Dynamic Balance Chiropractic Adult New Patient Questionnaire
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- Emory Floyd
- 5 years ago
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1 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 In the event that we need to reach you, what is the best time? Occupation Employer Hobbies and Interests In case of emergency, contact Phone Whom may we thank for referring you to our office? Are you: Single Married Common Law Widowed Separated Divorced Spouse/Partner Name D.O.B Are you pregnant? No Don t Know Yes, approximate due date Children s Names and Ages 1. Age: 2. Age: 3. Age: 4. Age: 5. Age: 6. Age: 2. Please tell us more about your current situation: Why did you choose this office? What are your expectations from working with us? Do you have any issues keeping you from experiencing and enjoying your life as much as you would like? In other words, is something bothering you? No, I am here for continued health development and/or the ongoing pursuit of wellness. Yes, I have some symptoms. (please list them below, in order of their effect on your life) 1. How long has this affected your life? 2. How long has this affected your life? 3. How long has this affected your life? What is the name of the last doctor that put you on a health development program? Were you able to stick to that program? Yes No Never had a health development program Please list any medications you currently take: Please list any surgeries or hospitalizations you have had: Please list any allergies/sensitivities you may have (drug or food): What else stands in the way of full expression of your health potential? Have you ever been to a Chiropractor before? No Yes: Who is your family medical doctor? Address/ Phone: Please list any other health care professionals currently treating you:
2 Compared to 5 years ago, are you: More healthy Less healthy About the same Are you satisfied with your current perceived overall health status? Yes No What could you do to improve your health in the next 5 years? 3. Family History Please check if your mother, father or siblings have experienced any of these conditions: Mother Father Siblings Diabetes Heart Disease Cancer Arthritis Other family history that you feel is important: 4. Are you seeking care as a result of an accident or injury? Yes No (If no, please skip to section 5) Date of Accident Type of Accident: Sports Auto Work Other Details: (How did it happen?) 5. Daily Habits Exercise: Heavy (Competitive Training) Daily (4-7 times/wk) Moderate (1-3 times/wk) None Work Activity: Heavy Labor Light Labor Standing Sitting/Desk/Sedentary Habits: Coffee/Caffeine drinks: None Occasional Daily cups/day Alcohol: None Occasional Daily drinks/week Smoking: None Occasional Daily packs/day I want to quit. Please list any Vitamins/Herbs/Minerals you take: 6. Have you ever had, or been diagnosed with: cancer: diabetes / pre-diabetes been in a car accident stroke / cerebrovascular accident had a spine or spinal cord injury heart attack, angina, other heart problems fracture or broken bone gout high cholesterol high blood pressure carotid artery stenosis polycystic ovarian syndrome 7. Have you experienced: ongoing fatigue blurry vision tinnitus / ringing in ears unexplained weight loss / gain frequent feeling of thirst frequent urination frequent infections numbness/tingling in hands or feet sexual dysfunction 8. Responsible Party Who is responsible for decisions related to the care of this patient? Myself 1. Name: Relationship Phone 2. Name: Relationship Phone 9. Payment for services rendered To best serve you, we operate our office under the guidelines of payment at the time of service. This allows our staff to focus their time and energy on your health care needs, and minimizes administrative efforts. This allows us to keep our costs (and yours) at a reasonable level. Thank you for honoring this system and fulfilling your financial obligations on the day that the services are performed. The above information is true, complete and accurate to the best of my knowledge. Patient/Guardian Signature: Date:
3 INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE We use a multitude of techniques and tailor the care of our patients and practice members to their individual needs and limitations. We take great care to maximize results while minimizing risks. However, as in all forms of care and treatment, some risk is inevitable and unavoidable. In chiropractic care in general, some of the associated risks are listed below: o As we seek to make changes in the way your body works, sometimes patients may experience a short term aggravation of their symptoms, muscle strains, or ligament sprains. If you have symptoms, they may get worse before they get better. o While it has never occurred in our office, rib fractures have been reported as a result of manual adjustment of the midback. For patients with increased risk (osteoporosis, etc), we will alter the way in which we adjust these areas in order to minimize that risk. o There are reported cases of cerebrovascular incidents or stroke that have been associated with many common neck movements, including painting a ceiling, backing up a car, having your hair washed at a salon, and manipulation of the cervical spine. The most up to date research does not show a causal relationship between chiropractic adjustment and stroke. We are, however, required to inform you of these reports. Strokes have potentially serious neurological impairments, and possible paralysis, no matter the cause. The possibility of such injury to happen after a visit to a chiropractic office has been shown to be the same as a visit to a medical office, and is extremely remote. No reputable study has shown that a stroke was caused by a chiropractic adjustment. We screen each patient for risk factors of stroke and modify our treatments to reduce risk of any sort. o Rarely, there are reported cases associating an injury to the intervertebral disc following cervical and lumbar adjustments, although these cases also have not been supported by the demonstration of causal relationship. We take care to screen each patient to determine which adjustment techniques would best suit them to achieve maximum benefit with minimized risk. Chiropractic treatment and chiropractic adjustments have been the subject of many government reports and interdisciplinary studies conducted over the last 115 years, and have been demonstrated to be safe and effective. Chiropractic care contributes to your overall well being, and the risks of injuries or complications from chiropractic treatments is substantially lower than many other forms of treatment. I acknowledge that I have had the opportunity to discuss with my chiropractor the nature and purpose of