Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
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1 Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907) PATIENT DEMOGRAPHICS Today's Date: *** PLEASE WRITE IN BLACK INK ONLY*** Name: Birth Date: - - Age: Male Female Address: City: State: Zip: Address: Do you have Insurance? Home Phone: Cell Phone: Work Phone: Social Security #: Driver s License #: Employer: Occupation: Marital Status: Single Married Partner Divorced Widowed Spouse s Name Spouse s Employer Number of children and ages: Name & Number of Emergency Contact: Relationship: Whom may we thank for referring you to our office? HISTORY of COMPLAINT Please identify the condition(s) that brought you to this office: 1. PRIMARY COMPLAINT: Date of Onset: How did it happen? Does the Pain Radiate? YES or NO if yes, where does it start and where does it end? 2. SECONDARY COMPLAINT: Date of Onset: How did it happen? Does the Pain Radiate? YES or NO if yes, where does it start and where does it end?
2 3. THIRD COMPLAINT: Date of Onset: How did it happen? Does the Pain Radiate? YES or NO if yes, where does it start and where does it end? 4. FOURTH COMPLAINT: Date of Onset: How did it happen? Does the Pain Radiate? YES or NO if yes, where does it start and where does it end? PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B= Burning D =Dull A = Aching N = Numbness S =Sharp/Stabbing T= Tingling How long does it last? Have your condition(s) ever been treated by anyone in the past? No Yes If yes, when: By whom? How long were you under care: What were the results? Name of Previous Chiropractor: Is your problem the result of ANY type of accident? Yes, No Please circle: Auto Accident on the Job Accident Other
3 PAST HISTORY Identify any other injury(s) to your spine, minor or major, that the doctor should know about: Have you suffered with any of this or a similar problem in the past? Yes No if yes, how many times? When was the last episode? How did the injury happen? What other forms of treatment tried: Yes No If yes, please state what type of treatment: who provided it: how long ago? What were the results? Favorable Unfavorable please explain. Please identify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body: Please circle if you have had any of these conditions: () AIDS/HIV ( ) Cancer ( ) Osteoporosis () Chest Pain ( ) Alcoholism ( ) Diabetes ( ) Pacemaker () Dizziness ( ) Allergy shots ( ) Emphysema ( ) Parkinson s disease () Loss of Balance ( ) Anemia ( ) Epilepsy ( ) Pinched Nerve () Ringing in the Ears ( ) Anorexia ( ) Glaucoma ( ) Pneumonia () Depression ( ) Appendicitis ( ) Heart Disease ( ) Polio () Digestive Problems ( ) Arthritis ( ) High Cholesterol ( ) Prostate Problems () Lung Problems ( ) Asthma ( ) Kidney Disease ( ) Rheumatoid Arthritis () Digestive Problems ( ) Bleeding Disorder ( ) Liver Damage ( ) Stroke () Blurred Vision ( ) Breast Lump ( ) Measles ( ) Thyroid Problems ( ) Bulimia ( ) Bronchitis ( ) Migraine Headaches ( ) Tumors ( ) Multiple Sclerosis ( ) Other: Family History/ Hereditary High Risk Diseases: Current Medical Doctors/ Alternative Doctors: Broken/Fractured bones: Surgeries: _ Illnesses/Injuries/Hospitalizations: Medications: Allergies: Vitamins/minerals/herbs: Specific diet restrictions:
4 Are You Pregnant: Yes No Due Date: Name of Midwife/OBGYN Any Complications with your pregnancy? FAMILY HISTORY: 1. Does anyone in your family suffer with a same condition(s)? No Yes If yes, what is the same condition(s): Whom: grandmother grandfather mother father sister(s) brother(s) son(s) daughter(s) Have they ever been treated for their condition? No Yes I don t know 2. Any other hereditary conditions the doctor should be aware of? No Yes: SOCIAL HISTORY 1. Smoking: cigars pipe cigarettes how often? Daily Weekends Occasionally Never 2. Alcoholic Beverage: consumption occurs Daily Weekends Occasionally Never 3. Recreational Drug use: Daily Weekends Occasionally Never 4. Exercise: Daily 2-3xper week 1x week none 5. Hobbies -Recreational Activities- Exercise Regime: I hereby authorize payment to be made directly to Gray Chiropractic Health Clinic LLC, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Gray Chiropractic Health Clinic LLC for any and all services I receive at this office. Patient or Authorized Person s Signature - - Date Completed Doctor's comments: Doctor s Signature - - Date Form Reviewed
