Danielle Fryer RD, CSSD, CSCS Contact: Rainbow Drive/Suite 2 ~ Gadsden, Al
|
|
|
- Hannah Waters
- 5 years ago
- Views:
Transcription
1 Thank you for scheduling with me, Danielle Fryer, RD, CSSD, CSCS. It is my pleasure to be a part of your nutrition therapy, personal training, yoga healing and wellness journey. I take this calling very seriously and appreciate your confidence in considering and choosing me. Know that I value your time and commitment to this process, and am delighted to assist you in any way I can to make it a most gratifying experience. Please take a moment to print and complete the intake below. I ask you plan to bring this with you and NOT it in advance. At your first session, I will allot time to review your intake and ask any questions I may have regarding your needs and medical history. If it has been a year or more since your last session, you will be asked to update this information, that I can maintain current records. If you are joining me for a personal training, Yoga, Pilates, or Thai Yoga Bodywork, you will need to wear something comfortable, as you would to the gym. Please bring water to your sessions. If you are receiving a Thai Yoga session, wear warm socks, since many experience a drop in their body temperature. No special attire is required, so if you don t have any gym clothes, wear what is most comfortable for you. I would recommend you have your last heavy meal at least 2 hours PRIOR to your session, or hold off until AFTER we are done. To avoid any unnecessary discomfort, it is ideal to have an empty belly. Online clients: Phone sessions will begin and end on time. I will call you for each session. If you do not hear from me ON TIME, please call me within 5 min. post start time, as there may have been an error in scheduling. Please note there is a 24 hour cancellation policy, which I strictly enforce for all services rendered. Should you need to reschedule, PLEASE contact me immediately, or at least within 24 hours PRIOR to your scheduled appointment, that we can find an alternate day/time that works for you. This prevents you from payment of work you didn t receive. I appreciate your understanding and commitment to this policy. My office studio is located in the building behind Tuxedo Inn off Rainbow Drive. I am not visible from the highway. You will be entering through the main door, suite #2, within the same building as David Scott, attorney at law. (His sign out front is huge and hard to miss) My office door is on the right, which is clearly marked and typically open when I am NOT in session. If the door is closed, PLEASE DO NOT KNOCK. I may be wrapping up another session. If my door is open and I am not present, I am upstairs finishing up a private training session. Please sit quietly in the waiting room, and I will come collect you shortly. My standard poodle often comes to work with me. She is very obedient and super friendly. However, if you are afraid of dogs, I ask that you let me know and I will respect your needs and not bring her on the days of your session. You can find out additional information on services at Please be prepared with payment upon time of visit. I accept cash, checks or credit. I strive to be accessible by phone when you are finding your way here, so please don t hesitate to contact me should you have any trouble
2 1513 Rainbow Drive, Suite 2 ~Gadsden, Alabama REASON FOR CONSULT Medical Nutrition Therapy Sports Nutrition Lifestyle Nutrition Personal Training Yoga/Pilates/Thai Yoga Bodywork Health Coaching Name Phone (work) (home) (cell) address (this is for Danielle's updates & specials Address City State Zip Birth date Age Weight Ht Referred by May I thank them for referral? Type of Employment Duties Include List any hobbies or current activities for stress relief Are you currently under a physician s care? Physician s Name & Number Are you currently taking ANY medications? (Please include any medications including over-the-counter, herbal or home remedies and their intended use) Have you had ANY major accidents, surgeries or injuries? If so, when? Describe Have you ever experienced whiplash? When? How? Have you ever broken any bones? When? How? Do you have a history of seizures? If so, when was your last one? Do you exercise? If so, what type of exercise? How often? Describe your areas of pain or concern: When did you first notice this? Do you know what caused your discomfort? Please explain Have you noticed what aggravates this condition? Is this condition progressively worsening? Is it constant? Does it come & go? Does this condition interfere with daily activities, work or sleep? If so, how? Has there been a medical diagnosis? If so, what? Do you have any allergies? If so, please list What would you like to accomplish in your session? Have you any areas you would prefer NOT be worked on? If so, please list Are you interested in learning about other services offered with Danielle? FOR PREGNANT CLIENTS ONLY: What trimester are you in? What is your due date? OBGYN name Have you taken any medications prior or during your pregnancy? Please describe 2
