Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?
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1 136 Wilson Pike Circle Brentwood, TN NEW PATIENT INFORMATION Please complete ALL questions below unless otherwise indicated. First Name Last Name Date Street Address City State Zip Cell Phone Provider Cell Phone Address Employer Occupation M D S W Birth Date Age Social Security # Marital Status (circle) Spouse s Name Employer Birth Date Children s Name and Ages: Who may we thank for referring you? Name of Insurance Company (if applicable) Is your visit the result of an auto or work injury? Yes No Have you had chiropractic care in the past? Yes No If yes, how long ago? What condition took you to the chiropractor? Who was your previous chiropractor? When was your last adjustment? HIPAA Privacy Review
2 136 Wilson Pike Circle Brentwood, TN PATIENT HISTORY Please complete ALL questions below. LIST ANY SURGERIES: Back Brain Elbow Foot Hip Knee Neck Neurological Wrist Shoulder Please Describe: LIST ALL PAST MEDICAL HISTORY CONDITIONS: Broken Bones HIV Arthritis Cancer Chest Pain Depression Diabetes Dizziness Epilepsy Parkinson's Minor Heart Problem Neurological Problems Fainting Fatigue Multiple Sclerosis Pacemaker Genetic Spinal Condition Headaches Hepatitis High Blood Pressure Significant Weight Change Menstrual Problems Prostate Problems Stroke/Heart Attack Spinal Cord Injury LIST ANY MEDICATIONS YOU ARE TAKING: Anxiety Muscle Relaxers Pain Killers Insulin Birth control Cardiovascular Allergy Seizure LIST YOUR FAMILY HISTORY: Arthritis Asthma Back Pain Cancer Depression Diabetes Epilepsy Genetic Spinal Condition High Blood Pressure Heart Problems Multiple Sclerosis Neurological Problems Parkinson s Polio Prostate Problems Stroke/Heart Attack PLEASE MARK YOUR AREAS OF PAIN ON THE DIAGRAM BELOW
3 PATIENT HISTORY (page 2) What is your major complaint? Date Problem Began: Is this the result of an auto or work injury? Yes No How did this problem begin (falling, lifting, etc.)? List other doctors you have seen for this condition: Do you have any family members with the same condition? Yes No If yes, who? How is your condition changing? getting better getting worse not changing Have you had this condition in the past? Yes No Please rate your pain on a scale of 0 to 10 (0 = no pain, and 10 = excruciating pain) How do your symptoms affect your ability to perform daily activities such as working or driving? (0=no effect, and 10=no possible activities) Describe the nature of your symptoms: Dull Sharp Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing What activities aggrevate your condition? What makes your pain better? How often do you experience your symptoms throughout the day? Constantly (76-100%) Frequently (51-75%) Occasionally (26-50%) Intermittently (0-25%) Do you have a secondary complaint? Date Problem Began: Please rate your pain on a scale of 0 to 10 (0 = no pain, and 10 = excruciating pain) How do your symptoms affect your ability to perform daily activities such as working or driving? (0=no effect, and 10=no possible activities) Describe the nature of your symptoms: Dull Sharp Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing What actitives aggrevate your condition? What makes your pain better? How often do you experience your symptoms throughout the day? Constantly (76-100%) Frequently (51-75%) Occasionally (26-50%) Intermittently (0-25%) Any Additional complaints?
4 INFORMED CONSENT (page 3) TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our Chiropractic method of correction is by specific adjustments of the spine. HEALTH: A state of optimal physical, mental and social well being not merely the absence of infirmity. VERTEBRAL SUBLUXATION: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. CONSENT FOR TREATMENT I, the undersigned, a patient in this office hereby authorize Dr. Jennifer Bett, Dr. Saira Kay (and whomever they may designate as their assistant(s)) to administer treatment as is necessary. I also certify that no guarantee or assurances have been made to me as to the results that may be obtained. I understand and agree that health and accident insurance policies are an agreement between the insurance company and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from any insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse remittances for the conveyance of credit to my account. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. Signature Date Witness Signature Women Only Is there any chance you are pregnant? Yes No If yes, how many weeks? Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and that Dr. Bett-Gray and Dr. Kay have my permission to perform an x-ray evaluation. I have been advised that x-rays can be hazardous to an unborn child. Date of last menstrual period: The above information is true and accurate to the best of my knowledge. Patient Signature Date Witness Parent or Guardian Signature Date Witness
5 Informed Consent (page 4) INFORMED CONSENT TO CHIROPRACTIC TREATMENT THE NATURE OF CHIROPRACTIC TREATMENT: The doctor will use her hand or a mechanical device in order to move your joints. You may hear a noise and/or feel movement in your joint during an adjustment. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, or intersegmental traction may also be used. POSSIBLE RISKS: As with any health care procedure, complications are possible following a chiropractic adjustment. Com-plications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves, or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritations, burns, or minor complications. PROBABILITY OF RISKS OCCURRING: The risks of complications due to chiropractic treatment have been described as rare. The risk of cerebrovascular injury or stroke, has been estimated at one in a one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered rare. RISKS OF REMAINING UNTREATED: Delay of treatment allows formation of adhesions, scar tissue, and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult. I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment. Printed Name Signature Date Parent or Guardian Signature Witness Signature Date
PATIENT FEE SCHEDULE As of January 1, 2017
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Name: Address: Dr. Simpson Leung Cascadia Chiropractic Centre New Patient Information & Clinical Record Date: City: Province: Postal Code: Phone: Cell: Work Phone: Date of Birth: E-mail Address: Care Card
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)
Great Lakes Chiropractic Adult Health History 116 Central Ave East St. Michael, MN Updated: 06/2018 PH: FAX: Page 1
PH: 763-515-6650 FAX: 763-777-9186 Page 1 Date Name Age Birth Date Email Social Security # Marital Status: M S W D Race/ethnicity Language Preference Address City State Zip Home Phone Work Phone Cell Phone
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
Address City State Zip Code
Name Cell Phone Address City State Zip Code Date of Birth / / Male/Female Age Email SS# Number of Children Name of Children Employer Type of Work Marital Status Married Single Divorced Separated Widowed
The Spinal Tuning Chiropractic Center s Health Profile Application and Practice Entrance & Policy Forms. Table Of Contents:
The Spinal Tuning Chiropractic Center s Health Profile Application and Practice Entrance & Policy Forms Table Of Contents: Health Profile Application, Pages 1&2: This standard health profile application
LIST YOUR HEALTH CONCERNS BELOW
T 1 2 3 ROOTS CHIROPRACTIC HEALTH PROFILE In Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Work Email Address Date of Birth / / Occupation Employer's Name Single / Married / Divorced
SPARROW FAMILY CHIROPRACTIC
Whom may we thank for referring you to this office? SPARROW FAMILY CHIROPRACTIC Today s Date: PATIENT DEMOGRAPHICS PM#: Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail Address:
Child (0-17) New Patient Intake Form. Child s Health Summary
Child (0-17) New Patient Intake Form Child s Name Age Birth Date / / Soc. Sec. # - - Parent/Guardian Name: Address: City: State: Zip: Parent/Guardian Email: Parent/Guardian Phone: Whom may we thank for
Describe the pain and it s location:
WELCOME TO ZIVKOVIC CHIROPRACTIC CENTER DATE: Please print clearly and fill in completely. ABOUT YOU: Patient Name:_ What do you prefer to be called:_ SS# Street Address City State Zip Date of Birth: Age:
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
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE ASTHMA EAR INFECTIONS SORE THROAT BED WETTING HEADACHES UPSET STOMACH
COMPLETE THIS PAGE FOR CHILDREN 4-8 YEARS OF AGE CHILD S CURRENT HEALTH STATUS DURING PREGNANCY DID YOU USE: DRUGS/MEDICATIONS TOBACCO/ALCOHOL IF YES, DESCRIBE YOUR DELIVERY: CHILD S HEALTH HISTORY INSTRUCTIONS:
New Member Contact Information
New Member Contact Information Date: Social Security #: - - File Number: First Name: Middle Initial: Last Name: Age: Birth Date: / / Gender: M F Marital Status: S M D W Home Address: Home Phone: - - City,
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
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.