Name: Date: Mark (c) for current problems, check and indicate the age when you had any of the following:
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1 Patient Intake Form Patient information contained within this form is considered strictly confi dential. Your responses are important to help us better understand the health issues you face and ensure the delivery of the best possible treatment. Name: Date: Insurance: (dd/mm/yr) Date of Birth: Address: male female Marital status S M W D SEP Phone #: home: work: address: Occupation: Employer: Mark (c) for current problems, check and indicate the age when you had any of the following: General Allergies Depression Dizziness Fainting Fatigue Fever Headaches Loss of sleep Mental illness Nervousness Tremors Weight loss / gain Muscle / Joint Arthritis / rheumatism Bursitis Foot trouble Muscle weakness Low back pain Neck pain Mid back pain Joint pain Skin Boils Bruise easily Dryness Hives or allergies Itching Rash Varicose veins Eye, Ear, Nose & Throat Colds Deafness Ear ache Eye pain Gum trouble Hoarseness Nasal obstruction Nose bleeds Ringing of the ears Sinus infection Sore throat Tonsilitis Vision problems Gastrointestinal Abdominal pain Bloody or tarry stool Colitis / Crohn s Colon trouble Constipation Diarrhea Difficult digestion Diverticulosis Bloated abdomen Excessive hunger Gallbladder trouble Hernia Hemorrhoids Intestinal worms Jaundice Liver trouble Nausea Painful defication Pain over stomach Poor appetite Vomiting Vomiting of blood Genitourinary Bed-wetting Bladder infection Blood in urine Kidney infection Kidney stones Prostate trouble Pus in urine Stress incontinence Urination Overnight more than twice More than 8x in 24hrs Decreased flow/force Painful urination Urgency to urinate Cardiovascular High blood pressure Low blood pressure Hardening of the arteries Irregular pulse Pain over heart Palpitation Poor circulation Rapid heart beat Slow heart beat Swelling of ankles Respiratory Chest pain Chronic cough Difficulty breathing Hay fever Shortness of breath Spitting up phlegm / blood Wheezing Women only Congested breasts Hot flashes Lumps in breast Menopause Vaginal discharge Menstrual flow Reg. Irreg. Pain / cramps Days of flow: Lenght of cycle: Date - 1 st day last period: Are you pregnant? yes, no If yes, how many months? How many children do you have? Birth control method: Date of last PAP test: normal, abnormal Date of last mamogram: normal, abnormal Check any of the conditions you have or have had: Alcoholism Anemia Appendicitis Arteriosclerosis Asthma Bronchitis Cancer Chicken pox Cold sores Diabetes Eczema Edema Emphysema Epilepsy Goiter Gout Heart burn Heart disease Hepatitis Herpes High cholesterol HIV/AIDS Influenza Malaria Measles Miscarriage Multiple sclerosis Mumps Numbness/tingling Pace maker Osteoporosis Pneumonia Polio Rheumatic fever Stroke Thyroid disease Tuberculosis Ulcers Please list any medication you are currently taking and why: Reproduction is permitted for personal use, not for resale or redistribution by Professional Health Systems Inc. Dedicated to Clinical Excellence.
2 Patient Intake Form (side 2) Give a breif detailed description of the problem you are currently experiencing: How long have you had this condition? Is it getting worse? yes, no Does it bother you (check appropriate box): work, sleep, other: What seemed to be the initial cause: Please mark you area(s) of pain on the figure below Please place a mark at the level of your pain on the scale below: Worst Possible Pain No Pain Past health history Have you... Yes No If yes, explain breifly... been hospitalized in the last 5 year?... had any mental disorders?... had any broken bones?... had any strains or sprains?... ever used orthotics? Do you take minerals, herbs or vitamins? How is most of your day spent? standing, sitting, other: How old is your matress? When was your last physical exam? Habits none light mod. heavy Alcohol Coffee Tobacco Drugs Exercise Sleep Soft drinks Salty foods Water Sugar Family history Alcoholism Anemia Arteriosclerosis Arthritis Asthma Bleed easily If any blood relative has had any of the following conditions, please check and indicate which relative(s) Cancer High blood pressure Diabetes High cholesterol Emphysema Multiple sclerosis Epilepsy Osteoporosis Glaucoma Stroke Heart disease Thyroid disease Do you have any other health issues or concerns that our staff should be made aware of? Reproduction is permitted for personal use, not for resale or redistribution by Professional Health Systems Inc. Dedicated to Clinical Excellence.