chiropractic treatment in general and my treatment in particular (including spinal adjustment) as well as the contents of this Consent. I consent to the chiropractic treatments offered or recommended to me by my chiropractor, including spinal adjustments. I intend this consent to apply to all my present and future chiropractic care. I reserve the right to withdraw my consent at any time with verbal or written notice of such a decision. correspondence is often used in our office to communicate with patients as well as to send our free monthly wellness newsletter. I do not want any from Dynamic Balance Chiropractic, even regarding appointment changes, invoices for insurance reimbursement, or care recommendations. I know I can unsubscribe at any time, but I do not want to receive the Free monthly wellness newsletter from Dynamic Balance Chiropractic. Patient Signature: (or Legal Guardian if underage) Print Patient Name: Date: Signature of Witness: (employee at Dynamic Balance Chiropractic) Print Witness Name: Date:
4 Pregnancy History Questionnaire Name: Age: DOB: Today s Date: 1. If you are trying to become pregnant: How many cycles have you been trying? How long are your cycles? days Are your cycles regular? Y / N What, if any, has been your previous method of birth control? None Birth Control Pill Condoms IUD Depo Provera shot Patch Fertility Awareness Method/Natural Family Planning Rhythm method Withdrawal Have you had any previous miscarriages? Y / N If yes, when: Please list any supplements (prenatal vitamin, herbs etc) you are taking: Are you taking any medications? Are you seeing a fertility specialist? (name/address/phone) Are any other health professionals treating you for fertility? Have you had any fertility testing/procedures done? 2. If you are currently pregnant or have recently been pregnant: What is/was your estimated date of delivery? How many weeks pregnant are you? wks What was the term of your pregnancy? wks How many previous pregnancies have you had? Do you have other children? Y / N How many? How did you conceive this pregnancy? Natural Medical intervention (IUI, IVF, medications, etc.) Who is/was in charge of your care for this pregnancy? (name/ address/phone) Any other professional attendants? How many ultrasounds have you had/having during this pregnancy? Any other testing? Throughout your pregnancy, have you had any of the following: (if yes, list details) Falls? Motor Vehicle Accident? Near miss MVA? High Blood Pressure? Diabetes? Anemia? Morning Sickness? Indigestion? Seizures? Swelling (hands/feet)? Thyroid Problems? Heart Problems? Back Pain?
5 Bleeding from the vagina? Were you hospitialized? Been told your baby was in the breech position? Any other illnesses? Any other issues? 3. During your pregnancy, or while trying to conceive, did you use any of the following: Tobacco? Never Occasionally Daily packs/day Alcohol? Never Occasionally Daily drinks/day Non-prescribed drugs? Never Occasionally Daily /day Prescription medications? Never Yes Medication: Reason: Over-the-counter meds? Never Yes Medication: Reason: Is there anything else that you think we should know about your pregnancy? For better co-management of your case, may we contact the health professionals working with you? Yes No If yes, please list which ones: I certify that all above information is true, to the best of my knowledge. Patient Signature: Date: Patient Name Printed:
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Chiropractic Wellness Center Date: Patient Intake Form Please Write Legibly Patient Legal Name: Male Female Preferred Name: Date of Birth: Age: Home Address: Apt#: City: State: Zip: Home Phone: Cell Phone:
Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:
Name Age Date Please list All your current health complaints, including the reason that brought you to our office: List any other doctors see for current problems and list treatment received and results:
Nashoba Valley Chiropractic (978)
(978) 448-2800 Last Name: First Name: MI: Mailing Address: City: State: Zip: O.K. to call home? Yes No Home Phone: O.K. to call cell? Yes No: Cell Phone: Sex M F Birthdate: Age: Marital Status: Single
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
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?
CORAL REEF CHIROPRACTIC CENTER, PA NAME (Last, First, Middle Initial) HOME PHONE TODAY S DATE COMPLETE ADDRESS (Include City, State & Zip) CELL PHONE DATE OF BIRTH OCCUPATION EMPLOYER NAME EMAIL AGE SEX
Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)
Patient Information Name: First Last M.I. Date: Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Email: Phone: Cell/Home/Work (please circle one) How did you hear about us? Door hanger, Fargo
Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other
Patient s Name Date: What is the reason for you visit today? Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other Personal Information Address City/State/Zip Phone # (home)
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
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
PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
Patient# WELCOME Today s Date / / Please fill out this form as completely as possible. Please print. PERSONAL INFORMATION Name What you prefer to be called Age Date of Birth / / Sex SS# E-Mail Home Address
Cascadia Chiropractic Centre
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
Ages 6 to E. Lohman Ave Ste 22 Las Cruces, NM (575) Today's Date: Date of Birth: Phone Number with Area Code:
3961 E. Lohman Ave Ste 22 Las Cruces, NM 88011 (575) 652-3358 Ages 6 to 18 Today's Date: Name: Date of Birth: Sex: Male Female Mailing Address: Parent/Guardian Names & Phone Numbers: Phone Number with
History & Review of Systems Screening. Medical History
History & Review of Systems Screening Patient name: Date: / / Pharmacy name:_ Primary Care Physician: Referring Physician: Height: Weight: R or L handed Medical History Please tell the doctor if you have
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
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
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
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
Sydney Chiropractic, DR. DAVID DUNN
PERSONAL HISTORY Name: Address: City: Province: Postal Code: Home Phone: Birthdate: Age: Sex: M F # of Children Business/Employer: Business Phone: Type of Work You Do: E-mail: Emergency Contact: Phone
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
Adult New Patient Intake. Your Health Summary
Adult New Patient Intake Name Age Birth Date / / Soc. Sec. # - - Home Phone Cell Phone Address: City: State: Zip: Occupation: Email Marital Status: M W D S Spouse s Name: Children # and Ages: Whom may
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