3 Do you have any particular areas of pain or discomfort? Have you had any difficulties during this pregnancy? Please describe Have you had a history of previous difficulties or miscarriages during pregnancy? If so, when? PLEASE MARK ANY OF THE FOLLOWING THAT APPLY: High/Low Blood Pressure Aching Muscles Bruise easily Swelling in Hands/Ankles/Feet Aching Joints Open cuts/soars Frequent Headaches Low Back Pain Tender areas on skin Neck pain/tightness Shoulder Pain Asthma/Bronchitis Lumps or swelling in head Painful feet Easily out of breath Varicose Veins Hemmhoroids Constipation Diarrhea Sinus Congestion Heartburn Morning sickness/nausea Edema Thyroid Problems Menstrual cramps Diabetes Stroke Kidney Disease Phlebitis Heart Problems Auto Immune disease/dysfunction Communicable disease Binge eating/drinking Anemia Hypoglycemia (low sugar) Addiction Disordered eating/eating disorder Food allergies Celiac disease Bariatric surgery (PRE or POST) Other Weekly Exercise Information Explain in detail what type of resistance exercises, cardiovascular or sports activities you perform on average during a 7-day period. Exercise/Activity Days/week Duration Lifestyle /Activity How would you rate the activity level of your profession, or what you do during the day (non-exercise related). Sedentary Moderately Active Active Very Active What time do you normally wake up? What time do you normally go to bed at night? If you smoke, how many per day? 3
4 If you smoke, how many years have you smoked? If you drink alcoholic beverages, what and how many per day/week? Nutrition Clients: Which best applies to what you want to accomplish? Sports Nutrition Weight Loss Maintain /Improve Eating Habits Gain Weight Other Do you have any food allergies? If so, what are they? Protein Requirements Which best describes you? sedentary adult exercising adult competitive athlete growing teenage athlete adult building muscle athlete restricting calories Body Type Which of the following statements best describes you? I can eat practically anything I want and I don not gain weight. I find it very hard to gain weight. I can lose or gain weight by adjusting my activity level and eating habits. I find it difficult to lose weight. I can gain weight easily and have to watch what I eat. Have you ever been placed on any type of nutritional program in the past? Yes No If yes, by whom and what did it consist of? Please explain below. What were your results? RD Notes: 4
5 ALL CLIENTS! PLEASE READ CAREFULLY & SIGN THE FOLLOWING Because Danielle Fryer must be informed and aware of any existing physical, mental and/or emotional conditions, I have thoroughly & truthfully answered & listed all know medical conditions & physical limitations, as well as medications in the questions above. I understand I must inform Danielle Fryer in writing of any changes to my physical health and/or medications, including surgeries &/or injuries. I understand I am responsible to utilize or discard the information received at my time of visit. I understand that the therapy received is for the sole purpose of improved health, food education, stress reduction, relief from muscular tension, and/or improving circulation. I understand that Danielle Fryer does not diagnose any diseases or any other medical, physical or mental disorder. I understand it is my responsibility to consult a qualified physician or alternative health care provider in the event I need further treatment for a physical or mental condition. I understand that my services are not a substitute for medical examinations. I understand all suggestions made for nutrition therapy, fitness and self-care are given with the intent to improve my state of physical being and nutritional status. I understand that during my visit, it is imperative for me to communicate with Danielle Fryer on pressure, discomfort, referred pain, concerns and any other emotions or issues that might arise as a result of the service. I will be honest with Danielle Fryer at all times to ensure both our safety, as well as, to obtain the best results possible from my visit. If I feel uncomfortable at any time, feel Danielle Fryer's behavior is inappropriate, or that I am being injured, I will inform my her immediately. Both I, and Danielle Fryer, have the right to end the session at any time, regardless of circumstance, with the understanding that payment in full is still expected, unless done so within the 24 hour cancellation time frame. I understand that during Thai yoga bodywork, I will be fully clothed at all times. I understand that all bodywork is non-sexual. If I touch or approach Danielle Fryer or make advances with sexual intent, or give rise to behavior interpreted as such, the massage will be immediately terminated, and payment in full is still expected. I understand that due to the number of request for appointments, there is a twenty-four hour cancellation policy. I am responsible for payment of any appointment scheduled and not canceled within 24 hours prior to my appointment. I understand my appointment time BEGINS at the time agreed upon, and will still be responsible for payment in full of the appointment. I understand that if I am late, my appointment time will be reduced to the time left in accordance to what was scheduled. I understand that any package purchased is non-transferable to others, and is valid with expiration dates set at purchase. I understand that any appointment made after the purchase of a package will be deducted and documented as used, including canceled appointments or those appointments made but not attended (considered no-shows ). I understand any purchases of gift certificates are non-transferable (single sessions are valid for one month; packages valid for 4 months). I understand there are NO REFUNDS on ANY purchases, including but not limited to: all services, packages, gift certificates, workshops or events. Signature Date IF CLIENT IS UNDER THE AGE OF 18: Name of legal guardian Relationship Signature Date 5
6 Package details: Agreement 1. TOTAL SESSIONS: 2. TYPE: 3. DURATION: 4. PACKAGE EXPIRATION: 5. PAYMENT: ( Flex health-care account cards are accepted) 6. REMINDER--CANCELATION POLICY: Client agrees to a 24 hour cancelation policy, whereas if the client cancels in advance, he/she may reschedule the session with Danielle. If client cancels without the full 24 hours notice, session is forfeited and paid in full. Client's initials Liability Release I, (CLIENT) AGREE TO ALLOW DANIELLE FRYER RD, CSSD, CSCS (CONSULTANT), TO DESIGN A LIFESTYLE MANAGEMENT PROGRAM FOR ME TO ENHANCE MY HEALTH GOALS. I WILL FOLLOW THAT PROGRAM TO THE BEST OF MY ABILITY AND I WILL NOT HOLD DANIELLE FRYER RD, CSSD, CSCS OR ANY ONE RELATED PERSONS OR PARTIES PERSONALLY LIABLE FOR ANY PROBLEMS, ILLNESSES OR INJURIES THAT MIGHT OCCUR DUE TO A SUDDEN CHANGE IN MY EATING OR EXERCISE PROGRAM.. I HAVE GIVEN DANIELLE FRYER RD, CSSD, CSCS ALL NECESSARY INFORMATION ABOUT MYSELF TO PREVENT ANY POSSIBLE COMPLICATIONS. Signature: Date: 6
Recuperate Massage Intake Form
Recuperate Massage Intake Form Name Phone ( ) DOB Address City State Zip E-mail: Referred by/how did you hear about R.M : Phone ( ) Emergency Contact: Phone ( ) Occupation ( ) Male ( ) Female Physician
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage Patient Name Date Address City State Zip Phone (home) (cell) Emergency Contact Name Phone Employer Date of Birth Work Phone Social Security # Is condition
Corner on Wellness Chiropractic Center Therapeutic Massage
Corner on Wellness Chiropractic Center Therapeutic Massage Patient Name Date Address _ City State Zip Phone Email Emergency Contact Name Phone Employer Work Phone Date of Birth Social Security # Is condition
Tranquility Massage Therapy & Reiki, LLC
Client Contact Information Tranquility Massage Therapy & Reiki, LLC Client Name: Date: Date of Birth: Gender: Address: Phone: Email: Referred by: Emergency contact: Phone: Physician/Health-care Provider
Massage Office Policies
Massage Office Policies 1. All appointments are scheduled in advance. 2. Clients are expected to pay for all services at the time they are rendered. We accept cash and debit/credit cards for payment. 3.
HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC
HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social
ESSENTIAL ELEMENT Massage & Bodywork
Health Information Alchemy s ESSENTIAL ELEMENT Massage & Bodywork Client Contact Information Client Name: Date of Birth: Gender: M or F (circle one) Address: Email: Occupation: Referred by: Emergency contact:
New Patient Information
New Patient Information First Name: Last Name: M.I.: Address: City: State: Zip Code: Mobile Phone: Home Phone: Email: Preferred method of communication: Mobile Phone Home Phone Email Date of Birth: Age:
Training Application for
STRENGTH Rx REAL TRAINING NO GIMMICKS HARD WORK REAL RESULTS Training Application for STRENGTH Rx Welcome to STRENGTH Rx. We offer Strength & Conditioning training for all athletes looking to improve all
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED
MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED Patient Information Name: DOB: / / Gender: M F Home Address: Home Phone: City, State, Zip: Work Phone: Email Address: Cell Phone: I do not want
Client Intake Form. Phone:
Client Intake Form Name: Last First Date: Address: City: ST: Zip: Email: Phone: How did you hear about Skin Renew Day Spa? What are your main concerns? How long have you been experiencing your current
Welcome to our Office!
Welcome to our Office! Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don t hesitate to ask one of our qualified team members. It is our pleasure
Application for Patient
Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
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
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Patient Number: Date of First Visit: Last Name: First Name: MI: Address: City: State: Zip Code: Email address: Phone: H
Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information
Client Questionnaire Personal Information Basic Information First Name Last Name Date of Birth Male Female Other Not Specified Contact Information Email Preferred Phone Cell Address City State Zip Emergency
CompassionMassage.com. Client Intake Form
Name: Phone: ( CompassionMassage.com Client Intake Form ) E-Mail: Address: _ City: State: Zip: Date of Birth: Occupation: Referred by: In case of emergency: Phone: ( Chiropractor: ) General & Medical Information:
Child s Name Birth Date / / Age. Mother's Name. Father's Name. Phone: Home Cell. Address. Address Number & Street City State Zip
Welcome! Thank you for choosing our practice for your health needs. Your first visit to our center is an opportunity for us to learn all about you. If you have any questions or concerns, do not hesitate
Client Intake Form - Therapeutic Massage
Client Intake Form - Therapeutic Massage Personal Information: Date: Name: Phone #: Address: City/State/Zip: Email: DOB: Occupation: Emergency Contact: Phone #: HOW DID YOU HEAR ABOUT US? The following
Acupuncture & Herbal Therapies
Acupuncture & Herbal Therapies 2520 Central Ave. St. Petersburg, FL 33712 (Phone) 727-551-0857 (fax) 727-202-6896 Last Name: First Name: Male/Female: Date of Birth: Address: City: State: Zip: Home Phone#:
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM
CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell
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 INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
Client Intake Form Therapeutic Massage
Personal Information: Client Intake Form Therapeutic Massage Name Phone (Day) Phone (Eve) Address City/State/Zip email Date of Birth Occupation Emergency Contact Phone The following information will be
th Street Urbandale, IA YOST
YfC 3993 100th Street Urbandale, IA 50322 515.278.YOST www.yostfamilychiropractic.com Demographics: Language (Primary) Race: Unspecified American Indian or Alaska Native Black or African American Other
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
Lake Psychological Services, LLC
Lake Psychological Services, LLC Welcome to Lake Psychological Services and thanks for choosing our office for your health care needs. Seeking treatment is not an easy decision and you may have questions
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
Colorado Mesa University Campus Rec Services Massage Therapy Health History Questionnaire
Colorado Mesa University Campus Rec Services Massage Therapy Health History Questionnaire Client Name: Today s : Contact Number: E-Mail: Occupation: Age: How did you hear about us? Have you ever had a
Personal Medical History. Please describe the condition you are seeking treatment for and give a brief history, including onset:
Personal Medical History Name: Date: / / Please describe the condition you are seeking treatment for and give a brief history, including onset: What are your goals for treatment? What other treatments
Cardiovascular Consent Form
Cardiovascular Consent Form Dear Primary Care Provider, A patient currently under your care for a cardiovascular condition has come to the Kingsbury Club Therapy Center to receive a therapeutic massage.
Health and History Assessment ACCOUNT #: HIPPA: CTT:
ACTION Chiropractor LLC Health and History Assessment ACCOUNT #: HIPPA: CTT: NAME: SEX: M/ F BIRTHDATE: / / ADDRESS: CITY: STATE: Zip: PHONE # s: HOME: ( ) WORK: ( ) CELL: ( ) HEIGHT: WEIGHT: MARITAL STATUS:
New Client Reformer Session Packet
New Client Reformer Session Packet Welcome and thank you for your interest in the Pilates Reformer program with University Recreation. You are taking the first steps towards improved health and wellness.
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.
Jumpstart, Fitness Assessment, & Body Composition
Jumpstart, Fitness Assessment, & Body Composition Waiver, Release and Hold Harmless Agreement In consideration of permission granted by Purdue University allowing me to participate in Personal Training
PATIENT BASIC INFORMATION FORM (To be filled out by patient)
PATIENT BASIC INFORMATION FORM (To be filled out by patient) Name: Last First M.I. Street Address: City: State Zip Phone Number: ( ) - Cell Number: ( ) - Birth date: Current Age: Sex: M F E- mail address:
Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.
203-610-2681 New Patient Intake Form Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information. Name: Last Name First Name Today s date: Address:
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
Personal Training Registration Packet
Registration Packet Client name: Sessions Purchased: 3 Sessions 30 Minutes 60 Minutes 5 Sessions 10 Sessions 15 Sessions Purchase Date: General and Healthy History Questionnaire Name: Penn ID: Date of
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Patient Number: Date of First Visit: Last Name: First Name: MI: Address: City: State: Zip Code: Email address: Phone: H
PATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
(emergency room pain)
Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.-
Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.- INFORMED CONSENT Acupuncture involves the insertion of special needles into particular
Client Information:!!!! Date: Name: Address: Phone: Date of Birth: Age: Gender: M F. Parent/Guardian (if a minor): Phone:
The Holistic Wellness Center Biomeridian Assessment Statement of Intent: I, Dr. Sandra (Sandi) Queen, am a Doctor of Naturopathy and Educator, not a physician. I do not diagnose or treat a disease. I assist
Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer
Name First Middle Initial Last Today s Date Address Street City State Zip Date of Birth Age Social Security # Sex: Male Female mm/dd/year Primary Phone # Cell # Email Emergency Contact Name Number Marital
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 to Lone Lake Physical Therapy!
Welcome to Lone Lake Physical Therapy! **Please arrive 5-10 min prior to your appointment time for your first session. Your appointment will last approximately 55-60 min What you should know before your
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:
Rolfing Associates of the Triad APPLICATION AND CONSENT Structural Integration
APPLICATION AND CONSENT Structural Integration I fully understand the purpose of structural integration is to balance and align the physical body so that it is supported and maintained by gravity in three-dimensional
MEDICAL AND PERSONAL HISTORY
MEDICAL AND PERSONAL HISTORY Last First MI Today s Date Name Age Mr. Mrs Ms Dr Address Home Phone City, State, Zip Work Phone Sex: M F Patient SS# Cell Phone Date of Birth / / Responsible Party Referring
Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX
Liberty Chiropractic Clinic, -6154 Patient's Name Patient's Address City State Zip Code Age D.O.B. Single Married Divorced Widowed No. of children Occupation Employer Home Phone Work Phone Cell Phone Email
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
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
MEDICAL AND PERSONAL HISTORY
MEDICAL AND PERSONAL HISTORY Last First MI Today s Date Name Age Mr. Mrs Ms Dr Address Home Phone City, State, Zip Work Phone Sex: M F Patient SS# Cell Phone Date of Birth / / Responsible Party Referring
PERSONAL TRAINING CLIENT INFORMATION PACKAGE
WEST VANCOUVER COMMUNITY CENTRE PERSONAL TRAINING PERSONAL TRAINING CLIENT INFORMATION PACKAGE At West Vancouver Community Services, our approach to health and fitness is balanced. Being healthy means
We look forward to helping you achieve your fitness goals!
Personal Training Congratulations on your decision to invest in yourself! Our qualified, nationally certified personal trainers will provide you with the right information and right training to help you
Patient Sleep History and Physical
Dear Patient, We appreciate your selection of this office to serve your medical and health needs and we will do all we can to provide you with the very best care. You must bring the following items with
New You Weight Management Program
New You Weight Management Program Initial Evaluation Form (All questions MUST be answered to be considered for the program. Patients are NOT chosen on a first-come, first- served basis. The information
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 /
Welcome To Our Office
Welcome To Our Office Mission Statement Our office is dedicated to educating and adjusting as many families as possible towards optimal health through natural chiropractic care. We believe the greatest
Brisbin Family Chiropractic
Information reviewed with patient: Dr. Initials Today s Date Brisbin Family Chiropractic Name: Sex: Male Female Address: City: Postal Code: Home Ph# Work# Ext# Cell# Preferred number (circle one) Home
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Keeping Accurate Records and Session Notes of your Clients
Keeping Accurate Records and Session Notes of your Clients By: Bob Haddad, RTT Record keeping In all major forms of medical treatment, physical therapy, and bodywork, keeping accurate client records and
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 /
Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)
7035 Beracasa Way, Suite 103 Boca Raton Florida, 33433 Phone# (561)674-1217 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name middle Address City State Zip Date of Birth Age Social Security
New Patient Information
New Patient Information Bloomfield Children s Dentistry 6405 Telegraph Road Bloomfield Hills, MI 48301 In order to get to know your family better, and to provide you with the best service, we ask that
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had
Pediatric Intake Paperwork. Personal History
Pediatric Intake Paperwork Child s Name: Date: Address: City: Zip: Cell Phone: Work Phone: Email: Date of Birth: Social Security Number: Your occupation: Your employer: Whom to contact in case of emergency?
Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? I don t know
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Monticello Have you had labs (lipid profile & basic metabolic panel) done within
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
Personal Training Information Packet
Personal Training Information Packet Dubuque Community YMCA/YWCA 35 North Booth Street Dubuque, Iowa 52001 P 563.556.3371 F 563.556.2728 www.dubuquey.org Dear Member: Congratulations! You have just taken
Initial Pain Management Patient Questionnaire
Appt. Date: Appt. Time: Boston Out-Patient Surgical Suites North Tel Fax: 781-407-5892 Initial Pain Management Patient Questionnaire Dear New Pain Management Patient, Welcome to the New England Pain Management
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,
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months?
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Are you a Christie registered patient? Yes No Monticello Have you had labs (lipid
Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY (859) General Information
Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY 40517 (859) 268-8190 General Information Full Name Birth date / / Date / / Social Security # - - Driver s License
PATIENT APPLICATION FORM
2105 E. Clairemont Ave., Eau Claire, WI 54701 Phone (715)835-9514 Fax (715)835-2602 PATIENT APPLICATION FORM WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level
The Wellness Lounge Staff
Chiropractic Massage Acupuncture Nutrition Yoga Treatment Welcome, We would like to take a moment to welcome you to the wellness lounge. Whether you are here for a one-time visit, or are looking for a
3 Flr Scotia Centre, Calgary, AB T2P 2W3 DR. KATHRYN DOYLE, ND! Phone: Fax: !!!!! Naturopathic Doctor! Adult Intake Form!
3 Flr Scotia Centre, Calgary, AB T2P 2W3 DR. KATHRYN DOYLE, ND Phone: 403-237-6000 Fax: 403-263-0646 Naturopathic Doctor Today s date: Adult Intake Form Name: Age: Birth date: M F Address: Postal Code:
Waiver, Release and Hold Harmless Agreement Personal Training Services
Waiver, Release and Hold Harmless Agreement Personal Training Services I,, the undersigned, affirm that I am participating voluntarily in Personal Training Services. (Print name) I (together with my parent
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
How did you find out about our facility?
Thank you for choosing Real Rehab Sports + Physical Therapy. We would like to welcome you as a new patient. Our staff wants to ensure that your first visit goes smoothly and that all of your questions
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
Personal Training Health Screening Questionnaire
RC Health and Fitness, LLC. 10350 Ironbridge Road Chester, VA 23831 (804)248-0222 Personal Training Health Screening Questionnaire Personal Information Today s date: Title: O DR. O Mr. O Mrs. O Ms. Name:
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
MEMBERSHIP APPLICATION
MEMBERSHIP APPLICATION Join Date: Full Pay Draft 20/20 Membership Type: Household One Parent Household Two Adult Household Senior Household Adult Young Adult Youth Senior First Name MI Last Birth Date
COMPREHENSIVE HEALTH & WELLNESS PROFILE
Patient Name DOB COMPREHENSIVE HEALTH & WELLNESS PROFILE The human body is designed to be healthy. Throughout life, events occur which damage your natural health expression. As a full spectrum Chiropractic
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date:
NPM INTAKE FORM: ADULT INFORMATION: Name: Age: Date: Address: City/State/Zip: Home Phone No.: Work Phone No: Cell Phone: Email Address: Gender: Date of Birth: Occupation: Best Time to Contact: Number of
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
Standard Medicare and Managed Medicare plans pay for diabetes education.
614-447-9495, ext. 1 You are scheduled to attend a series of four diabetes education classes. If you are not able to attend the class series, we ask that you cancel your appointment at least 48 working
SOUTHSIDE COMMUNITY ACUPUNCTURE, LLC. Financial Policies
Disclosure of Information - Please Read the Following Carefully How to Prepare for Your First Visit : Plan on showing up a 15 minutes early to your first appointment and please wear, or bring with you
Peterson Physical Therapy
Peterson Physical Therapy Registration Form Last Name: First Name: Date: Name of parent/guardian (if patient is a minor) Mailing Address: City/State/Zip: Date of Birth: Home Phone: Email: Cell Phone: Cell
Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-9 months?
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy or Danville Are you a Christie registered patient? Yes No Have you had labs (lipid
Personal Training New Client Packet Personal Training/Fit for Hire
Personal Training New Client Packet Personal Training/Fit for Hire Date / / Name Address City State Zip Phone Number Email Trainer Preference Male Female No Preference **If you would like to work with