Patient Intake. Address: City: State: Zip: Social Security #: - - Sex: M / F. Phone: Home: ( ) - Cell: ( ) - Date of Birth: / / Age:
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1 Patient Intake Date:!!!! Referred By: Full Preferred Name: Address: City: State: Zip: Social Security #: - - Sex: M / F Phone: Home: ( ) - Cell: ( ) - Date of Birth: / / Age: Height: ft in! Weight: lbs Marital Status: Single In a Relationship Married / Life Partner!!!! Divorced Widowed Significant Otherʼs Emergency Contact: Phone: ( ) - Occupation: Employer: Length of Employment: Do you enjoy your job? Y / N Explain: Children? Y / N How many & age(s): Pregnant; # weeks: Planning to become pregnant;!!!!!! Approximately when: Have you ever received chiropractic care before? Y / N If yes, please list names and dates below: Dates: Dates: Have you been to a medical doctor in the past year? Y / N If yes, please list names and reasons below: 1. Reason:!!!!!!!! for visit 2. Reason:!!!!!!!! for visit 3. Reason:!!!!!!!! for visit 1
2 How would you rate your health? (Please circle one) (Poor) 1! 2! 3! 4! 5! 6! 7! 8! 9! 10 (Excellent) Please list the top 5 things you would like to change about your health: !!!! 5. List ALL medications you take (prescriptions and over-the-counter- use back of page if necessary) Drug name:!!! Dosage:!! How long have you taken this and for what condition? List ALL nutritional supplements you take. (Use back of page if necessary) Supplement name:!! Dosage:!! How long have you taken this and for what condition? List ALL previous hospitalizations, surgeries (include oral, appendix, hysterectomy, etc.), fractures, accidents, illnesses. (Use back of page if necessary) 1. Issue When Hospitalized? Y / N 2. Issue When Hospitalized? Y / N 3. Issue When Hospitalized? Y / N 4. Issue When Hospitalized? Y / N 5. Issue When Hospitalized? Y / N Past medical diagnosis / condition: (Use back page if necessary) 1. What: When: Diagnosed by: 2. What: When: Diagnosed by: 2
3 On average, how many times per year do you get sick? How long does it last? Do you get sick seasonally or during the same time each year? Y / N When? Do you have allergies? Y / N If yes, are they seasonal, pets, pollen, etc? Do you have any known food allergies? Y / N Please list: Do you consume the following? (Please mark N/A if it does not apply) Tobacco products (packs/day) # of years? Alcohol (drinks/day) # of years? Coffee/Espresso (cups/day) Reg or decaf? Soft drinks (#/day) Reg or diet? Tea (cups/day) Type (herbal, black, green, etc.) Amount of water/day oz. Do you use artificial sweeteners? Y / N If yes, please list: _ Other drinks and amount/day (juice, milk, etc.) Energy drinks? Y / N Level of exercise (please circle) None Moderate : days/week Strenuous : days/week Have you experienced any unexplained or rapid weight changes in the last six months? Y / N lbs List the #1 reason you want to start care at LifeLogic Health Center: Rate the severity of issue: (mild) 1! 2! 3! 4! 5! 6! 7! 8! 9! 10 (extreme) When did this first begin? Date of most recent flare-up: Have you seen anyone for this issue? Y / N Whom? When? What was the treatment or advice? What was the result? Did it seem to work? What aggravates this condition? What makes it better? Is it worse at certain times of the day, week or month? Y / N When? Is it getting progressively worse? Y / N Do you get flare-ups? Y / N How often? Have you had this or something similar in the past? Y / N When? What treatment did you receive at that time? 3
4 Please check any of the following activities that the above condition interferes with: Personal Care Lifting Bending Pushing Pulling Walking Reading Driving Standing Sleeping Hobbies Sports Work Concentrating Family/Home Responsibilities Eating/Breathing Socializing Going to the Bathroom Sexual Interactions Having Children School Being Healthy Do you currently have or have you experienced ANY of the following within in the past 2 years? Mark N for now and/or P for in the past 2 years. GENERAL Fainting Fatigue Fever Headache Migraine Polio Nervousness Numbness in Hands &/or Feet Night Sweats Acne/Blemishes Rashes Addiction Anemia Alcoholism Bleeding Disorder Cancer Blood Clots Diabetes Depression Eczema Eating Disorder Glaucoma HIV+ Hernia Influenza Liver Disease Low Back Pain Mental Illness Hyperthyroidism Goiter Gout Hypothyroidism/Hashimotoʼs Measles Mumps Chronic Fatigue Syndrome Parkinsonʼs Alzheimerʼs Dementia Lyme Disease Multiple Sclerosis Mark X if you have read all above conditions EYES/EARS/NOSE/THROAT Lazy Eye Crossed Eyes Double Vision Blurred Vision Vision Loss Deafness Hearing Loss Ear Pain Ear Infection Ringing in Ears Nose Bleeds Sinus Infections Sore Throat Difficulty Swallowing Thyroid Problems Mark X if you have read all above conditions RESPIRATORY Wheezing Bronchitis Pleurisy Pneumonia Asthma Chronic Cough Difficulty Breathing Coughing/Spitting Blood Shallow Breathing COPD/Emphysema Excessive Mucous/Phlegm Mark X if you have read all above conditions CARDIOVASCULAR High Blood Pressure Low Blood Pressure Pain Over Heart Cold Hands/Feet Chest Pain Shortness of Breath Poor Circulation Rapid Heartbeat TIA Slow Heartbeat Stroke Swollen Ankles Varicose Veins Aortic Aneurysm Bruise Easily Heart Disease High Cholesterol Previous Heart Problem (Please Describe ) Mark X if you have read all above conditions GASTRO-INTESTINAL Appendicitis Abdominal Surgery Rectal Surgery Rectal Bleeding Gas Colon Issues Constipation Diarrhea Gallbladder Issues Gall Stones Hemorrhoids Liver Issues Nausea Stomach Ache Poor Appetite Poor Digestion Vomiting Vomiting Blood Bloating Food Sensitivities Crohnʼs Disease Colitis Colon Cancer IBS Celiac Disease Burping Heartburn Bad Breath Ulcer Constant Hunger Constant Feeling of Fullness Mark X if you have read all above conditions 4
5 GENITO-URINARY Blood in Urine Frequent Urination Inability to Control Urine Kidney Infection Painful Urination UTI Bladder Infection Kidney Stones Kidney Disease Wake During Night to Urinate Mark X if you have read all above conditions MUSCLE/JOINT/BONE Arthritis Rheumatoid Arthritis Backache Foot Issues Pain Between Shoulders Stiff Neck Painful Tailbone Scoliosis Swollen Joints Osteoporosis Fibromyalgia Broken Bones Joint Replacement Stiff Joints Deep Bone Pain Unexplained Muscle Soreness Popping/Cracking Joints Self-Adjusting (times/day ) Mark X if you have read all above conditions NEUROLOGICAL Epilepsy Seizures Dizziness Hand Trembling Weakness Blackouts Difficulty with Speech Memory Loss Loss of Coordination Movement Disorder Sleeplessness Narcolepsy AD/HD Dyslexia Balance Issues Vertigo Muscle Twitches Abnormal Sensations Numbness Sensitivity to Light Radiating Pain Pins/Needles Loss of Smell Concussion/Head Injury Car Sickness Mark X if you have read all above conditions FOR MEN ONLY Lump in Testicle Penis Discharge Erectile Dysfunction Numbness in Inner Thighs Prostate Issues Enlarged Breast Tissue Beer Belly Emotional Sex Drive Date of Last Prostate Exam Mark X if you have read all above conditions FOR WOMEN ONLY Menstrual Cramps Excessive Menstrual Flow Irregular Cycle Painful Periods Lack of Period Birth control Pills Abnormal Pap Smear Miscarriage Fluctuation in Weight During Period Skin Blemishes During Period Vaginal Dryness Painful Intercourse Ovarian Cyst Uterine Fibroid Cancer Lump in Breast Inability to Become Pregnant Yeast Infection Discharge from Nipples Facial Hair Loss of Hair Decreased Sex Drive C-Section Vaginal Birth PMS Over Emotional Mark X if you have read all above conditions Family History Mother- Passed Away / Alive ; Medical Conditions: Father- Passed Away / Alive ; Medical Conditions: Maternal Grandmother- Passed Away / Alive ; Medical Conditions: Maternal Grandfather- Passed Away / Alive ; Medical Conditions: Paternal Grandmother- Passed Away / Alive ; Medical Conditions: Paternal Grandfather- Passed Away / Alive ; Medical Conditions: Sibling Medical Conditions: How long has it been since you have felt at your best? 5
6 Your answers to the following questions will allow us to help you to better participate in a program of care specifically focused on your nervous system, your wellness, and your overall health. Which of the following choices best describes your level of motivation for creating changes in your health?! a.) I am uncomfortable/unwilling to change my current routines and lifestyle.! b.) I would be willing to make minor changes that fit into my current lifestyle.! c.) I am willing to make changes in my routines and habits, and am willing to step out of my comfort zone.! d.) I am willing to do anything necessary to create positive changes in my health. Which of the following choices best describes your willingness to alter your current diet and food choices?! a.) I am uncomfortable/unwilling to change my current diet and food choices.! b.) I would be willing to make minor changes that fit into my current lifestyle.! c.) I am willing to make changes in my diet and food choices, and am willing to step out of my comfort zone.! d.) I am willing to do anything necessary to create positive changes in my health. Which of the following choices best describes your level of motivation for becoming educated, doing work at home, and being responsible for your health outcomes?! a.) I am uncomfortable/unwilling to change my current routines and lifestyle and am unmotivated to learn.! b.) I would be willing to make minor changes that fit into my current lifestyle.! c.) I am willing to make changes in my routines and habits, and am willing to step out of my comfort zone.! d.) I am willing to do anything necessary to create positive changes in my health. Is there anything else which may help us understand you, your history, or your needs which have not been covered in this intake? Please explain: _ *Remember, health is a process. Past and present choices affect this process. Thank you for taking the time to provide us with the information we need to best help you achieve your health goals. Congratulations on taking an active step toward health and thank you for giving us the opportunity to participate in this process! Legal Agreements I agree that a photocopy or facsimile of any document I sign for LifeLogic Health Center, LLC will be deemed as valid and binding on all parties involved as if the photocopy was the original document I sign. Signature:!! Date: With my signature, I verify that I have gone to the U.S. Department of Health & Human Services website at to review my health information privacy rights. I understand that I can ask the doctors in the office if I have any questions regarding my HIPAA rights. Signature:!! Date: 6
7 Accuracy of Information Females Only: I,, to the best of my knowledge confirm that I am not pregnant, and waive all responsibility of the Doctor(s) for any complications if I am pregnant. (If you are, or might be pregnant, please inform the doctor(s) so they can modify your care plan accordingly.) All Patients: With my signature, I attest that all of the information on this form is accurate and that I am over the age of 18 years. If this information is pertaining to a patient under the age of 18, I am a legal guardian or parent of the aforementioned individual. Signature:!! Date: 7
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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.
Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Address: Sex: M F Age: Birth date: Height: Weight: Occupation: Hobby:
Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Sex: M F Age: Birth date: Height: Weight: Marital Status: Single Married Widowed Separated Divorced Occupation: Hobby:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
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
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New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
PATIENT INFORMATION FORM (WOMEN ONLY)
PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for
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
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
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)
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
Rockwood Natural Medicine Clinic
Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona 85258 480-767-7119 Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about
New Patient Intake Form
New Patient Intake Form Thank you for your interest pursuing health at the Riordan Clinic. As Co-learners you will work with the doctors and staff to understand your whole health picture; therefore, we
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:
Providence Neurosurgery PATIENT INFORMATION SHEET
Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI 48103 P (734) 547-3990 F (734) 547-3890 New Patient Intake Form Personal Information Name Age Sex Female Male Gender Identify
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:
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
NEW PATIENT INFORMATION FORM
NEW PATIENT INFORMATION FORM Name: LAST FIRST MIDDLE Date of Birth: Sex: Marital Status: SS Number: Address: City: State: Zip Phone: Home Cell Work Email: Communication Preference: Patient Portal Phone
HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
Holistic Health Care New Patient Intake Form
Holistic Health Care New Patient Intake Form Name * Address * Telephone number: * Email Address * May we use your email address occasionally for health related information? * Are you a current or past
Mayflower Acupuncture LLC
Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this form as completely as you can. All information provided here will be held in strictest confidence.
New Patient Medical History Intake Form
New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
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
Arizona Injury Medical Associates, P.L.L.C. Physiatry Care
GENERAL INFORMATION HISTORY QUESTIONNAIRE Name: Today s Date: Age: Date of birth: Sex: M F SS#: Home Address: Cell Phone: Your doctor: Home Phone: Your Attorney (if any): If questions arise after today
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
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:
Street address: City: State: Zip: Address:
Patient Information: Date: First name: Middle initial: Last name: Date of Birth: SSN# Best phone number to contact you at: Home Work Mobile How did you hear about us? Referral by: Street address: City:
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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