Rise Chiropractic 239 S. French Broad Ave Asheville, NC
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1 Rise Chiropractic 239 S. French Broad Ave Asheville, NC Name: of Birth: Age: Sex: M F Address: City/State: Zip: Phone: (H) (W) (C) SS# Occupation: Employer: Marital Status: Single Married / Partner Separated Divorced Widowed Spouse/Partner s Name: Children s Name/Age: How did you hear about our office? _ Have you been to a chiropractor before? Y N Approximate date of last adjustment: PRIMARY COMPLAINT: When did it start? Please rate the intensity of your symptoms on a scale of 1-10 (10 being the worst pain) Did it begin: Gradual Sudden Progressive over time Result of a specific incident? Y N of incident: If yes, please explain: Have you ever had same condition? Y N If yes, when? Type of Pain: Sharp Dull Ache Burn Other Do you have Numbness or Tingling? yes no Does the Pain Radiate into your: Arm Leg Does not radiate How often do you experience these symptoms? What makes the symptoms increase? What relieves the symptoms? Please list all previous treatments for this condition. SECONDARY COMPLAINT: When did it start? Did it begin: Gradual Sudden Progressive over time Please rate the intensity of your symptoms on a scale of 1-10 (10 being the worst pain) Result of a specific incident? Y N of incident: Type of Pain: Sharp Dull Ache Burn Other Do you have Numbness or Tingling? yes no What makes the symptoms increase? Please list all previous treatments for this condition. Does the Pain Radiate into your: Arm Leg Does not radiate How often do you experience these symptoms? What relieves the symptoms?
2 2 Please mark off the areas of your complaint on the diagram. FAMILY HEALTH HISTORY Indicate which family member has/had the following conditions: (Father, Mother, Sister, and Brother) p Diabetes p Heart Disease p High/Low Blood Pressure p Cancer p Stroke p Epilepsy p Other Please check what you currently experience and circle what you have had in the past. p AIDS/HIV p Alcoholism p Anemia p Allergy Shots p Anorexia p Anorexia p Arthritis p Asthma p Bleeding Disorders p Breast Lump p Bronchitis p Bulimia p Cancer p Cataracts p Chemical Dependency p Chicken Pox p Diabetes p Disc Degeneration p Emphysema p Epilepsy p Epilepsy p Glaucoma p Goiter p Whooping Cough p Gout p Heart Attack p Heart Disease p Hepatitis p Hernia p Herpes p High Blood Pressure p High Cholesterol p Kidney Disease p Liver Disease p Measles p Migraine p Miscarriage p Mononucleosis p MS p Mumps p Osteoporosis p Pacemaker p Parkinson s Disease p Pinched Nerve p Pneumonia p Polio p Prostate Problem p Prosthesis p Psychiatric Care p Stroke p Rheumatic Fever p Scarlet Fever p Suicide Attempt p Thyroid Problems p Tonsillitis p Tuberculosis p Tumors/Growths p Typhoid Fever p Ulcers p Vascular Disease p Venereal Disease p Rheumatoid Arthritis p Colitis p Other
3 TRAUMA HISTORY 3 Jobs of all types have inherent movements that may be repetitive in nature or require lifting, excessive sitting, computer work, etc. Please list any occupational stress you have or have had and note any/all traumas, whether reported or not. Sports and recreational activities can place stress on anyone s spine because they are usually one sided movements. Please list any/all sports or recreational activities you currently or have ever participated in, along with any injuries from them. Have you ever been struck unconscious? p YES p NO If yes, list date of incident and how it happened. Have you ever been hospitalized? p YES p NO If yes, please explain. Please list any accident small or large that may have occurred around your house i.e. falls off ladders, slips etc. Have you ever been in an auto accident? p YES p NO If yes, please explain. Have you ever broken bones? p YES p NO If yes, please explain. Have you had surgery? p YES p NO If yes, please explain.
