Please print and use only black ink. Thank you, from the staff of Curley Chiropractic
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- Shannon Turner
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1 Please print and use only black ink Thank you, from the staff of Curley Chiropractic
2 Curley Chiropractic Teenager s Health History Form Personal Data Date: Full Name Age: DOB: Parent s names: Home Address: City: State Zip Social Security #: Language: [ ]English [ ]Spanish [ ]Indian [ ]Japanese [ ]Chinese [ ]Korean [ ]French [ ]German [ ]Russian Other: Race/Ethnicity: [ ] White [ ]American Indian or Alaska Native [ ] Asian [ ]Native Hawaiian/ other pacific Islander [ ]Black or African American [ ] Hispanic or Latino [ ]Decline Answer Other: Cell Phone: Cell Provider: Emergency contact: Whom may we thank for referring you to our office? Insurance Information: A copy of your insurance cards will be made, in addition, please complete the information requested below Who is the policy holder? Policy holders DOB: Policy holders Social Security: Policy holders employer: Do you have secondary insurance? Y N If yes, please complete the following: Policy holders Name: DOB: Policy holders Social Security: Policy Holders employer: REASON FOR SEEKING CHIROPRACTIC CARE How do you think we may help be able to you re your teenager?
3 Are these concerns affecting your child s activities of daily living? (Circle Y to those that apply) Eating: Y N Sleep: Y N Running: Y N School: Y N Walking: Y N Sitting: Y N Exercise/sports: Y N Relationships: Y N Other: PREVIOUS CHIROPRACTIC CARE Has your teenager ever received Chiropractic care? Y N Name of D.C. How long were they under care? Date of last visit: FOR THE TEENAGER Tell us about you. Are you an athlete? Y N If yes which sport(s). Have you played this sport or have you ever played a sport? For how long? Do you remember ever getting hurt playing this sport? Y N If yes, tell us when and describe the injury. TELL US MORE Are you in the school band? Y N If yes what instrument do you play? Have you had any accidents or injuries in your life related to any of the following? (Check all that apply) Automobile Motorcycle Bicycle Playground If you have checked any of the above please state the type of injury and date: Have you ever hurt, broken, fractured or sprained any bones or joints? Y N If yes, list body parts injured and dates if not already listed above: Have you ever been hospitalized? Y N If yes, tell us the dates and reasons if not already listed above:
4 FOR PARENTS The following questions pertain to at any point in the patient s life did any of these occur. As a baby or toddler, did any of the following occur to your teenager? fall from a changing table frequent crying spells frequent fevers tumble from stair fall out of crib frequent diarrhea involved in car accident constipation sleeping problems play in jumper frequent colds colic tonsillitis fall off playground equipment did not gain weight reaction to vaccination other Explain any of the above if needed Has your teenager ever had any vaccinations? Did your teenager ever have any reactions to any vaccinations? Has your teenager experienced any of the following? headaches numbness in arm/hands foot/ankle/knee pain dizziness arm/wrist pains tingling in arms/legs ringing in ears sleeping problems neck/back pain asthma allergies shoulder pains hyperactivity stomach problems growing pains fatigue weight gain or loss other Which of the above that you checked would you consider the worst? Do any of the following still occur? If yes, list which ones Is this condition: constant intermittent occasional cyclic
5 QUALITY OF LIFE When this condition is at its worst, how does it make your child feel? Is there anything you have done for your child regarding this condition that has NOT worked? Describe any hospital or emergency room stays? Approximately how many times have antibiotics been prescribed for your child and for what conditions? List any medications your child is currently taking: Is there anything else you think we should know about your child? EXPECTATIONS I would like to have the following benefits for my teenager from Chiropractic Care: (check all that apply) Relief of a symptom or problem Relief and prevention of a symptom or problem Healthier spine and nerve system Optimal Health on all levels
6 Circle the number at where your pain is at: Neck Shoulders and Mid upper back Lower Back and Hips/Legs
7 YOUR INFORMED CONSENT The information I have provided on this case history form, is true and accurate to the best of my knowledge. Although Chiropractic is reported to be the safest health care system in the world, some say there are very slight risks associated with it. We feel that it is responsible to let you know: 1. While extremely rare, there have been reports of ligament sprains, and even rib fractures reported; 2. There have been rare reports of disc injuries although no clinical scientific study has ever demonstrated chiropractic care to be the cause. Chiropractic care has been proven to be both, clinically and cost effective. The risk of injuries and complications is so small that chiropractors carry the lowest malpractice insurance premiums of all the health care professions in the world. Compared to traditional medical/drug/surgical care, which has a yearly death rate of approximately 200,000 people in North America, Chiropractic is your safest health care system. I have read and understand the above consent and have had the opportunity to discuss it with my chiropractor. I have been informed and fully understand that Chiropractic care is not a treatment of any disease or condition. I consent to the care recommended by my chiropractor and extend this consent to include all doctors of Curley Chiropractic. This consent applies to all present and future care for me and my family Signature Date Signature of Parent (for minor) Date
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Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
WELCOME TO AGEWELL MEDICAL ASSOCIATES
WELCOME TO AGEWELL MEDICAL ASSOCIATES We offer the following checklist and suggestions to help make your first visit as easy and pleasant as possible. What to bring with you: [ ] All of your medications
Patient Enrollment Sheet
Patient Enrollment Sheet PATIENT INFORMATION: LAST NAME FIRST NAME MIDDLE INIT. STREET CITY STATE ZIP SSN DOB / / MALE / FEMALE HOME PHONE CELL PHONE WORK PHONE E-MAIL ADDRESS EMPLOYER YOUR OCCUPATION
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
APPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
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
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
Nashoba Valley Chiropractic (978)
(978) 448-2800 Last Name: First Name: MI: Mailing Address: City: State: Zip: O.K. to call home? Yes No Home Phone: O.K. to call cell? Yes No: Cell Phone: Sex M F Birthdate: Age: Marital Status: Single
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: