PLEASE ASK US FOR HELP IF YOU HAVE ANY QUESTIONS.
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- June Harrington
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1 Patient Entrance Form Michelle A. Gross, B.Sc. (Hons.), D.C. G. Murray Townsend, B.Sc., D.C. Brianne O Driscoll, B.Sc., D.C Name Date Date of Birth / / DAY MONTH YEAR Age Marital Status Home Address Town PO Box 911 # Apt. # Postal Code Home Telephone Work Telephone Other Telephone Address Occupation Employer Location Spouse s Name _ Children (names) Contact Name Contact Phone Please advise us of any changes made at a later date to the above information Most Recent Chiropractic Care: Name Location Last Visit Results: Excellent Good Fair Poor Current Medical Doctor/ Nurse Practitioner: Name Location You were referred to our office by: friend/ family member NAME phone book walk-in newspaper Medical Doctor Nurse Practitioner Other I have received treatment for this current problem from: Medical Doctor Hospital Other Chiropractor Massage Therapist Physiotherapist Other This visit is due to a: Recent Motor Vehicle Accident Work Related Injury (WSIB) PLEASE ASK US FOR HELP IF YOU HAVE ANY QUESTIONS. Mount Forest Chiropractic 148 Main Street South, Mount Forest, Ontario N0G 2L0
2 COMPLAINT HISTORY What problem(s) would you like the doctor to address? Explain how your complaint(s) occurred: No Reason At Work Car Accident Is your condition... Worse Better Same Fluctuates What makes your condition worse? better? Are you taking medications for this problem? No Yes (list) Please indicate other medications that you are taking. Pain Killers Muscle Relaxants Arthritis Meds. Nerve Pills Blood Pressure Pills Insulin Heart Meds. Birth Control Estrogen Vitamins Blood Thinners Thyroid Pills Cholesterol Other (please list) Mark the areas of the body where you feel the described sensations. Use the appropriate symbols. Include all affected areas. Stiff/ Tight... X X X X Dull/ Aching... A A A A Sharp/ Stabbing... / / / / / / Pressure... > > > > Pins & Needles/ Tingling... * * * * * Numbness... N N N N Burning... O O O O
3 Changes/ Limitations in Activities of Daily Living due to your injury: Sleep: Self Care: Sports: Hobbies: Care of Children: Care of Home: Moving in Bed Dressing Exercising Reading Lifting child Vacuum/clean Getting Settled Bathing/Showering Walking Watching TV Picking up toys Dishes/Cooking General Sleeping Hair Care Bathing/Washing child Lawn/Garden Personal Care/Hygiene General Care Garbage Limitations: Check all that apply: I have difficulty Kneeling Bending Twisting Sitting Standing Climbing Stairs Climbing Ladder Reaching Walking Driving Repetitive Work Writing Lifting floor to waist Lifting waist to shoulder Keyboarding/Computer use Car/ vehicle accident(s): Minor (no medical attention) Minor (some medical attention/ x-rayed) Major (injury/ hospitalization) Surgeries: Back Neck Joint Replacement Gall Bladder Appendix Tonsils Hernia Heart Other Significant Injuries (Broken bones, sprains, falls): Serious illnesses/ hospitalizations: Childhood Illnesses: Chicken Pox Mumps Measles Rheumatic Fever Polio Scarlet Fever Whooping Cough Rubella (German Measles) Other Other health problems (e.g. Diabetes, arthritis, heart/ stroke): Please list any X-rays you have had within the past 5 years: LIFESTYLE Height Weight Pregnant Yes No Due Date Regular Exercise Yes No Walking (usual distance) Running (usual distance) Sports (please list) Diet Satisfied with diet Dissatisfied with diet Weight Satisfied with weight Dissatisfied with weight Stress Low Moderate High Why high stress? Sleep Good Poor Why poor sleep? Intake (Indicate amount) Coffee (cups/ day) Tea (cups/ day) Soft Drink (Cola) (cups/day) Alcohol Cigarettes Soft Drink (non-cola) (cups/day) If you stopped smoking, when did you stop?
4 REGULAR ACTIVITY HISTORY I am... Full Time Part Time Not Working Retired Student DAILY ACTIVITIES (including work, hobbies, etc.): My daily activities include... Prolonged Standing Extensive Walking Bending / Twisting Reaching Repetitive Movements Heavy Lifting (over 20 lbs) Telephone Use Extensive Sitting Prolonged Driving Care of Children Computer Use My Work is... Home based Farm Work Factory Setting Trades Office Setting Traveling Retail / Food Services Other My drive to/from work is... Less than 30 minutes 1/2-1 hour Over 1 hour No driving Walk/Bicycle The vehicle I typically drive is... Small Car Large Car Bicycle Horse-drawn vehicle Van Truck Other OTHER REGULAR ACTIVITIES Gardening Sports Biking Hiking/Walking Swimming Other (please list) FAMILY HISTORY Does anyone in your family have (or had) a history of the following? Please indicate the relationship. 1. Heart Attack 2. Stroke 3. High Blood Pressure 4. Cancer:(Type) 5 Cancer:(Type) 6. Cancer: (Type) 7. Tuberculosis 8. Kidney Disease 9. Anemia 10. Epilepsy 11. Alcohol / Drug Addiction 12. HIV / AIDS 13. Arthritis 14. Diabetes 15. Scoliosis Other (please name)
5 PERSONAL HISTORY Please check any of the following you have had in the past 2 years. Muscles / Joints Neck pain Back pain Elbow pain Hand Trouble Wrist pain Hip pain Knee pain Ankle pain Foot Trouble Weakness Swollen joints Painful Tailbone Shoulder pain General stiffness Pain between shoulders Difficulty chewing Clicking jaw Other (please name) General Headaches Blackouts Dizziness Insomnia Skin problems Rashes Nervousness Sweats Fainting Abnormal weight gain Abnormal weight loss Loss of consciousness Allergies (please list) Depression Anxiety Convulsions Cardiovascular High blood pressure Angina Poor circulation Heart pain Heart / blood disease Bleeding disorder Hardened arteries Irregular heartbeat Cold/tingling -arms/legs Digestion Diarrhea Vomiting Poor appetite Nausea Constipation Jaundice Indigestion Stomach pain Food Intolerances Heartburn Gas/bloating after meals Black/bloody stool Colitis Painful bowel movement Weight trouble Cramping Gallbladder problems Liver problems Respiration Chronic cough Chest pain Spitting/Coughing blood Painful breathing Asthma Difficulty breathing Genitourinary Trouble urinating Blood in urine Painful urination Bladder infection Bedwetting Kidney infection MALE Prostate trouble FEMALE Painful menstruation Excessive flow Cramping Hot flashes Irregular cycle Breast problems Eyes, Ears, Nose, Throat Speech difficulty Earaches Frequent colds Noises (e.g. ringing) in ears Sinus infections Enlarged glands Difficulty swallowing Thyroid problems Eye/Vision problems Sore throat Hearing loss Ear infections Other
PATIENT INTRODUCTION
PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via
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
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
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
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM Which Chiropractor are
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)
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
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.
PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
COMPREHENSIVE HEALTH & WELLNESS PROFILE
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ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
CONSULTATION ADMITTANCE FORM
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Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)
Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac. Personal History: Name: Address: City: Province: Postal Code: Birth date: day /month /year Age: Sex: M F Home Phone: Business Phone: Cell Phone: E-mail: Health
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
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California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)
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Address: Yes! I would like to receive your Monday Morning Health Tips.
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Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
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
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD Phone: 706-850-8322 Fax: 706-850-8322 PATIENT HISTORY FORM Date of first appointment: / / Time of appointment: Birthdate: Name LAST FIRST MIDDLE INITIAL
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
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Patient Intake Form Please Write Legibly
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:
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
How frequent are the symptoms present? (#2) Constant (76-100%) Occasional (26-50%)
Name Date Occupation Age Birthdate Sex: M F Previous Chiropractor, if any: Present Concern(s): What bothers you most? (concern #1) Next most? (concern #2) Other Concerns: When did the problem first begin?
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Saleeby Chiropractic Centre, P.A.
Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code
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:
Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:
Leader Heights Spine, Joint & Nerve Associates Date: Chart # DC # Patient Information: Please print clearly and complete all sections. Please Circle : Mr. Mrs. Ms. Miss Dr. Rev. Marital Status : Single