior to your appointment Or come to your appointment 20 mins.early to fill out. HEALTHSOURCE Chiropractic & Progressive Wellness S. Roberts Road / Palos Hills IL P: Fax: Thank you, and we re glad you re here let your road to real wellness begin 9
Office Location: Media Glen Mills Havertown Date of Evaluation. Last Name, First, Address. City State Zip. Home Phone: ( ) -- Work Phone:( ) -- SS#
Pain Relief and Physical Therapy 203 E Baltimore Pike, Suite 2 101 W. Eagle Road, Suite 1 Media, PA 19063 Havertown, PA 19083 Phone: 610-565-0670 Phone: 610-789-9887 Fax: 610-565-7706 Fax: 610-789-9883
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REGISTRATION FORM (Please Print) Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid If not, what is
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WELCOME to the Florence Chiropractic and Wellness Center.
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Corner on Wellness Chiropractic Center Therapeutic Massage
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Chiropractic Case History/Patient Information
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Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
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MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
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ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY
Patient Information: Name: Date of Birth: Social Security #: Gender: Marital Status: Primary Address: City: State: Zip Code: Please put a check mark next to any phone number that we may leave a message
**PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax:
Helpful Telephone Numbers Pre-Registration 855-890-9241 Hospital Billing (NWH) 617-726-3884 Physician/Provider Billing (MGPO) 617-726-3884 Web Address nwh.org Pre-Registration Please call up to 7 days
Saleeby Chiropractic Centre, P.A.
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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
DENTAL QUESTIONNAIRE
Name: (First) (Last) (Preferred) Birthdate: (Month) (Day) (Year) Gender: Male Female Address: City: Prov: Postal Code: Cell Phone: (Number will be used for confirmation of appointments) Email Address:
Pain Clinic Packet Neal E. Coleman, MD Andrew Trobridge, MD Angelia Huffmeyer, FNP J. Mark Hannaford, PA Matthew Stinson, PA-C
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Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
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Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
New You Weight Management Program
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Phone (h) (w) (c) Address. Referred by. Birthday Age Height Weight. Ethnicity Marital Status Children. Occupation Hours in regular work week
Client Intake Form Please fill out the following questions as best you can. If there is a particular question you don t understand or want to fill out, we can discuss them at our first meeting. Thank you.
Standard Medicare and Managed Medicare plans pay for diabetes education.
614-447-9495, ext. 1 You are scheduled to attend a series of four diabetes education classes. If you are not able to attend the class series, we ask that you cancel your appointment at least 48 working
COMMUNITY ACUPUNCTURE A USER GUIDE. Statement of Inclusivity and Ethics
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(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
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
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