SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY
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1 SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY Welcome! PLEASE PRINT CLEARLY PERSONAL DATA Today s Date First name MI: Last name: Nickname Gender M F Age Date of Birth SS# (optional) Current address City State Zip Home phone ( ) Cell phone ( ) Work Phone ( ) ext Preferred phone contact - Home Work Cell address In which format do you prefer appointment reminders? Telephone Home Work Cell Occupation Employer Student F/T P/T Marital Status Single Divorced Widowed Married to: Emergency contact Relationship to you Names and Ages of Children Whom may we thank for referring you to our office? REASON FOR SEEKING CHIROPRACTIC CARE Please list your health Rate of severity When did Did the % of the time concerns according to 1 = mild this episode problem begin pain is present their severity 10 = worst start? with an injury? Is your pain dull? Or is your pain sharp? Does it radiate anywhere? If so, where? Since the problem started, is it: About the same Getting Better Getting Worse (circle applicable) What have you done for this condition? Was it of benefit? I do (do not) have a family history of this or similar symptoms (please explain) Are these concerns affecting your life? (Please put a checkmark in front of all that apply 1. Do they cause you: 2) Do they affect your WORK: 3) Do they affect your PERSONAL LIFE: Moodiness Decision Making Lose patience with spouse/children Irritability Poor attitude Restricted household duties Interrupted sleep Decreased Productivity Hinders ability to exercise/participate in Restricted Daily Activities Unable to work long hours Sports Exhausted at end of day Interferes with ability to participate in hobbies or other desired activities On a scale of 1-10 how is this affecting your life? (circle) Little affect Great affect
2 Name. Today s date.. Name... HEALTHCARE PRACTITIONER Today s HISTORY date... Have you consulted OR do you regularly consult any of the following providers? Chiropractor Medical Doctor(s) Others Doctor s details: Name: Address: When did you see them: What did they say was wrong? Did it help? What did they do? Doctor s details: Name: Address: When did you see them: What did they say was wrong? Did it help? What did they do? (IF YOU NEED TO PROVIDE ADDITIONAL DOCTORS PLEASE ATTACH A SEPARATE SHEET) Please list your current or past health problems in these areas? Please explain: Eyes/Ears/Nose/Throat. Vascular /Cardiovascular. Gastrointestinal.. Endocrine/Thyroid/Diabetes/Glands. Respiratory Urinary/Kidney/Bladder.. Reproductive Skin/hair/nails... Neurological (headaches/seizures/vertigo/stroke/tics).. Musculoskeletal (joints/muscles).. Mental/Phychological (anxiety/bipolar/depression).... Any history of cancer or other illnesses.. Any unexplained weight loss in the last 6 months Yes No HEALTH, WELLNESS AND CHIROPRACTIC CARE The Primary system in the body which coordinates health is the CENTRAL NERVOUS SYSTEM, which is comprised of the brain, spinal cord and spinal nerves. The vertebrae (bones of the spinal column) surround and protect the delicate nervous system. Chiropractors are specialists trained in 2
3 Name Today s date the early detection of injury to the spine and nervous system. The information below will help us to see the types of PHYSICAL, EMOTIONAL & BIOCHEMICAL STRESSES you have experienced because accumulation of stress affects your health and ability to heal. PHYSICAL STRESS: BIRTH AND INFANCY The birth process can traumatize a baby s spine and cause damage to the spine & nerve system. Please circle where and how you were birthed. (if you do not know, please skip to the next question) Home Natural Hospital C-Section Forceps Breech Cord around neck Prolonged Labor Induced Labor Suction PHYSICAL STRESS: CHILDHOOD THROUGH ADULT The minor & often ignored repetitive physical traumas that we have endured are often too numerous to list. Please list the major traumas that you remember from your childhood up to the present. Have you had any accidents, falls or injuries in your life related to any of the following? (check all that apply) Work related Motorcycle Bicycle Sports Playground Abuse Automobile daily life If yes, state type of injury and date: (If this is from a recent auto accident, please provide name of insurance company) Have you ever injured your spine, head, neck, ribs, chest, upper or lower back, pelvis or hips? Y N If yes, state type of injury and date: Have you ever broken, fractured or sprained any bones or joints? Y N If yes, list body parts injured and dates: Have you ever been hospitalized? Y N If yes, state reason and dates: What services were provided? WHEN WHY WHO HAS THE RESULTS X Ray MRI Other.. _ 3
4 Name. Today s date. EMOTIONAL STRESS It is difficult to separate the emotional stress in our life from the physical response that often occurs. Please indicate if you have experienced any of the emotional stresses below: Childhood Trauma Y N Loss of loved one Y N Abuse Y N Work or School Y N Divorce/separation Y N Financial Y N Lifestyle change Y N Parents divorce Y N Illness Y N Biochemical stress occurs when a substance that is toxic to the body is breathed, injected, taken by mouth, or placed on the skin (e.g. food allergies, drug reactions, exposure to chemicals in the air, etc.) The following will reveal exposures you may have had. Were you vaccinated? Y N If yes, did you have a reaction? Y N Have you been exposed to any of the following on a regular basis, (past or present)? Toxic chemicals Second hand smoke Drug therapy Radiation Chemotherapy Other If yes, please list: Do you have allergies to any foods? Y N If yes, please list: Do you consume any of the following presently? BIOCHEMICAL STRESS Coffee/caffeine Alcohol Tobacco Over the counter drugs Prescribed drugs DRUG CONDITION DRUG CONDITION It is imperative that you list ALL medications as they may have an influence on your care. QUALITY OF LIFE How do you grade your physical health? Good Fair Poor How do you grade your emotional/mental health? Good Fair Poor How do you rate your overall quality of life? Good Fair Poor Do you exercise regularly? If yes, how often? Do you miss meals? If yes, how often? Do you take supplements? If yes, please list: Do you follow a special dietary regime? If yes, what? 4
5 Name.. Today s date. Aspects of wellness you want for yourself (please check all that apply) Improved digestion Easier breathing Deeper relaxation I would like the following benefits from Chiropractic Care (check all that apply) Relief of a symptom or problem Healthier spine and nerve system More Energy Better Sleep Freedom from pain Better Concentration Enhanced emotional well- Reduce/eliminate medication use being Improved strength and endurance Better sports performance, reaction time/reflexes More balanced posture Greater Resistance to disease Overall health improvement Relief and prevention of a symptom or problem Optimal health on all levels Physical, Emotional and Biochemical STRESSES, common in everyday life, can result in misalignment of the spinal column causing damage to the nerve system. The result is a condition called Vertebral Subluxation. The Chiropractic Exam/evaluation is specifically designed to detect Vertebral Subluxations in all phases of their progression. FAMILY HEALTH At our office we are not only interested in your health and wellbeing but also that of your family and loved ones. Please mention below any health conditions or concerns you may have about your: Children Spouse Mother Father Brother/s Sister/s Others 5
6 Name.. Today s date FINANCIAL Payment in full is expected on all FIRST VISIT services. All other fees are to be paid at time of service until other arrangements have been made and agreed upon in writing. First visit fees: Comprehensive Exam $150 X Ray views: $30 - $40 per view (by necessity) Please indicate your method of payment Cash Check Credit Card INSURANCE Dr. Spratt is not a participating provider for any insurance company. However, if your insurance company covers chiropractic care, it is quite possible that they will reimburse you for some of our care if you submit your claims. We will be happy to assist you in this process by giving you a Superbill which is a receipt of services (which will include procedure and diagnosis codes) that you can send to your insurance company. Insurance coverage varies greatly. By providing you with a Superbill, we cannot guarantee that you will receive any reimbursement from your insurance company. If you do not have chiropractic care in your policy, or when your plan coverage is exhausted, we have several affordable plans to present to you. Please indicate below if you have a policy or a plan which could reimburse you for your care at this office Health Insurance Auto Accident Worker s Compensation The information I have provided, on this case history form, is true and accurate, to the best of my knowledge. I give Dr. Michael Spratt, permission to render care to me today. This initial visit includes a health history/consultation, chiropractic exam/evaluation, diagnostic X-Rays and any initial care that is determined to be clinically necessary and mutually agreed upon. Signature Today s Date Thank you for choosing Seeds of Hope Family Chiropractic.Let us help you to live your best life possible. We look forward to serving you with the utmost care and compassion. Seeds of Hope Family Chiropractic, 15 West Street, Suite 204, Douglas MA
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
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PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
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PATIENT INFORMATION. Address City State Zip. Home Phone Work Phone Cell Phone Is it okay to contact you at work? Yes No. SSN - - DOB Age
PATIENT INFORMATION Name Date Address City State Zip Home Phone Work Phone Cell Phone Is it okay to contact you at work? Yes No Carrier: E-mail @ SSN - - DOB Age Occupation: Employer: Marital Status: S
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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
CHIROCENTER. Home Address: City: State: Zip: I would like to receive notifications Please do not send notifications
CHIROCENTER PATIENT ADMITTANCE Name: (First) (Middle Int). (Last) Today s : Home City: State: Zip: Telephone: Work: Cell: of Birth: Sex: M or F Social Security#: (Month) (Day) (Year) Circle if you are:
WELCOME TO SOULSTICE WELLNESS CENTRE
WELCOME TO SOULSTICE WELLNESS CENTRE Name: Date: Age: Birth date: (mm/dd/yr) Address: Residence City Prov Postal Code Primary phone: ( ) Male Female Insurance Company:. Alberta Health Care # E-Mail Occupation
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?
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:
Dynamic Balance Chiropractic Adult New Patient Questionnaire
1. Please fill in the following Patient Information: Dynamic Balance Chiropractic Adult New Patient Questionnaire Patient Name Date Male Female Age D.O.B. Address City Province Postal Code Home Phone Work/Cell
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
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
Rosewood Family Healing Center. New Patient Intake Form
Rosewood Family Healing Center New Patient Intake Form Print Name Date Email Date of Birth Age Phone Number Marital Status- M D S W Occupation # of hours/day at a desk Repetitive movements Who may we thank
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: *** PLEASE WRITE IN BLACK
Health Intake Form Connected Chiropractic 32 S. Rutherford Ave.
Health Intake Form Connected Chiropractic 32 S. Rutherford Ave. Johnstown, CO 80534 (970) 587-7029 Name: Date: Address: City: State: Zip: Cell Ph: Home Ph: Work Ph: Best Number to contact you: Home Work
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:
Workers Compensation Questionnaire. Name: Address: Telephone: City: State: Zip: Social Security Number: Cell Phone: Home phone: Work Phone:
Workers Compensation Questionnaire Name: Address: Telephone: City: State: Zip: Social Security Number: Email: Cell Phone: Home phone: Work Phone: Date of birth Sex: Male Female Marital States S M D W Date
MVA Patient Health Record
Name: Date: AHC #: Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email for appointment reminders and information regarding your
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
Cascadia Chiropractic Centre
Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card
Pregnant Patient Introduction Form Form
1820 S. Westnedge Ave. Suite #1. Kalamazoo, MI 49008 269.344.5551 antoniottichiropractic.com Form : Patient name: Address: Estimated Due : Home Phone: INTRODUCTION MEDICAL HISTORY City, State, Zip: Work
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