Welcome to our clinic! NEW PATIENT HEALTH QUESTIONNAIRE

Similar documents
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

intake form About You : General Health Information: Page 1`of 5 State/Province: Country: Zip/Postal Code: Address:

PATIENT INTRODUCTION

New Adult Intake Form

Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone

Hamilton Back Clinic

History of Present Condition

Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information

HEALTH INFORMATION FORM

Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:

CHIROPRACTIC ASSOCIATES CLINIC

CompassionMassage.com. Client Intake Form

ACTIVE EDGE CHIROPRACTIC

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

CHIROPRACTIC ASSOCIATES CLINIC

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

Cascadia Chiropractic Centre

WELCOME TO THE MILLER CHIROPRACTIC CLINIC

PATIENTS DEMOGRAPHICS

CHIROPRACTIC INTAKE FORM

New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone

CONSULTATION ADMITTANCE FORM

Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:

Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?

Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO

New Patient Information

Welcome to MedWell. Patient Information. Name: Address: City: State: Zip Code: !Other. Name: Address: City: State:

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.

PERSONAL INJURY QUESTIONNAIRE

Dr. Michelle Cruickshank

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.

RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118

ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address

PATIENT ENTRANCE FORM

AHI - New Patient Information

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

New Patient Information

Welcome to MedWell. MedWell Health and Wellness Centers. Don t live with PAIN Live WELL MedWell. o Newspaper o Referred by.

Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me

Corner on Wellness Chiropractic Center Therapeutic Massage

MEDICAL DATA SHEET For Patients 18 years of age and older

Cascadia Chiropractic Centre

HEALTH INFORMATION FORM

Extended Health Care Company Do you need any help retaining information about your health insurance coverage? Yes No

LAKES INTERNAL MEDICINE

Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician

History of Present Problem

MASSAGE I TAKE FORM RAQUEL CARTER LICE SED MASSAGE THERAPIST EXERCISE PHYSIOLOGIST REFLEXOLOGIST

Thai Massage Health History Questionnaire

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

Patient First Name: Last Name: Street Address: City: State: Zip Code. Mobile Phone: Home Phone: Work Phone:

PATIENT MEDICAL HISTORY INTAKE FORM

PATIENT FEE SCHEDULE As of January 1, 2017

ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

Nambudripads Allergy Elimination Treatment - PATIENT REGISTRATION:

WELCOME TO THE BURLINGTON NATURAL HEALTH CENTRE PLEASE FILL IN THESE FORMS AS COMPLETELY AS POSSIBLE. THANKYOU!

Street address: City: State: Zip: Address:

Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #

Health and History Assessment ACCOUNT #: HIPPA: CTT:

PATIENT INFORMATION FORM

N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro

Patient History Form

New Patient Intake Form

Application for Patient

INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY

Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:

HEALTH HISTORY FORM. Doctor s Name: Telephone #: Permission to consult with your Doctor: Yes No Initials:

UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT

Chiropractic Case History/Patient Information

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

Reason forappointment:

Sydney Chiropractic, DR. DAVID DUNN

Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:

MEDICAL HISTORY QUESTIONNAIRE

Dawn Smallwood, DC, NTP PATIENT INFORMATION

Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:

Chiropractic Case History/Patient Information

Laser Vein Center Thomas Wright MD Page 1 of 4

Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY Tel # PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A

KEY TO LIFE CHIROPRACTIC

Patient Introduction

CHIROPRACTIC NEW PATIENT HEALTH HISTORY

Name (First, MI, Last) Date of Birth Age Male Female. Primary Care Physician. Referring Physician

Initial Patient Health Assessment Form

Practice Member Profile

Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE

BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage

NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:

Primary (First) Complaint and Location

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

Chiropractic Case History/Patient Information

Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:

Amarillo Surgical Group Doctor: Date:

Birth Date Age Social Security # Marital Status (circle) Have you had chiropractic care in the past? Yes No If yes, how long ago?

Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification

Transcription:

Welcome to our clinic! NEW PATIENT HEALTH QUESTIONNAIRE First Name: Last Name: Date of Birth (mm/dd/yyyy): / / Gender: Male Female Current Occupation: Address: Appt no. Postal Code: Home Phone ( ) - Work Phone ( ) - Cell Phone ( ) - E-mail: How would you like us to contact you? By E-mail By Telephone Emergency contact: Relationship to you: Phone: ( )- For our own data collection purposes, how did you hear about us? Website Family doctor Google search One of our health care provider Word of mouth by another patient Law firm (name: ) Walk-in / I live near the clinic Advertisement Conference/Seminar Other (specify: ) Medical Doctor Information: Our talented health care providers work closely with your medical doctor to ensure that he/she is aware of your ongoing progress. Please, document the following: Name of your medical doctor: Address of the medical clinic: Clinic s Telephone: ( ) - Approximate date of your last physical examination: OHIP number (for X-Ray referrals, if justified): Do you give us permission to contact your medical doctor to provide him/her with documentation regarding your case? NO YES What is the purpose of your visit? Consultation only Pain Relief Preventative Care Functional Rehabilitation Athletic Care Pregnancy Care Got in a car accident WSIB claim Do you have private insurance benefits for: Chiropractic Physiotherapy Chiropody Orthotics I don t have insurance Our physiotherapists and chiropractors can provide a computerized feet screen (at no charge) for our ongoing patients only to help them understand how erroneous their walking patterns and feet anatomy can impact their functionality. Would you be interested? YES NO

Are you currently on any prescription medication? YES NO If yes what are these medications?

Medical Information For your safety, we need information about your medical history. Please answer to the best of your knowledge: Are you or did you experience one or more of the following: SKIN Rashes Skin infection Psoriasis MUSCLES Pain in the: Neck Midback Low back Shoulder Elbow Arm Wrist Hand Hip Leg Knee Ankle Foot Loss of strength Clumsiness Osteoporosis (poor bone density) Osteoarthritis Rheumatism Other arthritis (list below): Tendonitis where: Strain where: Dislocation where: NOW PAST NOW PAST NOW PAST Shortness of breath. Stress Smoking Nausea Other (please list) Vomiting CARDIOVASCULAR Bleeding disorder High blood pressure High Cholesterol Diabetes Low blood pressure Heart Attack Stroke Angina Pacemaker Varicose Veins Phlebitis Poor circulation Other (please list) HEAD NECK Visual changes Hearing changes Speech changes Headaches Jaw Pain Sinus problems BOWEL Constipation Diarrhea Crohn s Disease Hiatus Hernia Ulcers Appendicitis INFECTION Hepatitis (type: ) HIV Tuberculosis Recent flu Recent cold Please CIRCLE what is applicable to your case: FRACTURES NONE YES If yes when and where? SURGERY NONE YES IF yes when and where? CAR ACCIDENTS Other injury (list below): LUNGS Asthma Bronchitis Chronic cough Difficulty breathing Emphysema OTHERS Allergies Cancer Fainting Fever Insomnia Numbness / tingling Seizures How many car accidents you had so far? Is this a new car accident? (circle) YES or NO

IMPORTANT By the law, Canada s new Anti-Spam Legislation (CASL) requires that we obtain your consent as of July 1 st, 2014 in order for you to continue receiving electronic communications from us. We would not want you to miss out on any information that is beneficial to you. First Name: Last Name: Email: Please check which of the following you would like to stay informed about. Appointment Reminders/ Confirmations Clinic Newsletter Kinesiology Information Focus Group News/ Information Clinic Seminars Acupuncture Information Orthotics Information Twitter Updates/Invites Facebook notifications I do NOT want to receive any emails You may withdraw your consent or modify your subscription preferences at any time. Signature:

Our Fees Kent Chiro-Med Wellness Clinic Health Services FEES ($ CAN) CHIROPRACTIC FEES Initial Examination 90.00 Subsequent Regular Chiropractic Treatment (per visit) ADULTS 50.00 FULL-TIME STUDENT* (23 and under) 40.00 Subsequent Graston Treatment only (per visit) 40.00 Combination: Graston + Chiropractic Treatment (per visit) 60.00 Combination: Acupuncture + Chiropractic Treatment (per visit) 60.00 Subsequent Acupuncture Treatment (per visit) ADULTS 50.00 FULL-TIME STUDENT (23 and under) 40.00 Subsequent Shockwave Therapy (options: 1000 shocks or 2000 shocks) (per visit) 60.00 / 90.00 Subsequent Spinal Decompression (per visit) 60.00 PHYSIOTHERAPY SERVICES Initial Examination 95.00 Subsequent Regular Physiotherapy Treatment (per visit) ADULTS 65.00 FULL-TIME STUDENT (23 and under) 55.00 OTHER SERVICES Kinesiotape (per one area of application during a treatment) 15.00 Kinesiotape (per roll) 27.00 Biofreeze (each) 22.00 Electrical Modalities (Ultrasound / IFC machine) (per application) 10.00 Thumper quick massage (15 minutes) 15.00 X-Ray Report 25.00 Exercise prescription (per visit) 10-25 TENS machine (for home use) 250 Ergonomic water-based pillow (for home use) 100 Custom-made Orthotics 500 *Students must present valid student ID prior to initial appointment visit. As a courtesy to all our patients, we ask that you give 24 HOUR notice for cancellation of any appointment. Failure to do so will result in a $25.00 cancellation fee. I am fully aware of the fees and am informed about them in advance. (Signature: ).

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback