Dawn Smallwood, DC, NTP PATIENT INFORMATION
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- Jade Carroll
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1 Dawn Smallwood, DC, NTP 120 East 1st Street Cle Elum, WA CleElumchiropractic.com PATIENT INFORMATION Name: Date: (Last) (M.I.) (First) Sex: M F Marital status: (circle) single married divorced partnered widowed Date of Birth: Age: Height: Weight: Mailing Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Please Circle best # to call Occupation: Employer: Name of Spouse: Referred by: Emergency Contact: (Name) (Phone) (Relationship to Patient) HEALTH INFORMATION DISCLOSURE I,, give permission to Cle Elum Chiropractic to disclose the following health information to : Scheduling Information Medical Information (Please initial any/all applicable categories) Financial Information I understand that this gives Cle Elum Chiropractic permission to disclose only the above-mentioned health information to only those above-mentioned individuals. PARENT/LEGAL GUARDIAN AGREEMENT FOR MINORS I,, am the individual who authorizes treatment and is responsible for the financial obligations of. I authorize treatment and agree to pay for all services provided to _ here at Cle Elum Chiropractic. Printed Name: Signature: Date:
2 Name: Date: Have you ever seen these types of practitioners? Doctor of Chiropractic Massage Therapist Nutritional Therapist Acupuncturist HEALTH HISTORY Main Complaint: When did this condition begin? How did this condition begin? Do you have any prior history of this problem? If Yes, please explain: Is this condition injury related? If Yes, is it: Work related? Motor vehicle collision related? Other injury- Please describe: Other doctors/practitioners seen for this condition: What makes this complaint worse? What makes the complaint better? Pain Intensity (circle the #) None Minimal Discomfort/ache/stiff Slight to Moderate Hurts/sore/bearable Severe Sharp/intense pain Headache Neck discomfort Arm/Hand symptoms Mid Back discomfort Low Back discomfort Leg/Foot symptoms Other: Pain Frequency None Occasional Intermittent Frequent Constant Neck 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Arm/Hand 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Mid Back 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Low Back 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Leg/Foot 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Other: 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Do you get headaches? How frequently? How many hours does your typical headache last? Do you get migraines? How frequently? How many hours does your typical migraine last? What is/are the cause(s) of your migraines?
3 Name: Date: Please check symptoms with which your pain has been associated: Numbness, tingling or pain into your shoulder, upper arm, lower arm, or hand/fingers? Circle areas. Numbness, tingling or pain into your hip/buttock, groin, front of thigh, back of thigh, knee, calf, shin, or foot/toes? Circle areas. Increased low back pain with coughing, sneezing, or bearing down to have a bowel movement Excessive fatigue-malaise Weight loss Low grade fever Bowel or bladder disorders (such as urinary or bowel incontinence or difficulty urinating or having bowel movements) Ovarian pain Kidney pain/painful urination Night pain or night time sweats Abdominal pain Balance problems Flu/cold Inflammation Infection Contagious disease Allergies: Food sensitivities: Describe any allergic/sensitivity reactions: Date of last physical exam and results: Job description: Have you been able to work? Y N Recreational activities/hobbies: Do you exercise? If Yes, please describe: Do you, or have you, smoke cigarettes or use tobacco products? If Yes, for how long? Medications and reason taken: Vitamins, minerals, or other supplements:
4 Name: Date: Past Surgeries Date Reason for surgery Past Accidents, Falls or Injuries Date Description of injury Past Fractures/broken bones Date Description/location of fracture Health problems of relatives: Other health related concerns or comments: WOMEN: Are you pregnant? Y N If so, how far along are you? Please list any pregnancy complications or restrictions?