3 Family Chiropractic Fee Schedule Examination $50 May be submitted to an Insurance Company for reimbursement. Adjustment $42 May be submitted to an Insurance Company for reimbursement. Child/Student Discount Adjustment $25 May NOT be submitted to an Ins. Co. 1 st Additional Family Member Adjustment $25 May NOT be submitted to an Ins. Co. 2 nd or More Additional Family Members $10 May NOT be submitted to an Ins. Co. PRE- PAYMENT PLAN 10 visits $350 Normal cost $420 = savings of $70 / Over 16% savings Must be paid in full & may not be submitted to insurance company for reimbursement. A MONTH of Care $255 This is a CASH UP FRONT Discount for Intensive Care (12 visits. 12 x $42 = $504; SAVINGS of $249!!). This plan is designed for practice members who are serious about their commitment to being well. You must attend a 'Wellness Class' in order to qualify for this program. This MUST be PAID IN FULL, at the BEGINNING of each month, and MAY NOT be submitted to an Insurance Company. If you wish to submit your bills to an insurance company for reimbursement, you must pay the FULL adjustment amount $42 at the time of each service, then we would be happy to bill your company for you, as a courtesy. A YEAR of Care $2550 This is a CASH UP FRONT Discount for Intensive Care (144 visits. 144 x $42 = $6048; SAVINGS of $3,498!! At 144 visits a year, 3X per week, that averages to $17.70 a visit!!). This plan is designed for practice members who are serious about their commitment to being well. You must attend a 'Wellness Class' in order to qualify for this program. This MUST be PAID IN FULL, at the BEGINNING of your year, and MAY NOT be submitted to an Insurance Company. If you wish to submit your bills to an insurance company for reimbursement, you must pay the FULL adjustment amount $42 at the time of each service, then we would be happy to bill your company for you, as a courtesy. Our mission is to motivate you, encourage you, and move you & your family members toward greater levels of well-being. Our Goal is to provide you with excellent care, outstanding service and fees that will allow you to receive the FULL benefit of chiropractic care. Chiropractic is an important part of the equation for good health. Please feel free to discuss any questions or concerns regarding you finances with our office assistants. They are prepared and authorized to work with you to find the payment plan designed for your needs. The Family Chiropractic Fee Schedule has bee thoroughly explained to me, I understand that I may ask to review these options at any time. If I have chosen a CASH UP FRONT or other DISCOUNTED option, and I wish to discontinue care before I reach the allotted number of visits, I will be refunded the balance in full minus $42 for each of the visits I used. Signature Date Witness Date
4 Terms of Acceptance When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of focus to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. (print name) All questions regarding the doctor s objective pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. (signature) (date) Consent to evaluate and adjust a minor child I, being the parent or legal guardian of have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual period: (Signature) (date)
5 Acceptance of Responsibility I, the undersigned, accept responsibility for any bills that I incur. If for any reason my insurance does not cover these expenses, I understand that I will be solely responsible. If my Insurance coverage includes a co-payment, I will also be responsible for the amount of each co-payment. Signature Date
Name: Date: Mark (c) for current problems, check and indicate the age when you had any of the following:
Patient Intake Form Patient information contained within this form is considered strictly confi dential. Your responses are important to help us better understand the health issues you face and ensure
B wel Chiropractic & Health Associates 3020 East College Avenue, Suite H Appleton, WI Dr. James M. Benzschawel
DATE: CASE HISTORY SEX: M / F LAST NAME: FIRST: M: DOB: ADDRESS: CITY: STATE: ZIP: APT OR UNIT #: HOME#: CELL#: SS #: - - MARITAL? M S W D # OF CHILDREN? SPOUSE NAME?: SPOUSE DOB?: OCCUPATION: EMPLOYER:
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
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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.
PATIENT INFORMATION Please print clearly and complete all blanks
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Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
New Patient Form Welcome!
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City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
PERSONAL INJURY QUESTIONNAIRE
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COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
Patient Information. Date: To See Dr. Patient s Name: Last First Middle. Insurance Company: Phone # Address: Street City State Zip
Shay B. Dean, M.D.FACS 9201 SUNSET BLVD., LOS ANGELES, CA 90069 PH 310-777-6677 FAX 310-777-6680 & 4832 Lincoln Blvd. Marina del Rey, CA 90292 PH 310-860-0696 FAX 310-821-1708 Patient Information : To
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
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Patient Admittance Form
Patient Admittance Form Mah Chiropractic Clinic 7222 Edgemont Blvd. N.W. World Health Club Calgary, AB. T3A 2X7 Phone: (403) 241-1886 Fax: (403) 241-0995 Name: (Family) (First) (Initial) Sex: Male Female
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
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Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
CONSULTATION ADMITTANCE FORM
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Personal and Family Health History
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Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
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UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT
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INFORMATION/APPLICATION FOR CARE
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Welcome To Our Office
Welcome To Our Office Mission Statement Our office is dedicated to educating and adjusting as many families as possible towards optimal health through natural chiropractic care. We believe the greatest
Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:
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Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information: