562 KINGWOOD DRIVE KINGWOOD, TX Application Form
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- Clemence Copeland
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1 Application Form WELCOME TO OUR OFFICE. We specialize in helping people achieve their highest level of health through our Neurological, Brain-Based, and Metabolic corrective programs. Our approach is unique and advanced from other rehabilitative programs; therefore, we have strict requirements in accepting new patients. This approach allows our patients to achieve far superior results compared to most other systems. In order to be seen, you agree to: 562 KINGWOOD DRIVE KINGWOOD, TX Fill out the following forms as thoroughly as possible so that we can determine whether we can accept your case. These forms must be completed and brought with you to your scheduled appointment. 2. Watch the VIDEO explaining What Makes Us Unique. 3. Wear loose fitting clothing (preferably without metal) so Dr. Clark can access from your elbows down and your knees down as he is going to be doing a complete structural and neurological examination and may need to take x-rays. 4. Please bring copies of all lab studies and diagnostic test results that you have had within the last year along with this packet. I agree to the above terms and understand that should I NOT meet these terms I will be asked to reschedule my appointment. Page 1 of 6
2 Patient Introduction Personal History: Name: First Middle Last Address: Telephone: Home: Cell: Address (office use only): Insurance Card: (Please bring health card to front desk) Birth Date: / / Social Security#: Marital Status: Spouse s Name: Occupation: Employer: How did you hear about our office? List Chiropractors you have seen before: 1. Name: When Visited: 2. Name: When Visited: List Medical Doctors consulted within the past year: 1. Name: Reason for visit? 2. Name: Reason for visit? List ALL medications you take. (Prescription and Over-the-counter) Drug Name: Dosage: Length of time taken? Page 2 of 6
3 Patient History Check ALL that apply to you, currently or in the past: CERVICAL SPINE (NECK): Postural distortions from subluxations, (causing Forward Head Syndrome), in your neck will weaken the nerves into your arms, hands, and head, affecting these parts of your body. Do you experience any of the following? Neck Pain Pain into your shoulders/arms/hands L R Vertigo/Dizziness Numbness/tingling in arms/hands L R Visual disturbances Sinusitis/sinus infections Low Energy/Fatigue Coldness in hands Weakness in grip Thyroid conditions TMJ/Pain/Clicking Migraines/Headaches Recurrent colds/flu Hearing problems THORACIC SPINE (UPPER BACK): Postural distortions from subluxations (resulting from Forward Head Syndrome) in the upper back will weaken the nerves to the heart and lungs and affect these parts of your body. Do you experience any of the following? Heart Palpitations Upper Back Pain Asthma/Wheezing Heart Murmurs Shortness Of Breath Tachycardia Pain On Deep Inhalation/Exhalation Heart Attacks/Angina Recurrent Lung Infections/Bronchitis THORACIC SPINE (MID BACK): Postural distortions from subluxations (resulting from Forward Head Syndrome) in the mid back will weaken the nerves into your ribs/chest and upper digestive tract and affect the following parts of your body. Do you experience do any of the following? Mid Back Pain Nausea Pain Into Your Ribs/Chest Ulcers/Gastritis Indigestion/Heartburn Hypoglycemia Reflux Tired/Irritable after eating LUMBAR SPINE (LOW BACK): Postural distortions from subluxations in the low back (resulting from Forward Head Syndrome) will weaken the nerves into your legs/feet and pelvic organs and affect these parts of your body. Do you experience any of the following? Low back pain Constipation / Diarrhea Numbness/tingling in your legs/feet L R Recurrent bladder infections Coldness in your legs/feet L R Frequent/difficulty urinating Muscle cramps in your legs/feet L R Menstrual irregularities/cramping (females) Pain into your hips/legs/feet L R Sexual dysfunction Weakness/injuries in your hips/knees/ankles Main Complaint: How did it start? Grade Intensity / Severity (0 = no pain; 10 = extremely severe pain) What have you tried to do to get rid of this problem that DID NOT work? Page 3 of 6
4 Have you become discouraged about handling this problem? How does this problem interfere with areas of your life? What do you do that makes this problem worse? What gives you some temporary relief? What is the pattern of this problem? Constant Intermittent Occasional Cyclic List ALL Previous hospitalizations, surgeries, accidents, fractures, and illnesses: 1. Type When Hospitalized? Yes No 2. Type When Hospitalized? Yes No 3. Type When Hospitalized? Yes No 4. Type When Hospitalized? Yes No 5. Type When Hospitalized? Yes No_ Check ALL that apply to you. ADD/ADHD Anemia High Blood Pressure Chronic Fatigue Alzheimer s Celiac Disease High Cholesterol Eczema Anxiety Gallbladder High Blood Sugar Lyme s Disease Depression Ulcers Miscarriage Lupus Epilepsy/Seizures Crohn s Disease Insomnia Fibromyalgia Stroke Ulcerative Colitis Diabetes Multiple Sclerosis Learning Difficulties IBS Gout Raynaud s Syndrome Memory Loss Cancer Rheumatoid Arthritis Unable to Focus Parkinson s Disease Please check all of the following conditions your family have or currently suffer from: Alzheimer s Cancer Diabetes Heart Disease Parkinson s MS Stroke Autoimmune conditions (i.e. Lupus, RA, Psoriasis, MS, Hashimoto s, etc.) Could your problem have been caused by an injury at work? If yes, please give us the details: Do you have any children? Do they have any health problems that you are aware of? Have you experienced any unexplained or rapid weight changes in the last six months? Yes No Page 4 of 6
