New Practice Member Application
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- Brice Simon
- 6 years ago
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1 New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Occupation Employer s Name Status: Single / Married / Divorced / Widowed Spouse s Name Number of Children Names, Ages, & Gender Who may we thank for referring you? List The Health Concerns That Brought You Into This Office Health Concern(s): Rate of Severity When did Have you had the Did the Are symptoms List according 0 = no pain this problem problem before? problem begin constant (C) or to severity. 10 = unbearable start? If so, when? with an injury? intermittent (I)? Primary: Second: Third: Fourth: Have you ever seen other doctors for these conditions? Yes No If Yes: Chiropractor Medical doctor Other Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have: Headaches Ear Infections Sinus Issues Kidney Problems Sexual Dysfunction Migraines Hearing Loss Frequent Colds Bladder Problems Sleep Problems Jaw/TMJ Pain Ringing in the Ears Thyroid Issues Menstrual Problems Tight/Sore Muscles Neck Pain Dizziness Asthma Prostate Problems Sports Injury Shoulder Pain Loss of Energy Chest Pain Infertility Sciatica Arm Pain Nervousness Heart Problems Fibromyalgia Arthritis/Joint Pain Upper Back Pain Double/Blurry Vision Nausea Epilepsy/Convulsions GERD/Gastric Reflux Mid Back Pain Anxiety Ulcers Tremors Numb/Tingling in Arms/Hands Lower Back Pain ADD/ADHD Digestive Issues Disc Problems Numb/Tingling in Legs/Feet Hip/Leg Pain Loss of Balance Diarrhea Scoliosis Stomach Problems Knee Pain Depression Constipation Poor Posture High/Low Blood Pressure Foot Pain Allergies Bed Wetting Skin Problems Difficulty Breathing Pregnant: Due Date?: Stroke Cancer Heart Attack Spinal Surgery Spinal Bone Fracture Scoliosis Diabetes Arthritis Seizures Other: PLEASE MARK the areas on the Diagram with the following letters to describe your symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/Stabbing T = Tingling What relieves your symptoms? What makes your symptoms feel worse? 1
2 When is the problem(s) at its worst? AM PM Mid-Day Late PM List all surgical operations & years: List any other injuries to your spine, minor or major, that the doctor should know about: List all over the counter & prescription medications you are on, & the reason for each: Have you ever been in an auto accident? List all: Have you ever been knocked unconscious? Yes No Fractured A Bone? Yes No If yes to either of the above, please describe: Other trauma: Social History 1. Smoking: How often? Daily Weekends Occasionally Never 2. Alcohol: How often? Daily Weekends Occasionally Never 3. Exercise: How often? Daily Weekends Occasionally Never 4. Have you consumed any caffeine or products with caffeine in the past 48 hours? Yes No Quadruple Visual Analogue Scale Please circle the number that best describes the question asked. If you have more than one complaint, please answer each question for each individual complaint and indicate the score of each complaint. Back pain Headaches Worst possible pain EXAMPLE: No pain 1. How would you rate your pain RIGHT NOW? 2. What is your typical or AVERAGE pain? 3. What is your pain level at its BEST? (How close to 0 does your pain get at its best?) What percentage of you re awake hours is your pain at its best? % 4. What is your pain level at its WORST? (How close to 10 does your pain get at its worst?) What percentage of your awake hours is your pain at its worst? % Activities Of Life Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life: ACTIVITY: 2 EFFECT: Sit to Stand No Effect Painful (can do) Painful (limits) Unable to Perform Climbing Stairs No Effect Painful (can do) Painful (limits) Unable to Perform Driving No Effect Painful (can do) Painful (limits) Unable to Perform Extended Computer Use No Effect Painful (can do) Painful (limits) Unable to Perform Household Chores No Effect Painful (can do) Painful (limits) Unable to Perform Lifting Children No Effect Painful (can do) Painful (limits) Unable to Perform Dressing No Effect Painful (can do) Painful (limits) Unable to Perform Shaving No Effect Painful (can do) Painful (limits) Unable to Perform Sexual Activities No Effect Painful (can do) Painful (limits) Unable to Perform
3 Sleep No Effect Painful (can do) Painful (limits) Unable to Perform Static Sitting No Effect Painful (can do) Painful (limits) Unable to Perform Static Standing No Effect Painful (can do) Painful (limits) Unable to Perform Walking No Effect Painful (can do) Painful (limits) Unable to Perform Washing/Bathing No Effect Painful (can do) Painful (limits) Unable to Perform Sweeping/Vacuuming No Effect Painful (can do) Painful (limits) Unable to Perform Yard work No Effect Painful (can do) Painful (limits) Unable to Perform Garbage No Effect Painful (can do) Painful (limits) Unable to Perform Concentration (Reading) No Effect Painful (can do) Painful (limits) Unable to Perform LIST RESTRICTED ACTIVITY CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL Family Health History This form is to assist the doctors by providing past health history information for their review. CONDITION SPOUSE SON DAUGHTER MOTHER FATHER Headaches Neck Pain Jaw/TMJ Pain Shoulder Pain Back Pain Hip/Leg Pain Arthritis/Joint Pain Ear Infections Hearing Loss Dizziness Loss Of Energy Nervousness Blurred/Double Vision Anxiety Example: Climbing stairs I can climb 2 flights before it hurts I used to climb 10+ fights without pain ADD/ADHD Depression Allergies Sinus Issues Thyroid Problems Asthma Breathing Problems Heart Problems High/Low Blood Pressure 3
4 Stomach Problems Bed Wetting Infertility Sciatica Fibromyalgia Poor Posture Sleep Problems Stroke Cancer Heart Disease Diabetes Arthritis Alzheimer s Informed Consent For Chiropractic Care Chiropractic care, like all forms of health care while offering considerable benefits may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases, injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include: sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the rarest complications associated with chiropractic care occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral injury that could lead to a stroke. Prior to receiving chiropractic care in the chiropractic office, a health history and physical examination will be completed. These procedures are performed to assess your specific conditions, your overall health and in particular your spinal health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant finding will be reported to you along with a care plan prior to beginning care. I understand and accept that there are risks associated with chiropractic care and give consent to the examination that the doctor deems necessary and the chiropractic care, including spinal adjustments, as reported following my assessment. I authorize and request payment of insurance benefits directly to Joey Kelbel, D.C. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the practice member. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment. Print Name: Signature: Date: If This Health Profile Is For A Minor/Child, Please Fill Out And Sign Below Written Consent For A Child Name of practice member who is a minor/child: I authorize Dr. Joey Kelbel and any and all Discover Life Chiropractic staff to perform diagnostic procedures, radiographic evaluations, render chiropractic care and perform chiropractic adjustments to my minor/child. As of this date, I have the legal right to select and authorize health care services for my minor/child. If my authority to select and authorize care is revoked or altered, I will immediately notify Discover Life Chiropractic. Guardian Signature: Date: Relationship To Minor/Child: 4
5 Notice of Privacy Practices Acknowledgement I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA). I understand that this information can and will be used to: 1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. 2. Obtain payment from third-party payers. 3. Conduct normal healthcare operations, such as quality assessments and physicians certifications. I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my private information is used to disclose to carry out treatment, payment, or healthcare operation. I also understand you are not required to agree to my requested restrictions, but if you agree, then you are bound to abide by such restrictions. Signature: Date: X-Ray Authorization As your healthcare provider, we are legally responsible for your chiropractic records. We must maintain a record of your x-rays in our files. At your request, we will provide you with a copy of your x-rays in our files. Digital x- rays on a CD will be available within 72 hours of request on any regular practice hours day. Please note: X-rays are utilized in this office to help locate and analyze vertebral subluxations. The doctor of Discover Life Chiropractic does not diagnose or treat medical conditions; however, if any abnormalities are found, we will bring it to your attention so that you can seek proper medical advice. By signing below you are agreeing to the above terms and conditions. Print Name: Date of Birth: Signature: Date: FEMALES ONLY: To the best of my knowledge, I BELIEVE I AM NOT PREGNANT at the time the x-rays are taken at Discover Life Chiropractic. Signature: Date: 5
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 /
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
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
New Practice Member Application
T 1 2 3 Date / / New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Cellular Provider Email Address Occupation Employer s Name Single / Married
Who may we thank for referring you? When did this episode start?
NEW PRACTICE MEMBER APPLICATION Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
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.
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
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
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
ADIO CHIROPRACTIC HEALTH PROFILE
ADIO CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appointments, would you prefer? EMAIL or TEXT CELL
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
CIRCLE ALL CURRENT PROBLEMS YOU HAVE
INSIDE OUT CHIROPRACTIC HEALTH PROFILE Name Date / / Age Male/Female Address City State Zip Phone: Home Cell_ Date of Birth / / Email Address For confirming appts, would you prefer? TEXT (cell carrier:
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
LIST YOUR HEALTH CONCERNS BELOW
Date / / HEALTH PROFILE T C E X Name D.O.B. / / Age Male/Female Address City State Zip Phone: Home Cell Cell Phone Carrier: Email Address Occupation Employer s Name _ Single / Married / Divorced / Widowed
Current Health Information
Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms
LIST YOUR HEALTH CONCERNS BELOW
LOCATION COMING SOON Lakewood Ranch, FL 32402 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 Position Single
LIST YOUR HEALTH CONCERNS BELOW
Name Date / / Age Male/Female Address City State Zip Phone: Cell Cell Phone Provider Date of Birth / / Email Address Occupation Employer s Name Single/Married/Divorced/Widowed Spouse s Name Number of Children
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:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date:
SMITH CHIROPRACTIC HEALTH PROFILE Today s Date: Name: Age: Male/Female DOB: Address: City: State: Zip: Home Phone:_ Cell: Cell Phone Provider: SSN#: Email Address: Single/Married/Divorced/Widowed Spouse
APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
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New Practice Member Application
a New Practice Member Application PATIENT DEMOGRAPHICS Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Cellular Provider Email Address Occupation Employer s Name Single /
New Practice Member Application
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APPLICATION FOR CARE AT CORE CHIROPRACTIC
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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: PATIENT DEMOGRAPHICS HRN: Name: Birth Date: - - Age: o Male o Female Address: City: State:
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
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Address City State Zip Code
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Today s Date: Have you ever received chiropractic care? No Yes, (Please list the City, State, & Doctor):
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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
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)
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE
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New Patient Form Welcome!
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Stacey Dent, D.C., B.C.A.O Three Notch Rd. Unit 104 Hollywood, MD P: F: HarborBayChiropractic.
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PATIENT APPLICATION FORM
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BalanceChiropractic 7165 E University Dr. Suite 102 Mesa, AZ
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PERSONAL INFORMATION. First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip:
ADULT INTAKE FORM Date: PERSONAL INFORMATION First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip: Cell Phone: ( ) Alternate Phone: ( Text Reminders: Y N Before
Hill Family Chiropractic Patient Application
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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
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate
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:
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE Personal Information: Name: Home phone #: Address: Alt. phone #: City/State/Zip: Email address: Date of birth: Age: Social Security #: Insurance Information: (Vehicle You
Today s Date: Have you ever received chiropractic care? No Yes, (Please list the City, State, & Doctor):
Tyler Leopardi D.C., Brittany Leopardi D.C. 1933 S. Narcoossee Rd. Saint Cloud, FL 34771 P: 321.430.3820 F:1.407.498.4051 info@avenueonechiropractic.com ADULT INTAKE FORM Discover Your True Health Potential.
Chiropractic Case History/Patient Information
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Patient Re-Examination Form
Harrisburg Family Chiropractic 220 S. Cliff Ave. Ste 106 Harrisburg SD 57032 (605) 767-7463 Name: Date: / / Patient Re-Examination Form Please fill out the information that has changed since your last
Welcome to Manna Family Chiropractic!
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Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability.
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Matthews Family Chiropractic
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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