(emergency room pain)
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- Henry Mason
- 5 years ago
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Transcription
1 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 to fill out all applicable information and include details. If you have any questions, please don t hesitate to ask. Patient Name: Address City State Zip Date of Birth Sex: Male / Female / Other Home Phone # Cell # Carrier Relationship Status: Single / Married / Divorced / Widowed / Civil Union Emergency Contact Name Relationship Phone # If Patient is under 18: Parent/Guardian Name & Phone: How did you hear about us? Primary Complaint: Any Other Concerns: When did this begin? Has it gotten better/worse since then? Has this occurred before? Yes / No If Yes, please explain: Describe the Quality of your Symptoms (circle all that apply) Deep/Dull Sharp/Stabbing Electrical/Shooting Achy/Burning Please Indicate the Severity of your Current Discomfort (no pain) (emergency room pain)
2 How often are your symptoms present? 0-25% 26-50% 51-75% % What makes your symptoms Better? What makes your symptoms Worse? Does your discomfort travel down your arms/legs? Have you experienced lack of sleep due to the pain? Have you experienced unexpected weight loss? Does this problem interfere with your life or work? What activities would you like to be able to do pain-free? Have you received any other treatment or had any imaging done for this condition? Y/ N If yes, please explain: Have you received chiropractic care before? If yes, where? To help you feel better faster, we treat the whole body every visit. In addition to your primary complaint, please indicate any other areas of pain or discomfort
3 Are you taking any vitamins or supplements? How many glasses of water do you drink in a day? How many glasses of alcohol do you consume in a week? How many servings of fruits & vegetables do you eat per day? How often do you exercise and what kind? Are you currently pregnant? What medications are you currently taking? Has any member of family (parents, grandparents, siblings) been diagnosed or treated for Cancer, Heart Disease, Diabetes, Arthritic Conditions or Neurological Conditions? If yes, please specify: Please Circle all that apply to your personal health history from the list below: Cardiovascular Gastrointestinal Neurological General Heart Trouble Chest Pain Heart Murmur Palpitations Varicose Veins Calf Pain with Walking Nausea Diarrhea Constipation Abdominal pain Flatulence Change in appetite Light headed/dizzy Convulsions/Seizures Numbness/Tingling Tremors Head Injury Memory Loss Fainting Poor Balance Weight Change Loss of appetite Fatigue Insomnia Fever Anemia Frequent Headaches Allergies Eyes Respiratory Ear/Nose/Throat Mental/Emotional Eye disease Hearing loss Glasses or contacts Shortness of Breath Ringing in the ears Depression Blurred or Double Vision Chronic Cough Sinus problems Anxiety Vision Loss Asthma Nose bleeds TMJ/Pain in Jaw Musculoskeletal Endocrine Skin Gynecological Joint pain Joint swelling Muscle weakness Back Pain Neck Pain Fracture/Dislocation Excessive Thirst Heat or cold intolerance Rash Itching Dry Skin Easily bruise Last Menstrual period: Menopause onset? Additionally, please list any diagnoses, surgeries or illnesses here: Patient Signature Date
4 Informed Consent Form for Chiropractic Patient Name (printed) Every type of healthcare is associated with some risk of potential problems. State law requires that you sign an informed consent prior to receiving care. Chiropractic focuses on the nervous system and spinal cord. During chiropractic treatment, the doctor will use his/her hands or a mechanical device in order to align your spine to correct interference to the nervous system and improve the body s ability to control and coordinate many functions. You may feel a click or pop, such as the noise when a knuckle is cracked, and you may feel movement of the joint. Spinal adjustments have been used routinely in the management of patients with a variety of symptoms and/or disorders, including those without symptoms who want to improve overall health. Any procedure provided at Moving Body Chiropractic is intended to aid in wellness. You consent to the performance of spinal examination in which the doctor uses their hands to feel the muscles and joints of the spine or other body parts (palpation), performs a visual inspection of your posture, checks the ability to move through a normal range of motion for spinal or other body parts, and performs any further orthopedic or neurological tests. X-rays or other imaging may be ordered by the chiropractor. I understand and am informed that the risk of complications due to chiropractic treatment have been described as rare, but, as with any medical treatment, complications are possible. Complications could include, but are not limited to, muscular strain, ligamentous sprain, dislocations of joint, injury to the arteries of the neck, headaches, or a worsening of the condition. Soreness is the most common reported after effect following an adjustment. The doctor will make every reasonable effort during the examination to screen for contraindications to care. I understand that I can discuss the risks and benefits of any procedure with my practitioner before signing this form. I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to her, is in my best interest. My signature indicates that I have read, or have had read to me, the above consent. I have had the opportunity to ask questions about its content, and by signing below I agree to chiropractic and related treatments prescribed by Dr. Emily Gerson at Moving Body Chiropractic. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I hereby give consent for myself, or my dependent, to be examined and/or treated by the practitioner at Moving Body Chiropractic. Patient Signature (Signature of Parent or Guardian (if under 18 years old) Date Doctor signature Date