5 Our Fee Structure Please note our fees for your initial visit: Consultation COMPLIMENTARY Complete Neurologic Examination $ (*X-rays will be included if deemed necessary) Exceptions: TOTAL= $ If you have been involved in a motor vehicle accident, our fee structure may differ due to the complexity of your needs in such cases. If you are coming in from an ad or a Facebook post our fee structure may differ from above. I fully understand the above fees and give my consent for the doctor to perform a complete neurologic exam. I also give my consent to have the doctor take any x-rays he/she deems appropriate to better understand my problem and monitor my progress. Consent for Radiology I,, give the doctors of this Chiropractic and Wellness Center my consent to take all x-rays needed to better understand my condition. I have been fully informed of the possible risks and safety standards of this office. I also give my consent for films of my child (children) for the same reasons, if applicable. [For women: To my best knowledge I am not pregnant and know of no contraindications for x-rays at this time.] Patient Signature: (Signature of Parent/Guardian required if patient under age 18) Date: Page 5 of 6
6 Treatment Consent Form Before receiving consultation or treatment in our office, Please review the principles outlined below: 1. I understand that Dr. Clark s goal is to provide me with adjunctive and supportive care for my health condition. Clark Chiropractic & Wellness does not claim to treat or cure any disease or medical diagnosis. 2. I understand that this office offers some services not covered by insurance. These services are considered experimental and may or may not be billed to my insurance. Dr. Clark will review all services that are considered covered services and those that are not. Nutritional support may also be offered for my case. Nutritional supplements are not FDA regulated and have not been proven to cure or treat any disease or illness. 3. I understand that Clark Chiropractic & Wellness services are not a replacement for my medical treatment. Clark Chiropractic & Wellness chooses to work alongside my medical provider, as this serves me in the most effective manner. 4. Dr. Clark will never give advice on the use of my medications. Medications must be managed by my medical doctor. I must work with a medical doctor for the management of any medications I take now or in the future. 5. I completely understand that there are no guarantees of help, correction, relief, or cure, whether written, spoken, or implied. I understand that this clinic does NOT treat any disease or any medical diagnosis. 6. I am making a sane and conscious decision to seek advice as per the above understood terms for either myself and/or my dependents. In doing so, I agree to the above terms and acknowledge this with my signature. Patient Signature: Date: Witness Signature: Date: Page 6 of 6
PATIENT APPLICATION FORM
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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
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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 /
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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 /
Patient Application Form
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HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
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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
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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
Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?
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
PATIENT APPLICATION FORM
Page 1 of 19 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach
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AUTHORIZATION FOR CHIROPRACTIC TREATMENT
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PATIENT APPLICATION FORM
Page 1 of 12 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach
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Address City State Zip Code
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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
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Luker Chiropractic Health Questionnaire
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(emergency room pain)
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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:
Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
Today s : MHSC REGISTRATION # (6 DIGIT) (9 DIGIT) First Name: Last Name: I am a Male/Female (circle) Birthday (d/m/y): / / Current Age: Street Address: City: Province: Postal Code: Home #: Work #: Cell
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
PATIENT FEE SCHEDULE As of January 1, 2017
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Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:
Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
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
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
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
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
Welcome to MedWell. Patient Information. Name: Address: City: State: Zip Code: !Other. Name: Address: City: State:
1 Welcome to MedWell Patient Information Date: Name: Date of Birth: / / Address: City: State: Zip Code: Home Phone: ( ) - Cell Phone: ( ) - Email: Gender:! Male! Female Last 4 of Social Security Number
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
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You
Thrive Family Chiropractic
Thrive Family Chiropractic Dr. Kaitlin Parker, DC 1121 S. Bowman, Suite C-3 Little Rock, AR 72211 501.712.1022 Pediatric Vitality Questionnaire Name: Date: Birth Date: Gender: Male Female Parent s phone
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 ( ) -
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Name: Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: Date of Birth: Your age: Care Card #: Address: City/Prov: Postal Code: Phone: Cell: Work Phone: E-mail Address: Marital