5 Name: Date: Please indicate on the drawing where you experience the following: pain (P), aches (A), numbness (N), swelling (S) Please check any of the following that currently affect you or that you have experienced. MUSCULOSKELETAL Low Back Pain Mid Back Pain Neck Pain Pain between shoulders Arm Pain Shoulder Pain Elbow Pain Wrist pain Finger Pain Hip Pain Thigh Pain Knee Pain Leg Pain Foot Pain Toe pain Ankle pain Jaw Pain Difficulty Chewing Joint Stiffness (Where: ) Joint Swelling (Where: ) Fibromyalgia Osteoporosis or Osteopenia Arthritis Rheumatoid Arthritis Postural Deviations Headache Muscle Weakness or Weak Grip Disc bulge/herniation (Where: ) Vertebrae Condition NERVOUS SYSTEM Multiple Sclerosis Paralysis Spinal Cord Injury Stroke Seizures/Convulsions Numbness/tingling in extremities Cold extremities Twitching/Ticks Fainting Depression Poor balance/coordination CIRCULATORY Anemia Abdominal Aneurysm Hemophilia High Blood Pressure Low Blood Pressure Raynaud s Disease Varicose Veins Hemorrhoids Heart Condition/Attack Blood Clots/Phlebitis Chest Pain Irregular heartbeat Ankle Swelling Light Headedness Body too cold Body too hot DIGESTIVE Abdominal pain Constipation Frequent Nausea Gall bladder problems Liver problems/hepatitis Vomiting Diarrhea Gas/Bloating Indigestion/heartburn Black or bloody stool Excessive thirst Excessive appetite URINARY Bladder trouble/infection Discolored urine Painful urination Excessive urination Scant urination Kidney Problems RESPIRATORY Lung Congestion Sinus Congestion/infection Asthma Difficulty Breathing Dizziness Lung Condition SKIN Fungal Infections Dermatitis/Eczema Psoriasis Open Wound or Sore Rashes Warts/Moles Athletes Foot Ring Worm OTHER Diabetes or Hypoglycemia Anxiety/Nervousness Muscle Cramping Trouble Sleeping Menstrual Problems Cancer Substance Abuse Herpes Fatigue HIV/AIDS Lupus Postoperative Situation Swelling Prosthetics Implanted device (ie: pacemaker) Joint Replacement Transplanted Organ Other:
6 Name: Date: PATIENT COMPLIANCE FORM My initials and signature on this document indicates that: 1) I acknowledge that all the information I have given is accurate to the best of my knowledge and is necessary in order to receive the best possible care. I agree and take responsibility for notifying my practitioner if any physical or mental changes occur with my health (ie: injury, illness, pregnancy, etc) to ensure that the most appropriate and effective care continues to be given. 2) I hereby acknowledge that I have read and fully understand the NOTICE OF PRIVACY PRACTICES outlining the policies and procedures concerning the privacy of my Patient Health Information and if there is anyone I do not want to receive my medical records, I have informed the office in writing. I agree to allow this office to use my Patient Health Information for the purpose of treatment, payment, healthcare operations and not share my health information with anyone, unless I have signed a Records Release Form. 3) I understand that it is my responsibility to make it to all scheduled appointments and to notify the office/practitioner at least 24 hours in advance if a situation arises that leads to cancellation or rescheduling. I agree to pay the $50 missed appointment fee in the event I miss my appointment or cancel last minute. 4) I have read and fully understand this wellness center s FINANCIAL POLICIES and know that I am ultimately responsible for any charges incurred at this office. I know that it is my responsibility to pay at the time of service if a cash patient or a co-payment for regular insurance patients. I know that in the event that I am on an injury claim and the claim closes or stops being paid by the insurance company, that I am responsible for payment, which is due at the time of service. I authorize the use of this signature on all insurance submissions. 5) I give my permission and consent to the general procedure or treatment I will receive and know that if at any time I no longer wish to receive a specific treatment (or an aspect of), I have the right to inform my practitioner. I will ask my practitioner if have any questions concerning the general procedure. Signature: Date:
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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ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
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intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:
intake form Page 1`of 5 About You : Name: Sex: Male Female Address: City: State/Province: Country: Zip/Postal Code: Home Phone Number: Mobile Phone Number: Email Address: Birthday: Marital Status: Married
Patient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
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
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
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
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
NEW SPINE PATIENT. Date Seen: Blood Pressure: Pulse: Weight: Height: O 2. How long (days, weeks, or years) has this complaint/problem been going on?
ROOM #: NEW SPINE PATIENT Date Seen: Blood Pressure: Pulse: Weight: Height: O 2 Sats: For office use only above this line. Patient Name: Referring Physician: Date of Birth: Age: Insurance Carrier: Present
PATIENT HEALTH QUESTIONNAIRE
PATIENT HEALTH QUESTIONNAIRE Name Date Please check all answers and fill in the blanks where appropriate. In the space below, please describe the major complaint which brought you to this office for care.
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:
Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:
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:
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No
PATIENT ENTRANCE FORM Date Circle: Male Female Name Birth Date (dd/mm/yy) Age Address Apt # City Province Postal Code Home # Cell # Work # E-MAIL Occupation Employer Name of Emergency Contact Contact #
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
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION
The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Email: Daytime Phone Number: Date of Birth: / / Age: How did you hear
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage Patient Name Date Address City State Zip Phone (home) (cell) Emergency Contact Name Phone Employer Date of Birth Work Phone Social Security # Is condition
CHIROPRACTIC NEW PATIENT HEALTH HISTORY
CHIROPRACTIC NEW PATIENT HEALTH HISTORY Name: Last: First: MI: Address: City: Province: Postal Code: E-mail address: Cell Phone: Home Phone: Age: Birth Date: Alberta Health #: Occupation: Employer: Marital
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information
Client Questionnaire Personal Information Basic Information First Name Last Name Date of Birth Male Female Other Not Specified Contact Information Email Preferred Phone Cell Address City State Zip Emergency
Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician
Current Problem Date Name (First, MI, Last) Date of Birth Age Male Female Primary Care Physician Referring Physician Height (feet/inches) Weight (lbs.) Right Handed Left Handed Both Current Problem: Right