4 Rise Chiropractic Dr. Steven Cassese 239 S. French Broad Ave. Asheville, NC INFORMED CONSENT TO CHIROPRACTIC TREATMENT When a person seeks chiropractic care it is essential that both they and the chiropractor are both working towards the same goals. It is important that the patient understands and accepts the objective of Rise Chiropractic. In this way, there will be no confusion, misunderstanding or false expectations. Vertebral Subluxations are misalignments of the spinal bones that interfere with the normal physiology of the nerve system. This results in abnormal transmission of neurological impulses, which in time may lead to symptoms, sickness and decreased health potential. Chiropractic adjustments remove this interference to the nerve system caused by subluxations of the spine. With proper nerve supply restored, the body can begin the process of repair leading to health. In some patients this happens quickly; in others, more slowly. For some, the repair and maintenance is complete; in others, only partial. We do not offer to diagnose or treat disease. We do not attack or suppress symptoms. If, during care, you become concerned about your symptoms or your condition, we suggest that you seek the help of a symptom care professional. Our only goal is to remove interference to the body s innate health potential caused by subluxations, allowing the body to achieve a higher level of health. I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy, and if necessary, diagnostic x-rays on myself (or on the patient named below, for whom I am legally responsible) by the chiropractic physician and/or anyone working in this office authorized by the chiropractic physician. I further understand that such chiropractic services may be performed by Dr. Steven Cassese and/or other licensed Physicians of Chiropractic who may treat me now or in the future at this office. I have had an opportunity to discuss with Dr. Cassese and/or with other office personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic carries some risks to treatment; including, but not limited to: fractures, disc injuries, strokes (CVA), dislocations, and sprains. I do not expect the physician to be able to anticipate and explain all risks and complications. Further, I wish to rely on the physician to exercise judgment during the course of the procedure which the physician feels are in my best interests at the time, based upon the facts then known. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by my physician. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at this facility. Print Patient s Name Patient Print Name of Representative Representative 4
5 How We Protect Your Private Health Information I consent to the use or disclosure of my protected health information by this office for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of this office. I understand that Rise Chiropractic may refuse to diagnose or treat me, if I do not consent to the use or disclosure of my protected health information for the above stated purposes. My signature on this document is evidence of this consent. I understand I have a right to request a restriction as to how my personal health information is used or disclosed to carry out treatment, payment or health care operations at this practice. This office is not required to agree to the restrictions that I may request. However, if this office agrees to a restriction that I request, the restriction is binding. This office will not share or sell any of your information including psychographic or demographic, to third party retailers. I have the right to revoke this consent, in writing, except to the extent that Rise Chiropractic or Dr. Steven Cassese have taken action in reliance on this consent. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions regarding the Privacy Policies, and all my questions have been answered fully and satisfactorily. Patient Printed Name Patient Witness Printed Name Witness PLEASE GIVE 24 HOURS NOTICE WHEN CANCELING AN APPOINTMENT. Initial Rise Chiropractic Dr. Steven Cassese 239 S. French Broad Ave. Asheville, NC
PATIENT REGISTRATION
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Registration and History Form
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Chiropractic Registration and History
Chiropractic Registration and History 1. Patient Information Name: Birthdate: SS/HIC/Patient ID #: Address: City: State: Zip: Phone: Cell: E-Mail: Sex: M F (Circle) Minor Single Married Divorced Separated
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Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
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PRIMARY COMPLAINT: Date when symptom first appeared Did it begin: Gradual Sudden Progressive over time
PATIENT HISTORY 1 Date of Birth Age Social Security # Last First Middle Initial Address City ST Zip Phone (H) (W) (C) Email May we send you our online newsletter? Yes No Your Occupation Employer Spouse
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Last First MI. Full Mailing Address:
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PATIENT INFORMATION. Name Last First Middle. Address Number Street Name Apt# Home Phone Work Phone Cell Phone. Date of Birth / / Age Sex: Male Female
Today s Date PATIENT INFORMATION Name Last First Middle Address Number Street Name Apt# City State Zip Home Phone Work Phone Cell Phone Date of Birth / / Age Sex: Male Female Employed Full-Time Student
Patient Information. Name: Last First MI. Address: Street City State Zip
Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:
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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:
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
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AMI: Intake /Chiro 1 Patient Information Form Name: (Last) (First) (MI) Name you prefer to be called: Patient Address for shipping: (No PO Boxes) City: State: Zip: Phone: Cell: E-mail: Birthdate: SS #:
Chiropractic Case History/Patient Information
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Who is resoonsible for this account? ls patient covered by additional insurance? n Yes E No. Subscriber's Name
Welcome Who is resoonsible for this account? ls patient covered by additional insurance? n Yes E No Subscriber's Name ASSIGNMENT AND RELEASE I certify that l, and/or my dependent(s), have n Partnered for
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
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
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Welcome To Health and Wellness Alternatives!
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Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
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Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
Who may we thank for referring you?
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 /
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
New Practice Member Application
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WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
Chiropractic Health Dr. Art Vanderhoef
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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
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/
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Address City State Zip Code
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Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:
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PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
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
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Patient Re-Examination Form
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Patient Information : MP Name: Last First MI Email address: Mailing Address: (City) (State) (Zip) Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Sex: Male Female SS#: Marital Status:
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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
United Medical, PA Rev. 8/2014. Date: City: State: Zip:
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APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
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CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
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(City) (State) (Zip) Number of Children and ages. Policy Holder Name: D.O.B. :
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Current Health Information
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Patient Information. Date: To See Dr. Patient s Name: Last First Middle. Insurance Company: Phone # Address: Street City State Zip
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PATIENT FEE SCHEDULE As of January 1, 2017
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New Practice Member Paperwork
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(City) (State) (Zip) Phone # (H) (W) (Other) Employer Address: Emergency contact: Name: Relation: Phone #: Policy Holder Name: D.O.B.
Patient Information : Name: Last First MI Email address: Mailing Address: (City) (State) (Zip) Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Sex: Male Female SS#: Marital Status: Single
PATIENT NAME DATE CONSULTATION QUESTIONNAIRE
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Revelation Chiropractic Health Profile
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SPARROW FAMILY CHIROPRACTIC
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Date: Last First MI. Mailing Address: City State Zip. Policy Holder Name: D.O.B. : PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)
: Patient Information Name: Email address: Last First MI Mailing Address: City State Zip Phone # (H) (W) (Other) Can we call you at work? q Yes q No of Birth: Sex: q Male q Female SS#: Marital Status:
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Date: Mailing Address: City State Zip. Policy Holder Name: D.O.B. : PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)
Patient Information : Name: Last First MI Email address: Mailing Address: City State Zip Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Sex: Male Female SS#: Marital Status: Single Married
MEDICAL HISTORY QUESTIONNAIRE
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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.
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
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
New Patient Registration
New Patient Registration Patient Information Name: Date: Address: City: State: Zip: Sex: M F Other: Age: Date of Birth: (mm/dd/yyyy) Single Married Widowed Separated Divorced Occupation: Employer: Mobile
TERMS OF ACCEPTANCE. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.
TERMS OF ACCEPTANCE In order to provide for the most effective healing environment, most effective application of chiropractic procedures, and the strongest possible doctor-patient relationship, it is
Date: Mailing Address: City State Zip. Policy Holder Name: D.O.B. : PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)
: Patient Information Name: Last First MI Email address: Mailing Address: City State Zip Phone # (H) (W) (Other) Can we call you at work? q Yes q No of Birth: Sex: q Male q Female SS#: Marital Status:
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Chiropractic Case History/Patient Information
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PATIENT INFORMATION FORM (PLEASE PRINT)
PATIENT INFORMATION FORM (PLEASE PRINT) DATE: / / PATIENT NAME: LAST FIRST MI DATE OF BIRTH: / / AGE: SEX: M F HOME ADDRESS: CITY/STATE: ZIP: MAY WE LEAVE A MESSAGE? HOME PHONE #: ( ) - YES NO WORK PHONE
634 N. STATE STREET, WESTERVILLE OH, (614) 901-WELL
eas 634 N. STATE STREET, WESTERVILLE OH, 43082 (614) 901-WELL www.abilitychiro.com Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: ( ) Cell Phone
Liver Health: Do you have liver problems? Yes No If so, please specify:
Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their
INSURANCE... ACCIDENT INFORMATION PATIENT CONDITION _.
WELCOME 3 LOCATIONS TO SERVE YOU BETTER! PINES WEST CHIROPRACTIC EAST SIDE CHIROPRACTIC MARTINEZ CHIROPRACTIC 18501 Pines Blvd., Suite 104 8228 Biscayne Blvd. 12595 S.W. 137 Ave., Ste 108 Miami, FL 33029
Matthews Family Chiropractic
Dr. John J. Hanna, Director Matthews Family Chiropractic Windsor Square 9808 Northeast Parkway Matthews, NC 28105 (704) 845-0699 CASE HISTORY PLEASE PRINT Name: Home Phone: Address: City: Zip: Page 1 Age:
-Who is responsible for this account? _
CHIROPRACTIC REGISTRATION AND HISTORY j] PATIENT INFORMATION Dffie ~ INSURANCE INFORMATION Who is responsible for this account? SS/HIC/Patient 10 # Relationship to Patient Patient Name ;::::;:..::= Last
Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
An Outpatient Department of PLEASE FILL OUT ALL INFORMATION COMPLETELY Date Completed Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:
PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:
TIMOTHY B. COLE, MD ALLISON TRAVIS, MD 7300 Eldorado Parkway, Ste 260, McKinney, TX 75070 Phone: 972-747-0440 / Fax: 972-747-0441 PATIENT REGISTRATION FORM Date: Last Name: First Name: Initial: Address:
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
ADIO CHIROPRACTIC HEALTH PROFILE
ADIO CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
Patient Intake Form. Name: First Middle Last
Terry Wulster, D.C. Andy Smith, D.C. Jeffrey Massarone, N.D., D.C. Chiropractic & Wellness Care 35 W. Main Street, Suite 100 Denville, NJ 07834 Office: 973.625.2600 Fax: 973.625.2650 Chiropractic healthcare
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Naturopathic & Acupuncture Intake Form (Age 14+)
Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair, B.Sc., ND 86 Norfolk St., Guelph 519-827-0040 Contact Information Naturopathic & Acupuncture Intake Form (Age 14+) Name: Gender: Age: Birth Date (dd/mm/yy):
PATIENT INFORMATION HEALTH INFORMATION
PATIENT INFORMATION PLEASE PRINT PATIENTS LAST NAME FIRST NICKNAME STREET ADDRESS APT # TODAYS DATE / / CITY STATE ZIP E-MAIL SEX M F MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DOB / / AGE SPOUSES
Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State
Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married
Healing Hands Chiropractic, LLC
AUTO INJURY QUESTIONNAIRE Name Age Birth Date / / Sex: M F Address City State Zip Home# Cell# Work# Email Who referred you to us? Marital Status M S D W Number of Children Are you Pregnant? Yes No Height
Hill Family Chiropractic Patient Application
Hill Family Chiropractic Patient Application WELCOME TO OUR OFFICE. WE THANK YOU FOR YOUR TRUST! (Please print using black or blue ink. If there is something that does not apply to you please put N/A on
Physician Assisted Weight Loss Program. Patient Name: Date: Patient Address: City: State: Zip:
Physician Assisted Weight Loss Program Patient Name: Date: Patient Address: City: State: Zip: DL / ID #: Phone Number: Birthdate: Age: E-mail: Employment Information: Patient Employer: Occupation: City:
Name: (Last) (First) (Middle) Address: (City) (State) (Zip) Home: ( ) Work: ( ) Cell: ( ) Age: DOB: SS#: Height: Weight: Occupation:
2124 Route 35, Tel: (732) 788-0349 Holmdel, Fax: (877) 211-6276 NJ, E-mail: info@gramercypaincenter.com 07733. www.gramercypaincenter.com Date: Name: (Last) (First) (Middle) Home: ( ) Work: ( ) Cell: (