5 Gray Chiropractic Health Clinic LLC. 360 E. International Airport Rd. #4, Anchorage, AK ACTIVITIES OF DAILY LIVING Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life: Patient Name: Date of Birth: Date of Service: ACTIVITIES: EFFECT: Carry Children/Groceries No Effect Painful (can do) Painful (limits) Unable to Perform Sit to Stand No Effect Painful (can do) Painful (limits) Unable to Perform Climb Stairs No Effect Painful (can do) Painful (limits) Unable to Perform Pet Care No Effect Painful (can do) Painful (limits) Unable to Perform Extended Computer Use No Effect Painful (can do) Painful (limits) Unable to Perform Lift Children/Groceries No Effect Painful (can do) Painful (limits) Unable to Perform Read/Concentrate No Effect Painful (can do) Painful (limits) Unable to Perform Getting Dressed No Effect Painful (can do) Painful (limits) Unable to Perform Shaving No Effect Painful (can do) Painful (limits) Unable to Perform Sexual Activities No Effect Painful (can do) Painful (limits) Unable to Perform Sleep No Effect Painful (can do) Painful (limits) Unable to Perform Static Sitting No Effect Painful (can do) Painful (limits) Unable to Perform Static Standing No Effect Painful (can do) Painful (limits) Unable to Perform Yard work No Effect Painful (can do) Painful (limits) Unable to Perform Walking No Effect Painful (can do) Painful (limits) Unable to Perform Washing/Bathing No Effect Painful (can do) Painful (limits) Unable to Perform Sweeping/Vacuuming No Effect Painful (can do) Painful (limits) Unable to Perform Dishes No Effect Painful (can do) Painful (limits) Unable to Perform Laundry No Effect Painful (can do) Painful (limits) Unable to Perform Garbage No Effect Painful (can do) Painful (limits Unable to Perform Driving No Effect Painful (can do) Painful (limits) Unable to Perform Other: No Effect Painful (can do) Painful (limits) Unable to Perform Please choose 5 of your most worst functional deficits Patient Name: please print: Patient signature: Date: Doctor signature: Date reviewed:
6 Informed Consent REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures: I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments. Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at (Gray Chiropractic Health Clinic LLC) have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. / / Witness Initials Patient or Authorized Person s Signature Date REGARDING: X-rays/Imaging Studies FEMALES PLEASE READ please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation. The first day of my last menstrual cycle was on - - (Date) I am not pregnant. ***ALL PATIENTS PLEASE SIGN BELOW*** By my signature below I hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case. / / Witness Initials Patient or Authorized Person s Signature Date
7 360 E. International Airport Rd. #4, Anchorage, AK DR. CHARLIE GRAY & DR. JENNIFER WALDROUP-GRAY CONSENT FOR PURPOSES OF TREATMENT, PAYMENT & HEALTHCARE OPERATIONS (08/09) IN THIS DOCUMENT I AND MY REFER TO PATIENT, AND CHIROPRACTIOR REFERS TO GRAY CHIROPRACTIC HEALTH CLINIC LLC. I CONSENT TO THE USE OR DISCLOSURE OF MY PROTECTED HEALTH INFORMATION BY CHROPRACTOR FOR THE PURPOSE OF ANALYZING, DIAGNOSING, PROVIDING TREATMENT TO ME, OBTAINING PAYMENT FOR MY HEALTH CARE BILLS, AND TO CONDUCT HEALTH CARE OPERATIONS OF CHIROPRACTOR. I UNDERSTAND THAT ANALYSIS, DIAGNOSIS, OR TREATMENT OF ME BY CHIROPRACTOR