! " Chiropractic History/Patient Information
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- Chester Gallagher
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1 Chiropractic History/Patient Information Date: Patient # Name: SocialSecurity# HomePhone: Address: City: State: Zip: E=mailaddress: Fax# CellPhone: Age: BirthDate: Race: Marital:MSWDDP Occupation: Employer: Employer'sAddress: Office Phone: Spouse: Occupation: Employer: Howmanychildren? NamesandAgesofChildren: NameofNearestRelative: Address: Phone: Howwereyoureferredtoouroffice? FamilyMedicalDoctor: Whendoctorsworktogetheritbenefitsyou.Maywehaveyourpermissiontoupdateyourmedicaldoctorregarding yourcareatthisoffice? Pleasecheckanyandallinsurancecoveragethatmaybeapplicableinthiscase: MajorMedical Worker'sCompensation Medicaid Medicare AutoAccident MedicalSavingsAccount&FlexPlans Other NameofPrimaryInsuranceCompany: NameofSecondaryInsuranceCompany(ifany): AUTHORIZATIONANDRELEASE:IauthorizepaymentofinsurancebenefitsdirectlytoDr.Gerken/Osmonand/or to Indiana Family Chiropractic Center. I authorize the practitioners to release all information necessary to communicatewithpersonalphysiciansandotherhealthcareprovidersandpayorsandtosecurethepaymentof benefits.iunderstandthatiamresponsibleforallcostsofchiropracticcare,regardlessofinsurancecoverage.i alsounderstandthatifisuspendorterminatemyscheduleofcareasdeterminedbymytreatingdoctor,anyfees forprofessionalserviceswillbeimmediatelydueandpayable. The patient understands and agrees to allow the Indiana Family Chiropractic Center to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. The following person(s) have my permission to receive my personal health information: Patient'sSignature: Guardian'sSignatureAuthorizingCare: Date: Date:
2 PATIENTNAME: DATE: HISTORYOFPRESENTANDPASTILLNESS: *Sothatwecanbetterserveyourhealthneeds,itisrequiredthateachformbecompletelyfilledoutpriorto seeingthedoctor. 1. Whatisyourmajorsymptom? 2. Isthisareoccurrence,whenwasthefirsttimeyounoticedtheproblem? Howdidthisoriginallyoccur?n Hasitbecomeworserecently?Yes No Better GraduallyWorse 3. Howfrequentisthecondition?Constant Daily Intermittent Nightonly Howlongdoesitlast?AllDay FewHours Minutes 4. Arethereanyotherconditionsorsymptomsthatarerelatedtoyourmajorsymptoms? Yes No Ifyes,describe: 5. Describethepain:Sharp Dull Numbness Tingling Aching Doyouhaveahistoryofstrokeorhypertension? 6. Isthereanythingyoucandotorelievetheproblem?Yes No Ifyes,describe: Ifno,whathaveyoutriedtodothathasnothelped? 7. Whatmakestheproblemworse?Standing Sitting Lying Bending Lifting Twisting Other 8. Haveyouhadanybrokenbones,majorillnesses,injuries,falls,autoaccidentsorsurgeries? Women,pleaseincludeinformationaboutchildbirth(includedates): 9.Haveyoubeentreatedforanyhealthconditionbyaphysicianinthelastyear? Yes No Ifyes,describe: 10.Whatmedicationsordrugsareyoutaking? 11.Doyouhaveanyallergiesofanykind(includinganymedications)? Yes No Ifyes,describe: 12.DoyouhaveanyCongenitalConditions? Yes No Ifyes,describe: Women:Isthereanychanceyouareyoupregnant?Yes No Maybe Pleaseprovideanyfurtherinformationthatmaybeofhelpinprovidingyourtreatment.Thisisalsoanopportunityto provideinformationontheotherareasofcomplaint/discomfortyouwouldliketoaddress.
3 PATIENTNAME: DATE: Haveyouhadordoyounowhaveanyofthefollowingsymptoms/conditions?PleaseindicatewiththeletterNif youhavetheseconditionsnoworpifyouhavehadtheseconditionspreviously. N=NowP=Previously Headaches Frequency LossofBalance NeckPain Fainting StiffNeck LossofSmell SleepingProblems LossofTaste BackPain UnusualBowelPatterns Nervousness FeetCold Tension HandsCold Irritability Arthritis ChestPains/Tightness MuscleSpasms Dizziness FrequentColds Shoulder/Neck/ArmPain Fever NumbnessinFingers SinusProblems NumbnessinToes Diabetes HighBloodPressure IndigestionProblems DifficultyUrinating JointPain/Swelling WeaknessinExtremities MenstrualDifficulties BreathingProblems WeightLoss/Gain Fatigue Depression LightsBotherEyes LossofMemory EarsRing BuzzinginEars BrokenBones/Fractures CirculationProblems RheumatoidArthritis Seizures/Epilepsy ExcessiveBleeding LowBloodPressure Osteoarthritis Osteoporosis Pacemaker HeartDisease Stroke Cancer Ruptures CoughingBlood EatingDisorder Alchoholism DrugAddiction HIVPositive GallBladderProblems Ulcers OtherSymptomsweshouldknowabout: SOCIALHISTORY Pleaseindicatebesideeachactivitywhetheryouengageinit: OFTEN= O SOMETIMES= S NEVER= N VigorousExercise FamilyPressures ModerateExercise FinancialPressures AlcoholUse OtherMentalStresses DrugUse Other(specify) TobaccoUse Caffeine Pleaselisttypesofexercise/physicalactivity: PleaseListsupplements/vitaminstaken:
4 PATIENTNAME DATE FAMILYHISTORY Pleasereviewthebelow=listeddiseasesandconditionsandindicatethosethatarecurrenthealthproblemsofthe familymember.leaveblankthosespacesthatdonotapply.circleyouranswersifyourrelativelivesaroundthis locality,assomehereditaryconditionsareaffectedbysimilarclimate. FATHER MOTHER SPOUSE BROTHER(S) SISTERS CHILDREN CONDITION Age[] Age[] Age[] Age[]Age[] Age[]Age[] Age[]Age[] Arthritis Asthma=HayFever BackTrouble Bursitis Cancer Constipation Diabetes DiscProblem Emphysema Epilepsy Headaches HeartTrouble HighBlood Pressure Insomnia KidneyTrouble LiverTrouble Migraine Nervousness Neuritis Neuralgia PinchedNerve Scoliosis SinusTrouble StomachTrouble Other: Ifanyoftheabovefamilymembersaredeceased,pleaselisttheirageatdeathandcause: Icertifytheinformationprovidedisaccuratetothebestofmyknowledge: NameofPatient SignatureofPatient Parent/LegalGuardian Date
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Chiropractic Case History/Patient Information
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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:
Chiropractic Case History/Patient Information
1 Chiropractic Case History/Patient Information Name: Social Security # Home Phone: Address City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Race: Marital: M S W D Occupation: Office Phone:
Chiropractic Case History/Patient Information
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1 Chiropractic Case History/Patient Information
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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:
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CORNERSTONE PAIN MANAGEMENT
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WOODLANDS FAMILY CHIROPRACTIC
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Registration and History 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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DAVID P. SNIEZEK, DC, MD MBA, FAAIM, FAAMA
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LIST YOUR HEALTH CONCERNS BELOW
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ADIO CHIROPRACTIC HEALTH PROFILE
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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:
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
PATIENT INFORMATION FORM First Name MI Last Preferred Name Date of Birth / / Age Gender Patient/Guarantor SS# - - Email Address Martial Status Single Married Other Street Address City State Zip Code Profession
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
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:
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!
WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU! NAME DATE ADDRESS Gender CITY, PROVINCE HOME PHONE E MAIL POSTAL CODE DATE OF BIRTH (D/M/Y)
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
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Street address: City: State: Zip: Address:
Patient Information: Date: First name: Middle initial: Last name: Date of Birth: SSN# Best phone number to contact you at: Home Work Mobile How did you hear about us? Referral by: Street address: City:
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
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:
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
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)
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