5 Patient Name (printed) HIPAA I hereby acknowledge that upon request, I will receive a copy of HIPAA privacy forms. Initial Privacy Practices Acknowledgment I understand that my personal health information will not be shared with any agencies or individuals without my written consent. For more details, a Notice of Privacy Practices is available, ask your healthcare provider. Initial Financial Policies Payment is required at time of service. Although Moving Body Chiropractic will give you all the information you need to obtain reimbursement from your insurance company if you have chiropractic benefits, the ultimate financial responsibility remains with you, the patient. By signing this, you are consenting to receive chiropractic care and agreeing to pay for services rendered. Initial Cancellation and No Show policies Moving Body Chiropractic strives to keep all appointments on time. Out of respect to the chiropractor, and other patients, we ask that you please arrive a few minutes prior to your scheduled appointment. Relax and enjoy the calming vibes of the center! If you are unable to keep an appointment, please call 24 hours in advance to cancel or re-schedule. We understand that delays sometimes occur, but please be courteous and contact the office if running late. Accommodations will try to be made, but if the doctor is unable to provide appropriate patient assessment and treatment due to time constraints, the appointment will have to be rescheduled. A $45.00 no show or late cancellation will be applied. Initial Your signature below states that you agree to and understand office policies and procedures. Patient Signature Date
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
WELCOME TO FALLS CHIROPRACTIC AND INJURY!
WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
New Patient Intake Forms. Patient Data Date. Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other. First Name Middle Initial Last Name
New Patient Intake Forms Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name I prefer to be called by Address Line City State Zip Code Home Phone ( ) -
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Cell Phone: Age: Birth Date: Race: Marital Status: [M] [S ][W] [D] Occupation:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
General Information: (Circle One) (Circle One) Primary Insured's Information Skip if you are primary
General Information: First Name: Middle Initial: Last Name: Suffix: Called Name: Street Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email Address: Marital Status:
Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
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
SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Welcome to Compass Chiropractic!
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Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
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Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip:
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
Hospital he hospital is located near the interchange of highway 217 and (US 26).
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Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
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CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
Application for Patient
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Adult New Patient Intake. Your Health Summary
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PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
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Terms of Acceptance:
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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
COMPREHENSIVE NEW PATIENT QUESTIONNAIRE
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Avery Acupuncture & Natural Medicine New Patient Registration
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New Patient Pain Evaluation
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PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
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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 /
Office Policy for New Patients
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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
PATIENT HISTORY FORM
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PATIENT INTAKE AND HISTORY FORM
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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
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
Please describe, in detail, when the symptoms began:
161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Please complete this questionnaire and bring it to your first appointment.
Please complete this questionnaire and bring it to your first appointment. Name: Date: DOB: Age: Legal Guardian if other than self Name of Person filling out form (if different than patient): What brought
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RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)
PATIENT INFORMATION DATE: BP: P: Patient Name: (First) (Last) (M.I.) Address: City, State: Zip Code: Home #: ( ) Cell #: ( ) Work #: ( ) Date of Birth: Age: Sex: M / F Email: Automatic Appointment Reminder
WELCOME TO FALLS CHIROPRACTIC AND INJURY!
WELCOME TO FALLS CHIROPRACTIC AND INJURY! PATIENT INFORMATION (Most of the information below is required for insurance purposes) DATE: / / FIRST NAME: M.I.: LAST NAME: DATE OF BIRTH: / / CALLED NAME /
UnityPoint Clinic - Cardiology
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Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
www.monctonnaturopathic.com 12 Fifth Street, Moncton, NB, E1E 3G9 Ph: 506-382-1329 Fax: 506-382-1828 Pediatric Intake Form (6-12 years) Name: Date: Age: Date of Birth: / / Gender (circle one): female or