Derry Joint & Spine Center PC. Patient Health History Welcome to our office
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- Amie Ward
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1 Derry Joint & Spine Center PC Date: Patient Health History Welcome to our office Last Name: First : Middle Initial: Date of Birth: Age: Sex: M F SS Number: Address (street, city, state, zip): Address: Home ph #: Work ph #: How did you hear about our office? Business/Employer: Type of work: Name of emergency contact: Phone #: Check one: married single widowed divorced separated Number of children: Social History Describe what kinds of exercise you do. (please check all that apply) Walking Biking Swimming Weight Training Yoga Other I do not exercise How often do you exercise? Once per week Twice per week 3 times per week 4 times per week 5 times per week 6 times per week 7 times per week For how long do you exercise each day? Less than 15 minutes Minutes Minutes 45 Minutes 1 Hour Over 1 hour Do you use any of the following substances? Tobacco 1+ Pack per day Less than 1 Pack per day Less than 1 pack per week Ocassionally Never Quit Date: Alcohol Do not drink Rarely Occasionally Regularly Heavily Illicit Drugs Never Rarely Occasionally Regularly Heavily
2 What is the reason for your visit today? : Please rate the pain on a scale from being no pain, 10 being unbearable pain Please describe the symptoms (check all that apply) What makes the pain better: Numbness Sharp Throbbing Stiffness Stabbing Other Dull Ache Shooting What makes the pain worse: Cramps Burning Since starting the pain has been Getting Worse Getting Better staying the same Since starting the pain has been Constant Frequent Intermittent Occasional Rare Have you seen anyone else for this condition? Have the symptoms interfered with your Work: Social life: Household chores: Personal relationships: Past Medical History Have you had any of the following? Please check all that apply. Head Trauma Eyes Blindness Cataracts Glaucoma Wear glasses Ears Hearing aids Nose Seasonal allergies Sinus infection Mouth/Throat/Teeth Dentures Heart Aneurysm Angina DVT Dysrhythmia Hypertension Murmur Heart Attack Lungs Asthma Bronchitis COPD Pleuritis Pneumonia Gastrointestinal Cirrhosis GERD Gallbladder Disease Heartburn Hemorrhoids Hepatitis Hiatal Hernia Jaundice Ulcer Genitour inar y Hernia Inconctinence Nephrolithiasis Other kidney disease STDs UTIs Muskuloskeletal Arthritis Gout M/S Injury Skin Dermatitis Moles Other skin conditions Psoriasis Neurological Epilepsy Seizures Headaches/Migraines Stroke TIA Psychiatr ic Bipolar disorder Depression Hallucinations, delusions Suicidal ideation Suicide attempts Endocrine Goiter Hyperlipidemia Hypothyroidism Thyroid disease Thyroiditis Type I DM Type II DM Heme/Onc Anemia Cancer Infections HIV STDs Tuberculosis (dz) Tuberculosis (exposure)
3 Surgeries/Hospitalizations Have you been hospitalized or had any surgeries? Please list them below Surgery Date Complications? Please explain any complications: Are you allergic to any medications? If yes please explain: Family Medical History Has any immediate family member had any of the following conditions? Condition Arthritis Asthma Bleeding Disorder CAD < age 55 COPD Diabetes Condition Heart Attack Heart Disease Hyperlipidemia Hypertension Mental Illness Osteoporosis Cancers Stroke Breast Colon Ovarian Prostate Uterine Are you currently taking any medications? Please list them below Medication Dosage When
4 Derry Joint & Spine Center, P.C. 16 Manning Street, Suite 107 Derry, NH FORM: NOTICE OF PRIVACY PRACTICE SUMMARY This summary discloses how health information about you may be used. A full notice of your privacy rights is posted for your review. Derry Joint & Spine Center, P.C. uses health information about you for treatment, to obtain payment for treatment with your authorization as required (check your state laws), for administrative purposes, and to evaluate the quality of care that you receive. Derry Joint & Spine Center, P.C. will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. Derry Joint & Spine Center, P.C. may use your information to provide appointment reminders, information about treatment alternatives or other health-related issues. Derry Joint & Spine Center, P.C. may disclose your information for public health activities, to funeral directors to enable them to carry out their activities, for organ and tissue donations, research, health and safety, governmental function in order to comply with workers compensation laws and regulations, a right to request restriction, report and retain a copy of your health record, request communication of your information by alternative means at alternative locations, revoke your authorization and request an accounting of your health records. You may complain to the Privacy Officer, Janice T. Boardman, and to the Department of Health and Human Services if you believe your privacy rights have been violated. You will not be retaliated against for filing a complaint. Derry Joint & Spine Center, P.C. must maintain the privacy of protected health information, provide you with notice of its legal duties and privacy practices with respect to your health information, abide by the terms of the notice, notify you if it was unable to agree to the requested restriction on how your information is used or disclosed, accommodate reasonable requests you may make to communicate with health information by alternative means or by alternative locations and obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law. If you have any questions or complaints, please contact Janice T. Boardman at (603) Patient Signature Date I,, authorize the release of my records to my other providers, health insurance company, and myself. I acknowledge that any other release of records will require a written request from me. Patient Signature Date
5 Informed Consent to Care You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major Gl events of the entire (upper and lower) Gl tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users. It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office. Patient Name: Signature: Date: Parent or Guardian: Signature: Date: Witness Name: Signature: Date:
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Date: Can we leave messages on voice mail at home/work/cell? Yes No. Sex: Male Female SS#: If yes, what type? Auto Work Other.
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1275 Olentangy River Rd. Ste 120 Columbus, Ohio 43212 Telephone (614) 291-5555 Fax: (614) 291-7720 Dr. David B. Kaplansky Dr. Randall Contento PATIENT Dr. INFORMATION Garrett Kalmar FORM www.columbusohiopodiatrist.com
Patient Data Sheet. Emergency Contact Name: Relationship: Contact phone number: Name: Specialty: Office address: Office phone: Fax:
Today s Date: / / Your Information Patient Data Sheet Last ame: First: MI: Sex: M F Date of Birth: / / Age: SS: Address: Home phone: Cell phone: Can we leave message on Home? Y or Cell? Y Are you currently
ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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.
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
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)
Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska 99518 (907)563 7700 PATIENT DEMOGRAPHICS Today's Date: Name: Birth Date: Age: Male
Insurance. Patient Family Information. Patient Condition
Welcome to Amarillo Family Wellness Group In order to serve you best we would like to know more about you and your health history. Please print clearly and fill this out completely prior to your appointment
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
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:
Chiropractic Health Dr. Art Vanderhoef
Patient Information Form Chiropractic Health Dr. Art Vanderhoef File # Name Address City State Zip Home Phone ( ) Work Phone ( ) Cell Phone ( ) Email Address How do you prefer to be contacted? Mail Home
Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone
Patient Name: Date: Address City State Zip Code H. Phone W. Phone Cell Phone Email Address: Sex M F Marital Status M S D W Date of Birth Age SS# Occupation Employer Referred by: Have you ever received
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
OhioHealth Orthopedic & Sports Medicine Physicians
Page 1 of 6 OhioHealth Orthopedic & Sports Medicine Physicians 335 Glessner Avenue, Mansfield, Ohio 44903 PATIENT INTAKE ASSESSMENT OFFICE USE ONLY Fax to: OR Control 419-520-2831 For Joint Replacement
Initial Visit Forms. Life in Motion Chiropractic & Wellness 6139 Route 96 -Suite 1 Farmington, NY (585)
Initial Visit Forms 6139 Route 96 -Suite 1 Patient Name: Patient Intake Form Name: Date: Address: City: State: Zip: Home #: ( ) Cell #: ( ) Work #: ( ) E-mail: Preferred method of contact: Date of Birth:
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE
PATIENT INFORMATION PATIENT INTAKE FORM BANGOR PODIATRY, LLC Cheralyn Perkins, DPM David Scalzo, DPM Kathleen Hope, DPM Nicole Branning, DPM TODAY S DATE: / / LEGAL NAME: LAST FIRST MIDDLE ADDRESS: STREET
*** ADDRESS: (If address is not provided, you MUST write Patient denied.)
PATIENT INFORMATION NORTHWEST BROWARD ORTHOPAEDICS DATE: ***E-MAIL ADDRESS: (If e-mail address is not provided, you MUST write Patient denied.) Pharmacy Name: Pharmacy Phone Number: Pharmacy Location PATIENT
Family First Chiropractic
Family First Chiropractic Personal Information Title: (Check one) Mr. Mrs. Ms. Miss Other First Name Middle Initial Last Name Street City State Zip Code Email Home Phone ( ) - Cell Phone ( ) - Date of
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