B wel Chiropractic & Health Associates 3020 East College Avenue, Suite H Appleton, WI Dr. James M. Benzschawel
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1 DATE: CASE HISTORY SEX: M / F LAST NAME: FIRST: M: DOB: ADDRESS: CITY: STATE: ZIP: APT OR UNIT #: HOME#: CELL#: SS #: - - MARITAL? M S W D # OF CHILDREN? SPOUSE NAME?: SPOUSE DOB?: OCCUPATION: EMPLOYER: INS CO: DOB: POLICY HOLDER: EMPLOYER : How did you hear about our office? Referred by Phone book Newspaper Website: Other: What type of problem are you having? Back pain Yes No Neck pain Yes No Hip pain Yes No Knee pain Yes No Did you know chiropractic may also help with the following? Digestion Headaches Bed Wetting Arthritis Muscle Tension Vertigo/Balance Carpal Tunnel Foot/Ankle Pain Other: *** PREGNANT: Y / N SURGERIES: MEDICATION: OTHER DOCTORS SEEN FOR THIS CONDITION: Doctor s Name: Diagnosis: Did you have any of the following? (circle) X-rays MRI CT scan Injections: Y / N Length of time under care? Name of family doctor/clinic: Phone: I authorize B wel Chiropractic and Health Associates to inform my Family Doctor that I am receiving treatment here. Yes / No I (we) agree to pay for services rendered to the above-mentioned patient as the charge is incurred. I (we) understand that health and accident insurance are arrangements between the insurance carrier and myself and that I am personally responsible for payment of any and all services, covered or not covered. If the doctor is a contracted provider for my managed care plan, I understand I am responsible for all copayments and non-covered services. I also understand and agree to pay all copays and fees for non-covered services, prior to seeing the doctor. I understand that if I terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. I understand that unpaid fees for services beyond thirty (30) days are subject to a 1.5% monthly finance charge (18% annually). I also understand that if my account is sent to collections, 35% will be added to the balance owed. I (we) authorize the doctor and his staff to release any information deemed appropriate concerning my physical condition to any insurance company, claim adjuster, employer, health care provider, or attorney in order to process any claim for reimbursement or charges incurred by me as a result of professional services rendered and herby release him/her of any consequences thereof. I (we) hereby authorize and direct payment of any medical/ chiropractic expense benefits allowable to the doctor as payment toward the total charges for professional services rendered. I agree that a photocopy/facsimile of this agreement shall serve as the original. Patient signature: Date: B wel Chiropractic & Health Associates 3020 East College Avenue, Suite H Appleton, WI Dr. James M. Benzschawel
2 QUADRUPLE VISUAL ANALOGUE SCALE INSTRUCTIONS: Please circle the number that best describes the question being asked. NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your average pain levels and pain at minimum / maximum using the last 3 months as your reference. If you have completed this form before, indicate you average pain level since the last time you completed this form. EXAMPLE: headache neck low back no pain possible ############################################################################################################ 1. What is 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 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 )? What percentage of your awake hours is your pain at its? % NAME AGE DATE SCORE
3 Review of Systems Please mark (c) for current problems, check and indicate the age or year when you had any of the following: General Allergies Depression Dizziness Fainting Fatigue Fever Headaches Loss of sleep Mental illness Nervousness Tremors Weight loss / gain Muscle / Joint Arthritis / rheumatism Bursitis Foot trouble Muscle weakness Low back pain Neck pain Mid back pain Joint pain Skin Boils Bruise easily Dryness Hives or allergies Itching Rash Varicose veins Gastrointestinal Abdominal pain Bloody or tarry stool Colitis / Crohn s Colon trouble Constipation Diarrhea Difficult digestion Diverticulosis Bloated abdomen Excessive hunger Gallbladder trouble Hernia Hemorrhoids Intestinal worms Jaundice Liver trouble Nausea Painful defecation Pain over stomach Poor appetite Vomiting Vomiting of blood Genitourinary Bed-wetting Bladder infection Blood in urine Kidney infection Kidney stones Prostate trouble Pus in urine Stress incontinence Urination Overnight more than twice More than 8x in 24hrs Decreased flow/force Painful urination Urgency to urinate Women only Congested breasts Hot flashes Lumps in breast Menopause Vaginal discharge Menstrual flow: Reg. Irreg. Pain /cramps Days of flow: Length of cycle: Date - 1st day last period: Are you pregnant? yes, no If yes, how many months? # of pregnancies:- # of live births Date of last PAP test: normal, abnormal Date of last mammogram: normal, abnormal Check any of the conditions you have or have had: Alcoholism Anemia Appendicitis Arteriosclerosis Asthma Bronchitis Cancer Chicken pox Cold sores Diabetes Eczema Edema Emphysema Epilepsy Goiter Gout Heart burn Heart disease Hepatitis Herpes High cholesterol HIV/AIDS Influenza Malaria Measles Miscarriage Multiple sclerosis Mumps Numbness/tingling Pace maker Osteoporosis Pneumonia Polio Rheumatic fever Stroke Thyroid disease Tuberculosis Ulcers Family history: If any blood relative has Eye, Ear, Nose & had any of the Throat following conditions, Colds please check and Deafness indicate which Ear ache relative(s) Eye pain Alcoholism Gum trouble Anemia Hoarseness Arteriosclerosis Nasal obstruction Arthritisit Nose bleeds Asthma Ringing of the ears Cardiovascular Bleed easily Sinus infection High blood pressure Cancerer Sore throat Low blood pressure Diabetes Tonsilitis Hardening of the Emphysema Vision problems arteries Epilepsy Respiratory Irregular pulse Glaucomacoma Chest pain Pain over heart Heart disease Chronic cough Palpitation High blood pressure Difficulty breathing Poor circulation High cholesterolole Hay fever Rapid heart beat Multiple Shortness of breath Slow heart beat Sclerosissclerosi\ Spitting up phlegm / Swelling of ankles Osteoporosist blood Stroke Wheezing Thyroid disease Name: Date:
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6 Please Read: This questionnaire is designed to enable us to understand how much your neck pain has affected your ability to manage everyday activities. Please answer each Section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just circle the one choice which closely describes your problem right now. SECTION 1--Pain Intensity A. I have no pain at the moment B. The pain is mild at the moment. C. The pain comes and goes and is moderate. D. The pain is moderate and does not vary much. E. The pain is severe but comes and goes. F. The pain is severe and does not vary much. SECTION 2--Personal Care (Washing, Dressing etc.) A. I can look after myself without causing extra pain. B. I can look after myself normally but it causes extra pain. C. It is painful to look after myself and I am slow and careful. D. I need some help, but manage most of my personal care. E. I need help every day in most aspects of self-care. F. I do not get dressed, I wash with difficulty and stay in bed. SECTION 3--Lifting A. I can lift heavy weights without extra pain. B. I can lift heavy weights, but it causes extra pain. C. Pain prevents me from lifting heavy weights off the floor but I can if they are conveniently positioned, for example on a table. D. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. E. I can lift very light weights. F. I cannot lift or carry anything at all. SECTION 4 --Reading A. I can read as much as I want to with no pain in my neck. B. I can read as much as I want with slight pain in my neck. C. I can read as much as I want with moderate pain in my neck. D. I cannot read as much as I want because of moderate pain in my neck. E. I cannot read as much as I want because of severe pain in my neck. F. I cannot read at all. SECTION 5--Headache A. I have no headaches at all. B. I have slight headaches which come infrequently. C. I have moderate headaches which come infrequently. D. I have moderate headaches which come frequently. E. I have severe headaches which come frequently. F. I have headaches almost all the time. SIGNATURE: DATE: SECTION 6 -- Concentration A. I can concentrate fully when I want to with no difficulty. B. I can concentrate fully when I want to with slight difficulty. C. I have a fair degree of difficulty in concentrating when I want to. D. I have a lot of difficulty in concentrating when I want to. E. I have a great deal of difficulty in concentrating when I want to. F. I cannot concentrate at all. SECTION 7--Work A. I can do as much work as I want to. B. I can only do my usual work, but no more. C. I can do most of my usual work, but no more. D. I cannot do my usual work. E. I can hardly do any work at all. F. I cannot do any work at all. SECTION 8--Driving A. I can drive my car without neck pain. B. I can drive my car as long as I want with slight pain in my neck. C. I can drive my car as long as I want with moderate pain in my neck. D. I cannot drive my car as long as I want because of moderate pain in my neck. E. I can hardly drive my car at all because of severe pain in my neck. F. I cannot drive my car at all. SECTION 9--Sleeping A. I have no trouble sleeping B. My sleep is slightly disturbed (less than 1 hour sleepless). C. My sleep is mildly disturbed (1-2 hours sleepless). D. My sleep is moderately disturbed (2-3 hours sleepless). E. My sleep is greatly disturbed (3-5 hours sleepless). F. My sleep is completely disturbed (5-7 hours sleepless). SECTION 10--Recreation A. I am able engage in all recreational activities with no pain in my neck at all. B. I am able engage in all recreational activities with some pain in my neck. C. I am able engage in most, but not all recreational activities because of pain in my neck. D. I am able engage in a few of my usual recreational activities because of pain in my neck. E. I can hardly do any recreational activities because of pain in my neck. F. I cannot do any recreational activities at all. Vernon H and Hagino C, 1991 (with permission from Fairbank J) DISABILITY INDEX SCORE: %
7 THE NECK DISABILITY INDEX QUESTIONNAIRE NAME DATE How long have you had neck pain years months weeks On the diagram below, please indicate where you are experiencing pain or other symptoms, right now. Please complete both sides of this form. A = ACHE P = PINS & NEEDLES B = BURNING S = STABBING N = NUMBNESS O = OTHER OVER PLEASE
Name: Date: Mark (c) for current problems, check and indicate the age when you had any of the following:
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INFORMATION/APPLICATION FOR CARE
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My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
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Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
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.
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
PATIENT MEDICAL HISTORY INTAKE FORM
Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information:
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
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:
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Dr. Michelle Mackay Patel, ND
NATUROPATHIC ADULT INTAKE PERSONAL INFORMATION: First Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: What is your current gender identity? Male Female Transgender Male/Transman/FTM Transgender
CURRENT COMPLAINTS. FOR OFFICE USE ONLY: Patient Number Doctor Insurance Emp. Initials. Complaint 3. Complaint 2. Complaint 1
FOR OFFICE USE ONLY: Patient Number Doctor Insurance Emp. Initials PATIENT INFORMATION Please give your Driver s license and insurance card to the front desk for your records. Patient Name: Last First
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:
CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE
CHRISTIANA SPINE CENTER NEW PATIENT QUESTIONNAIRE NAME Today s Date CHIEF COMPLAINT _ (Please use your pen to mark painful areas) Front Back Date of Birth When did the pain begin: Allergies and reaction:
Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
Successful healthcare and preventive medicine require a healthy relationship between provider and patient. Your responses to the following questions will significantly contribute to your doctor's understanding
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
PERSONAL HISTORY AUTO ACCIDENT QUESTIONNAIRE. Personal Injury Questionnaire. Name Date. Date of Accident: Time. Location of Accident (Streets)
Personal Injury Questionnaire Patient# HISTORY OF OCCURRENCE Name Date Date of Accident: Time Location of Accident (Streets) As a result of the accident you were: Rendered unconscious In shock Dazed, circumstances
Patient Name (last, first) Sex: Male / Female
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email:
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask the receptionist. (PLEASE PRINT.) Today s Date
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
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)
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children: