NEW CHIROPRACTIC PATIENT INFORMATION Dr. Bryan Mock, LLC 2101 Greentree Rd Pittsburgh, PA
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- Reynold Thompson
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1 NEW CHIROPRACTIC PATIENT INFORMATION Dr. Bryan Mock, LLC 2101 Greentree Rd Pittsburgh, PA Allergies: WELCOME The doctor and staff would like to welcome you and want to provide you with the best possible care. We will conduct a history and chiropractic examination to determine your best course of treatment. OUR GOAL The goal of our care is to enhance your wellbeing. We will focus on your current complaints, but we want to assist you in identifying the cause of your problems and eliminate them improving the overall quality of life. To achieve this goal, we need a complete patient health and wellness history. Discomfort and diseases are caused by stress that affects us in three areas: Physical, Biochemical, and Psychological. To get the best results, we need to work to address all three causes of stress. Patient Identification Today s Date: Date of Birth: Last First Address: Apt #: City: State: Zip: Phone number: Would you like to receive confirmation text messages or s? (circle one) Text Both In case of emergency, please contact: #: Relation: Your Occupation: Employer: Have you been to a Chiropractor before? Yes No Who referred you to Chiropractic care with us? What brings you to our office? Are your concerns/complaints related to an auto accident or a work-related injury? Yes No If yes, what is the date of the injury? Briefly describe the incident.
2 First (major) concern/complaint: Date when first symptom appeared: Does this interfere with: Recreational Activities Work Walking Sleep Driving Have you ever been to another doctor for this problem? Yes No If so, who? Did it begin: Gradually Sudden Progressive over time What makes symptoms increase? Type of pain: Sharp Dull Ache Burn Throb Does the pain radiate into your: Arm Leg Does not radiate Do you experience numbness or tingling? Yes No How often do you experience these symptoms? 100% 75% 50% 25% of the time Pain Intensity: Please circle a number, 1 being almost no pain, 10 being unbearable Other concerns/complaints: Please mark with pain location and type for each complaint: Please mark off areas of your complaint on the diagrams above. Please use the following symbols on the pain diagram to accurately describe your condition. P N T C WHERE YOU EXPERIENCE PAIN WHERE YOU EXPERIENCE NUMBNESS WHERE YOU EXPERIENCE TINGLING WHERE YOU EXERIENCE CRAMPING
3 General History Please check all the symptoms/problems you experience or have, even if they don t seem related to what brought you here. Headaches Pins/Needles in legs/arms Fainting/vertigo Vision problems Ringing/buzzing in ears Nervousness/anxiety Numbness in hands/fingers Numbness in feet/toes Mood swings Fatigue Sleep problems Irritability Tension Diarrhea Constipation Hot flashes Depression Urinary problems Heartburn Ulcers Upset stomach Get colds every year Get sore throats Blood sugar issues Weight gain Weight loss Arthritis High blood pressure Personal history of cancer: Other: Other: Other: Please list any past surgeries and the surgeon: List any accidents or injuries: (car wrecks, broken bones, concussions, slips & falls) Do you have any allergies? Yes No If yes, list them below: Have you had any x-rays of your spine? Yes No If yes, when and where were they taken? Please list any medications or vitamins you are currently taking & what they re for:
4 Consent for Treatment If you have questions, please ask! I acknowledge that I have shared my complete health history and that I understand I am encouraged to ask questions regarding my care at any point during any visit to this office and NO GUARANTEE NOR ASSURANCE HAS BEEN MADE REGARDING THE OUTCOME OF MY CARE. I have been advised of the types of care (relief, rehabilitation, enhancement of wellbeing) available at this office and listed on the back of this page. I am aware it is my obligation to ask questions of the doctor and staff. I give the staff at Dr. Bryan Mock, LLC full authority to diagnose and treat me within the scope of practice guidelines set forth by the state of Pennsylvania Department of Licensing for Doctors of Chiropractic. I understand that chiropractic care and physical rehabilitation will require person to person contact by the doctor. I have been made aware that, as with any health care procedure, there are risks associated with chiropractic care. These risks include, but are not limited to, increased soreness and muscle spasms, headaches, radiating pain, numbness, ligament sprain, tendon strain, in very rare instances intervertebral disc damage, and in extremely rare instances there has been clinical evidence suggesting upper cervical vertebral manipulations may increase instances cerebral vascular or neurological insult. State licenses of the chiropractors at Dr. Bryan Mock, LLC are visible on the wall and a copy are available upon request. I have had to the chance to ask questions regarding my care and this policy; I also understand it is my responsibility to ask questions for any aspect of my care or office policy I don t understand. Signature: Date:
5 Medical Information Release Today s Date: Last Date of Birth: First Release of Information I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: (Please list specific names) Spouse: Child(ren): Other: Information is not to be released to anyone This Release of Information will remain in effect until terminated by me in writing. To contact me, please call: My Home: My Cell: My Work: If unable to reach me: You may leave a detailed message Contact Information Please leave a message asking me to return your call Other: In the event that someone else answers the phone, please: Leave instructions with them to return your call. You may disclose information regarding my treatment to those have listed above Leave instructions with them for returning your call. Do not disclose any medical information regarding my treatment. The best time of day to reach me is between and. (day) (time) (time) I authorize that I have been presented with, and offered a copy of my HIPAA rights, and that the above information is correct to my desires. Signature: Date:
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
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
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NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
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NPM INTAKE FORM. INFORMATION: Name: Age: Date: Home Phone No.: Work Phone No: Cell Phone: Address:: Gender: Date of Birth:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
NPM INTAKE FORM INFORMATION: Name: Age: Date:
NPM INTAKE FORM INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address:: Gender: Date of Birth: Occupation: Best Time to Contact: Number of Children
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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
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
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
Back In Balance Chiropractic, LLC
Back In Balance Chiropractic, LLC Date Name What do you prefer to be called Address City State Zip Code Birth Date: / / Social Security Number: - - Height: Weight: E-mail Home Phone ( ) - Cell ( ) - Contact
ADULT CHIROPRACTIC INTAKE FORM
ADULT CHIROPRACTIC INTAKE FORM Welcome to our office! It is well known that families who maintain strong, healthy, wellaligned spines have greatly improved health. People whose spines are not healthy and
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:
SPINE PROGRAM NEW PATIENT FORM
Name: Date of Birth: Today s Date: Are you right or left handed? What are your goals for the visit? Who referred you to us? Primary Doctor Another Doctor Dr. Of what specialty? Someone else: PAIN 1. Tell
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Re-Exam Questionnaire
Re-Exam Questionnaire Patient Name: Date: The following hi-lighted symptoms are what brought you into our office originally. DIRECTIONS: Please rate ALL hi-lighted symptoms: S = same; B = better; W = worse
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address:
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: HRN: PATIENT DEMOGRAPHICS Name: DOB: Age: Male Female Address: City: State: Zip: E-mail: Home
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician: