New Practice Member Application
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- Shana Rogers
- 5 years ago
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1 T Date / / New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Cellular Provider Address Occupation Employer s Name 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 Rate of Severity When did Have you had the Did the Are symptoms Health Concern: 0 = no pain this problem problem before? problem begin constant (C) or List according 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 and when? What were the results? Favorable Unfavorable (please explain) 1
2 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 Other: Please Mark P For In The Past, OR Mark C For Currently Have: Stroke Cancer Heart Attack Spinal Surgery Spinal Bone Fracture Scoliosis Diabetes Arthritis Seizures Other Conditions/Diseases 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 2
3 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. EXAMPLE: No pain Headaches Back Pain 1. How would you rate your pain RIGHT NOW? Worst possible pain 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 your 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? % Practice Member Name: Date: Score: Q1 +Q2 +Q4 = /3x10= (Low Intensity = <50; High Intensity = >50) 3
4 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: EFFECT: Carrying Groceries No Effect Painful (can do) Painful (limits) Unable to Perform 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 Pet Care 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 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 Dishes No Effect Painful (can do) Painful (limits) Unable to Perform Laundry 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 Other: No Effect Painful (can do) Painful (limits) Unable to Perform Other: No Effect Painful (can do) Painful (limits) Unable to Perform 4
5 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 Dizziness Loss Of Energy Nervousness Blurred/Double Vision Anxiety ADD/ADHD Depression Allergies Sinus Issues Thyroid Problems Asthma Breathing Problems Heart Problems High/Low Blood Pressure Stomach Problems Bed Wetting Infertility Sciatica Fibromyalgia Poor Posture Sleep Problems Stroke Cancer Diabetes Arthritis 5
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
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 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 /
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:
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
i New Practice Member Application PATIENT DEMOGRAPHICS Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Would you like to receive text reminders for your appointments? Cellular
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
APPLICATION FOR CARE AT CORE CHIROPRACTIC
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT CORE CHIROPRACTIC Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male Female Address: City: State: Zip: E-mail
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:
APPLICATION FOR CARE
3023 Eastland Blvd. Suite 101 Clearwater, FL 33761 Ph: 727-797-9900 Fax: 727-797-7695 APPLICATION FOR CARE Date: Name: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Email Address: Birth
APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY
Whom may we thank for referring you to this office? APPLICATION FOR CARE AT ORION FAMILY SPINAL CENTER AND OAKLAND LASER THERAPY Today s Date: HRN: PATIENT DEMOGRAPHICS Name: Birth Date: - - Age: Male
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.
LIST RESTRICTED ACTIVITY: CURRENT ACTIVITY LEVEL USUAL ACTIVITY LEVEL
Whom may we thank for referring you to this office Today s Date: PATIENT DEMOGRAPHICS? HRN: Name: Birth Date: Age: Male Female Address: City: State: Zip: E mail Address: Home Phone: Mobile Phone: Marital
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
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
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APPLICATION FOR CARE AT LAUNCH CHIROPRACTIC
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Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
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CIRCLE ALL CURRENT PROBLEMS YOU HAVE
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LIST YOUR HEALTH CONCERNS BELOW
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Saleeby Chiropractic Centre, P.A.
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APPLICATION FOR CARE AT
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3. How Long Has This Been An Issue?
NEW PATIENT INTAKE FORM Aspire Chiropractic 124 W Harwood Rd. Ste. B Hurst, TX 76054 Name: Occupation: DOB: Age: Sex: Male Female Employer: Marital Status: Single Married Other Name/Age of Kids: Phone:
NEW PATIENT QUESTIONNAIRE Spine pt acct #
NEW PATIENT QUESTIONNAIRE Spine pt acct # Name: Date of Visit: Male Female (please fill in the circles) Date of Birth: Height: Weight: Age Today: What studies have been done on your spine? Where/When?
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
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:
Patient Information. Name: Last First MI. Address: Street City State Zip
Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:
Personal and Family Health History
Personal and Family Health History Date Name Social Security Address Occupation City State Zip Employer Phone: (H): (W): Marital Status: S M D W E-mail Spouse s Name Date of Birth Age Spouse s Occupation
PATIENT INFORMATION HEALTH INFORMATION
PATIENT INFORMATION PLEASE PRINT PATIENTS LAST NAME FIRST NICKNAME STREET ADDRESS APT # TODAYS DATE / / CITY STATE ZIP E-MAIL SEX M F MARITAL STATUS MARRIED SINGLE WIDOWED DIVORCED DOB / / AGE SPOUSES
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
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
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth