MVA Patient Health Record
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- Marjory O’Neal’
- 5 years ago
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1 Name: Date: AHC #: Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via for appointment reminders and information regarding your health. Do you consent? (YES) (NO) Sign or Initial here MVA Patient Health Record Relax Breathe Smile We are happy you are here! As a full spectrum Wellness Centre, we focus on your ability to be healthy. Our goals are firstly, to address the issues which brought you into our office, and secondly to offer you the opportunity of improved health potential and wellness services in the future. On a daily basis, you experience physical, chemical and emotional stress which can accumulate and result in a serious loss of health and compromised function. Most times the effects are gradual, not even detectable until they become serious. Answering the following questions will provide us with a profile of the specific stressors you face and have dealt with over your lifetime, allowing us to better assess the challenges to your health. Beacon Hill Chiropractic and Massage Sarcee Trail NW Calgary, AB
2 About You! Name: M F Address: City: Prov: PC: Phone (h): Phone (c): Phone (w): Birthdate: Age: # of Children: Married Single Divorced Separated Widowed Employer: Work Address: Type of Work: Person to Contact In Case of Emergency: Name: Phone Number: (h) (c) Please check to receive the following via Appointment Reminders Patient Newsletters Address We change people s lives through inspiration, empowerment, and excellent health care delivery in a beautiful, efficient team environment making us Calgary s first choice for natural health care. Reason For This Visit Describe the purpose of this visit: Is this visit related to: Job Sports Auto Accident Fall Chronic Discomfort Injury Other Please explain: If job related, have you reported your accident to your employer? Y N When did this condition begin? Has this condition: gotten worse gotten better stayed the same comes and goes Does this condition interfere with: work/school sleep daily routine athletic activities Explain: Have you seen anyone else for this condition? Y N Doctor or Clinician s Name: Type of Treatment: Result: Beacon Hill Chiropractic and Massage Sarcee Trail NW Calgary, AB
3 Experience with Chiropractic Who referred you to our office? Have you ever been adjusted by a Chiropractor? Y N Reason for visits? How long ago? Doctor s Name? Date of last visit? Has any adult in your family seen a Chiropractor? Y N Has any child in your family seen a Chiropractor? Y N Were you aware that: Doctors of Chiropractic work with the nervous system? Y N The nervous system controls all bodily functions and systems? Y N Chiropractic is the largest natural healthcare profession in the world? Y N If Chiropractic care starts at birth, you can achieve a higher level of health throughout your whole life? Y N We look at the entire individual to get to the cause of problems, rather than simply treating symptoms. Unlike other NW Calgary chiropractors, we have a multidimensional focus and take an integrated approach when helping practice members. About the Spouse or Parent Name Employer Work Phone Type of Work Beacon Hill Chiropractic and Massage Sarcee Trail NW Calgary, AB
4 Goals For My Care People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and goals when recommending your treatment program. Please check the type of care desired so that we may be guided by your wishes whenever possible. Relief Care Symptomatic relief of pain or discomfort Corrective Care Corrective and relieving the cause of the problem as well as the symptoms Comprehensive Care Bring whatever is malfunctioning in the body to the highest state of health possible with Chiropractic care I want the Doctor to select the type of care appropriate for my condition Patient Signature Date Health Systems Review Please check each of the diseases or conditions that you have now or have had in the last 6 months. Headaches Congenital Heart Defect Ankle swelling Kidney problems Arthritis Sinus problems Hepatitis Heart Surgery/Pacemaker Vison problems Rheumatic fever Difficulty swallowing Motor Vehicle Accident Heart problems Cancer Loss of sleep High/Low Blood Chemotherapy Pain between For Women: Pressure Difficulty breathing shoulder blades Infertility issues Yes No Dizziness Frequent neck pain Asthma Are you pregnant Yes No Psychiatric problems Numbness or pain in Shingles Are you nursing Yes No Thyroid problems Arms/Legs/Hands Alcohol/Drug abuse Using birth control Yes No Lower back problems Venereal Disease Digestive problems Do you experience painful HIV/Aids Ulcers/Colitis Diabetes menstruation Yes No Heart Attack/Stroke Tuberculosis Excess/Painful urination Irregular cycles Yes No Health and Lifestyle Habits How many fruits and vegetables do you eat per day? How many glasses of water do you drink per day? Do you smoke? Y N packs/day Do you consume salty/sugary treats? Heavy Moderate Light None Do you drink alcohol? Y N drinks/day Do you wear Heel lifts Insoles Arch supports N/A Do you drink coffee? Y N cups/day How do you rate your energy? High Normal Low Describe your sleep: Do you do cardiovascular exercise regularly? 0x per wk 1x per wk 2-3x per wk over 4x per wk Do you do strength training? 0x per wk 1x per wk 2-3x per wk over 4x per wk Family Health History Diabetes Depression MS Heart Disease Osteoporosis Stroke High Blood Pressure Arthritis Cancer Adverse Vaccine Reactions Digestive Issues/Irritable Bowel Beacon Hill Chiropractic and Massage Sarcee Trail NW Calgary, AB
5 Medications/Supplements You Now Take Why This Form Is Important Certain drugs can cause or neuro-musculoskeletal symptoms, therefore it is important for our chiropractors to know what medications you are currently taking. The symptoms that you have presented to the clinic with may be related to these medications. If you are unsure of the medication name and dosage it is imperative that you make note of it and let us know at your next visit. Likewise certain nutritional supplements can alleviate neuro-musculoskeletal symptoms and it is just as important for our chiropractors to know if you are currently taking any nutritional supplements. Stimulants Antidepressants Blood Thinners Muscle Relaxers Birth Control Insulin Acid reducers Blood Pressure Medication Pain Killers (NSAIDS/Aspirin/Ibuprofen) Please list your current prescription and over-the-counter medications: Medication Dosage Reason Duration Please list all nutritional supplements you are currently taking: Supplement Name Dosage Reason Duration Patient Name Dated this day of, 20 Patient Signature Witness Signature Beacon Hill Chiropractic and Massage Sarcee Trail NW Calgary, AB
6 Patient: The Stress Test Date: The following three areas of stress can cause misaligned vertebra (subluxation). Do you recognize any of these stresses? Please indicate if and when you experienced these stresses; Any descriptions are helpful to us. 1. PHYSICAL STRESS: Birth Traumas Y N Describe: Slips/Falls Y N Car Accidents Y N Sports Injuries Y N Physical Abuse Y N Work Injuries Y N Poor Posture Y N Sitting on wallet for years Y N Sleeping Position- Stomach Y N Extensive Computer Work Y N Carrying a Heavy Purse/Bookbag/Child Y N Repetitive lifting/bending Y N Driving for many hours Y N Continuous hours sitting/standing Y N Shoveling, Painting, Gardening, Cleaning Y N 2. EMOTIONAL STRESS: Explain: Relationships Y N Career Y N Children Y N Fast-Paced Life Y N Hold in Feelings Y N Quick Tempered Y N Verbal Abuse Y N Perfectionist Y N Procrastinator Y N Loss of a Loved One Y N 3. CHEMICAL STRESS List: Smoker- Amount? Y N Second-hand Smoke Y N Poor Diet Y N Caffeine - Amount? Y N Excessive Sugar Y N Artificial Sweeteners Y N Prescription Drugs Y N Over-The-Counter Drugs Y N (Example: Tylenol; Motrin) 4. What do you feel are your primary sources of stress? Beacon Hill Chiropractic and Massage Sarcee Trail NW Calgary, AB
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23 Beacon Hill Chiropractic and Massage Payment Authorization Regarding MVA Claims Please note, on rare occasions, insurance companies do not authorize claims. If your insurance company does not authorize any part of your claim, it is your responsibility as our patient to pay for your chiropractic/massage/acupuncture treatments and any related rehabilitative products or supplements. As well, if appointments are cancelled or an appointment is missed without 24-hours notice, you will be charged a cancellation fee. Name: Credit Card Number: Expiry Date: Signed: Date: Witness Name: Witness Signature: MVA Claim Number: Beacon Hill Chiropractic and Massage Sarcee Trail NW Calgary, AB
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Patient Health Record
Patient Name: Date: AHC #: (required by the Alberta College of Chiropractors) Email Address: Under Canada s new anti-spam legislation, we are required to ask you for your consent to contact you via email
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
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
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
Welcome to our Office!
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Chiropractic Health Dr. Art Vanderhoef
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Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
Basic Information Full Name: Address: City: State: Zip: Cell: Home: Work: Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S Email: Occupation: Emergency Contact: Phone: Children: O No
COMPREHENSIVE HEALTH & WELLNESS PROFILE
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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
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CHIROPRACTIC INTAKE FORM
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Insurance. Patient Family Information. Patient Condition
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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 /
HEALTH INFORMATION FORM
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PATIENT INFORMATION HEALTH INFORMATION
PATIENT INFORMATION PLEASE PRINT PATIENTS LAST NAME FIRST NICKNAME STREET ADDRESS APT # TODAYS DATE / / CITY STATE ZIP E-MAIL SEX M F MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DOB / / AGE SPOUSES
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.
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Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
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PATIENT INTRODUCTION
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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
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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
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire
Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire Name: MR#:_ Date: Date of Injury: Referred By: Age: Date of Birth: Handed: R L Ambidextrous Male Female **** Mark
WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE. Name: Date of Birth. Age: Social Security No.: Driver's Lic.# Occupation: Employer:
Date: IDENTIFICATION: WESTERN NEUROSURGICAL CLINIC MEDICAL EVALUATION QUESTIONNAIRE Name: Date of Birth Age: Social Security No.: Driver's Lic.# Occupation: Employer: ******************************************************************************
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated
Patient Information Full Name: First MI Last Patient Intake Form Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Social Security Number: Email Address: Home Phone: Work Phone: Cell/Other:
Welcome to Lone Lake Physical Therapy!
Welcome to Lone Lake Physical Therapy! **Please arrive 5-10 min prior to your appointment time for your first session. Your appointment will last approximately 55-60 min What you should know before your
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
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
Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone
Barcode Label Interviewer: Office: **PLEASE USE BLACK INK** Patient Information Please Print Name Date Date of Birth Social Security #: Street Address City State Zip Home Phone Cell Phone E-Mail Address
PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
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
Welcome to Compass Chiropractic!
Welcome to Compass Chiropractic! Name Age Birth Date / / Home Phone: Cell Phone: Preferred Number: Cell / Home Address: City: State: Zip: Occupation: Email Marital Status: M W D S P Spouse s Name: Number
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
Address: City: State: Zip: Home #: Cell #: Other #: Employer Address: City: State: Zip: Phone #: Sex: DOB: / / Address: Policy ID: Group ID: Employer:
Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E mail newsletters, reminders, statements, etc. Emergency Name: Phone: City: State: Zip: Home
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
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
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
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
LIST YOUR HEALTH CONCERNS BELOW
8209 Natures Way Unit 115 Lakewood Ranch, Florida 34202 (941) 877.1507 Name Date / / Age Male Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Date of Birth / / Employer s Name
CHIROPRACTIC NEW PATIENT FORM REASON FOR VISIT
DR. ANN IZARD, B.COMM, DC DOCTOR OF CHIROPRACTIC 4353 HASTINGS STREET BURNABY, BC V5C 2J7 TEL: 604.293.2941 FAX: 604.298.2941 WWW.BHIHC.COM WWW.ANNIZARD.COM FULL NAME: DATE OF BIRTH (DD/MM/YYYY): STREET
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to