MAY BE CONDITIONED UPON MY CONSENT AS EVIDENCE BY SIGNATURE BELOW. I UNDERSTAND I HAVE THE RIGHT TO REQUEST A RESTRICTION AS TO HOW MY PROTECTED HEALTH INFORMATION IS USED OR DISCLOSED TO CARRY OUT TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS OF THE PRACTICE. CHIROPRACTOR IS NOT REQUIRED TO AGREE TO THE RESTRICTIONS THAT I MAY REQUEST. HOWEVER, IF CHIROPRACTOR AGREES TO THE RESTRICTIONS THAT I REQUEST, THE RESTRICTION IS BINDING ON THE CHIROPRACTOR. I HAVE THE RIGHT TO REVOKE THIS CONSENT, IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT CHIROPRACTOR HAS TAKEN ACTION IN RELIANCE ON THIS CONSENT. MY PROTECTED HEALTH INFORMATION MEANS HEALTH INFORMATION, INCLUDING MY DEMOGRAPHICS INFORMATION, COLLECTED FROM ME AND CREATED OR RECEIVED BY MY PHYSICIAN, ANOTHER HEALTH CARE PROVIDER, A HEALTH CARE PLAN, MY EMPLOYER OR HEALTH CARE CLEAINGHOUSE. THIS PROTECTED HEALTH INFORMATION REALTES TO MY PAST, PRESENT, OR FUTURE PHYSICAL OR MENTAL HEALTH OR CONDITION AND IDENTIFIES ME, OR THESE IS A RESONABLE BASIS TO BELIEVE THE INFORMATION MAY IDENTIFYME. I HAVE BEEN PROVIDED WITH A COPY OF THE NOTICE OF PRIVAY PRACTICES OF CHIROPRACTOR AND UNDERSTAND THAT I HAVE A RIGHT THAT INFORMS ME OF THE NOTICEOF PRIVACY PRACTICES PRIOR TO SIGNING THIS DOCUMENT. THE NOTICE OF PRIVACY PRACTICES DESCRIBES THE TYPE S OF USES AND DISCLOSURES OF MY PROTECTED HEALH INFORMATION THAT WILL OCCUR IN MY TREATMENT, PAYMENT OF MY BILLS OR IN THE PREFORMANCE HEALTH CARE OPERATIONS OF CHIROPRACTOR. THE NOTICE OF PRIVACY PRACTICES FOR CHIROPRACTOR IS ALSO POSTED IN THE WAITING ROOM AT 360 EAST INTERANTIONAL AIRPORT ROAD SUITE #4, ANCHORAGE, AK THIS NOTICE OF PRIVACY PRACTICES ALSO DESCRIBES MY RIGHTS AND DUTIES OF THE CHIROPRACTOR WITH RESPECT TO MY PROTECTED HEALTH INFORMATION. CHIROPRACTOR RESERVES THE RIGHT TO CHANGE THE PRIVACY PRACTICES THAT ARE DESCRIBED IN THE NOTICE OF PRVACY PRACTICES. I MAY OBTAIN A REVISED NOTICE OF PRIVACY PRACTICES BY CALLING THE OFFICE OF CHIROPRACTOR AND REQUESTING A REVISED COPY TO BE SENT IN THE MAIL OR ASKING FOR ONE AT THE TIME OF MY NEXT APPOINTMENT. SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE PRINTED NAME OF PATIENT DATE OF SIGNING DESCRIPTION OF PERSONAL REPRESENTATIVES AUTHORITY
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska 99518 (907)563 7700 PATIENT DEMOGRAPHICS Today's Date: Name: Birth Date: Age: Male
SPARROW FAMILY CHIROPRACTIC
Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail 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:
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
APPLICATION FOR CARE
3023 Eastland Blvd. Suite 101 Clearwater, FL 33761 Ph: 727-797-9900 Fax: 727-797-7695 APPLICATION FOR CARE Date: Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email Address: Birth
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: HRN: PATIENT DEMOGRAPHICS Name: DOB: Age: Male Female Address: City: State: Zip: E-mail: Home
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital
New Practice Member Application
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 /
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 /
Rise Chiropractic 239 S. French Broad Ave Asheville, NC
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APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
Today s Date: APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC PATIENT DEMOGRAPHICS Name: Birth Date: / / Age: Male Female Address: City: State: Zip: E-mail Address: Home Phone: Cell Phone: Martial
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 Practice Member Application
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PATIENT REGISTRATION
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New Practice Member Application
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New Practice Member Application
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New Patient Form Welcome!
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Chiropractic Registration and History
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Who may we thank for referring you? When did this episode start?
NEW PRACTICE MEMBER APPLICATION 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 # (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
LIST YOUR HEALTH CONCERNS BELOW
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WELCOME to the Florence Chiropractic and Wellness Center.
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APPLICATION FOR CARE AT
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
New Practice Member Paperwork
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Registration and History Form
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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
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LIST YOUR HEALTH CONCERNS BELOW
T 1 2 3 ROOTS CHIROPRACTIC HEALTH PROFILE In Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Work Email Address Date of Birth / / Occupation Employer's Name Single / Married / Divorced
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
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Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
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3. How Long Has This Been An Issue?
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Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
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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
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PRIMARY COMPLAINT: Date when symptom first appeared Did it begin: Gradual Sudden Progressive over time
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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
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
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
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Child (0-17) New Patient Intake Form. Child s Health Summary
Child (0-17) New Patient Intake Form Child s Name Age Birth Date / / Soc. Sec. # - - Parent/Guardian Name: Address: City: State: Zip: Parent/Guardian Email: Parent/Guardian Phone: Whom may we thank for
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
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
Welcome to our office!
Welcome to our office! Today s Date / / Patient Title: Mr. Mrs. Ms. Miss Dr. Name: Preferred Name: Address: City: State: Zip Code: Home Phone: Work Phone: Mobile Phone: Email Address: Preferred Contact
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
Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other
Patient s Name Date: What is the reason for you visit today? Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone # (home)
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
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED Patient Information Name: DOB: / / Gender: M F Home Address: Home Phone: City, State, Zip: Work Phone: Email Address: Cell Phone: I do not want
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
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
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
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:
Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Tassin Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
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
Area of Complaint: Right Left Bilateral. When did your complaint begin? Unknown Work Accident Auto Accident Sports Injury Other:
Quality Chiropractic 6231 Leesburg Pike Suite 200 Falls Church VA 22044 (703) 237-0404 fax (703) 237-7828 Quality Chiropractic & Rehab 102 Elden Street Suite 12 Herndon VA 20170 (703)581-8999 fax (703)
COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC FX:
COOK CHIROPRACTIC CLINIC 1715 S MAIN ST KANNAPOLIS NC 28081 704-938-7111 FX:704-932-4066 Patient Data Date Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address Line
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
Initial Patient Health Assessment Form
Initial Patient Health Assessment Form General Information: Patient Name:, Date: / /20 Patient s Address:. City:, State:, Zip Code: Home Phone #: - -, Work Phone #: - -, Cell #: - - E-mail address:, Date
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
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 ( ) -
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ 85207 480.830.0175 Health History Name Address City State Zip Day Phone Evening Phone E-mail Address Employer Birth Date Age Gender Emergency
New Patient Intake Form. About You
New Patient Intake Form 4610 Amber Valley Pkwy, Suite B, Fargo, ND 58104 Phone: 701-364-9355 Fax: 701-364-4032 About You First Name: Occupation: Last Name: Names and Ages of Children: Nickname: Date of
New Patient Health Information Form
Dr. Gerard Rosney Dr. Joseph Rosney New Patient Health Information Form Date: Name: DOB: Age: Sex: M / F Home Phone # Cell # Work # Address: City: State: Zip: Email: Marital Status: M / S / D / W Children: