PLEASE ASK US FOR HELP IF YOU HAVE ANY QUESTIONS.

Similar documents
PATIENT INTRODUCTION

WELCOME TO THE MILLER CHIROPRACTIC CLINIC

CHIROPRACTIC ASSOCIATES CLINIC

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

Sydney Chiropractic, DR. DAVID DUNN

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

CHIROPRACTIC ASSOCIATES CLINIC

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

Johanna M. Hoeller, DC PS

CONSULTATION ADMITTANCE FORM

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

PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE

COMPREHENSIVE HEALTH & WELLNESS PROFILE

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -

CONSULTATION ADMITTANCE FORM

Dr. Gary Malstrom B.Sc.(Hon.), D.C., C.Ac Brant Street, Burlington, Ontario L7R 2J9 (905) Fax (905)

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

New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

ACTIVE EDGE CHIROPRACTIC

HEALTH INFORMATION FORM

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.

California Chiropractic Boshears, Inc Yucaipa Blvd., Yucaipa Ca Phone: (909) Fax : (909)

Address: Yes! I would like to receive your Monday Morning Health Tips.

What is your occupation? Company Name Do you have extended healthcare benefits? Yes No Benefits are personal or from work

BACK PAIN QUESTIONNAIRE MELVIN D. LAW, JR., M.D.

PERSONAL INJURY QUESTIONNAIRE

Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program

Patient Introduction

HEALTH INFORMATION FORM

HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM

NEW PATIENT INFORMATION FORM

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

MacKay Chiropractic, LTD., 7450 W. Cheyenne Ave. #114 Las Vegas, NV (702)

PERSONAL HISTORY. Describe your pain or complaint:

Last Name First Name Middle Name MRN

LAKES INTERNAL MEDICINE

AHI - New Patient Information

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

MEDICAL HISTORY (To be filled in by patient)

Brisbin Family Chiropractic

History of Present Condition

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

Margie Petersen Breast Center

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

INFORMATION/APPLICATION FOR CARE

GENERAL PATIENT INFORMATION

Puritz Chiropractic Center Patient Health Questionnaire

Providence Neurosurgery PATIENT INFORMATION SHEET

New Patient Information

NEW PATIENT QUESTIONNAIRE Spine pt acct #

Patient Medical History Form

ILLINOIS BONE AND JOINT INSTITUTE Rheumatology Medical History Form

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

CHIROPRACTIC INTAKE FORM

New Adult Intake Form

New Patient Intake Form

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

Questionnaire for Lipedema Patients

Welcome to our office!

Amarillo Surgical Group Doctor: Date:

Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION

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

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

New Patient Intake Form. About You

Chiropractic Registration and History

Arizona Injury Medical Associates, P.L.L.C. Physiatry Care

Patient History Form

HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM

Personal Health Risk Appraisal

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

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

PERSONAL HISTORY AUTO ACCIDENT QUESTIONNAIRE. Personal Injury Questionnaire. Name Date. Date of Accident: Time. Location of Accident (Streets)

PATIENT HEALTH QUESTIONNAIRE

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

INSURANCE... ACCIDENT INFORMATION PATIENT CONDITION _.

MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History

Spine New Patient Questionnaire Rev

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

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

RHEUMATOLOGY PATIENT HISTORY FORM

Child History Form. Personal Information. Legal Guardian & Occupation: Home Phone: Alternate Phone: Provincial Health Care Plan

NEW PATIENT QUESTIONNAIRE

Please fill out this form as completely as possible. This information will determine how we treat your pain problem.

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

New Patient Pain Evaluation

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

PERSONAL INFORMATION REASONS FOR SEEKING CHIROPRACTIC CARE

PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:

Patient Intake Form Please Write Legibly

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

How frequent are the symptoms present? (#2) Constant (76-100%) Occasional (26-50%)

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

* CC* PATIENT QUESTIONNAIRE

Saleeby Chiropractic Centre, P.A.

Chiropractic Case History/Patient Information

Date: Chart # DC # Spouse / Parent / Legal Guardian Details: Name: Relation:

Transcription:

Patient Entrance Form Michelle A. Gross, B.Sc. (Hons.), D.C. G. Murray Townsend, B.Sc., D.C. Brianne O Driscoll, B.Sc., D.C Name Date Date of Birth / / DAY MONTH YEAR Age Marital Status Home Address Town PO Box 911 # Apt. # Postal Code Home Telephone Work Telephone Other Telephone E-mail Address Occupation Employer Location Spouse s Name _ Children (names) Contact Name Contact Phone Please advise us of any changes made at a later date to the above information Most Recent Chiropractic Care: Name Location Last Visit Results: Excellent Good Fair Poor Current Medical Doctor/ Nurse Practitioner: Name Location You were referred to our office by: friend/ family member NAME phone book walk-in newspaper Medical Doctor Nurse Practitioner Other I have received treatment for this current problem from: Medical Doctor Hospital Other Chiropractor Massage Therapist Physiotherapist Other This visit is due to a: Recent Motor Vehicle Accident Work Related Injury (WSIB) PLEASE ASK US FOR HELP IF YOU HAVE ANY QUESTIONS. Mount Forest Chiropractic 148 Main Street South, Mount Forest, Ontario N0G 2L0

COMPLAINT HISTORY What problem(s) would you like the doctor to address? Explain how your complaint(s) occurred: No Reason At Work Car Accident Is your condition... Worse Better Same Fluctuates What makes your condition worse? better? Are you taking medications for this problem? No Yes (list) Please indicate other medications that you are taking. Pain Killers Muscle Relaxants Arthritis Meds. Nerve Pills Blood Pressure Pills Insulin Heart Meds. Birth Control Estrogen Vitamins Blood Thinners Thyroid Pills Cholesterol Other (please list) Mark the areas of the body where you feel the described sensations. Use the appropriate symbols. Include all affected areas. Stiff/ Tight... X X X X Dull/ Aching... A A A A Sharp/ Stabbing... / / / / / / Pressure... > > > > Pins & Needles/ Tingling... * * * * * Numbness... N N N N Burning... O O O O

Changes/ Limitations in Activities of Daily Living due to your injury: Sleep: Self Care: Sports: Hobbies: Care of Children: Care of Home: Moving in Bed Dressing Exercising Reading Lifting child Vacuum/clean Getting Settled Bathing/Showering Walking Watching TV Picking up toys Dishes/Cooking General Sleeping Hair Care Bathing/Washing child Lawn/Garden Personal Care/Hygiene General Care Garbage Limitations: Check all that apply: I have difficulty Kneeling Bending Twisting Sitting Standing Climbing Stairs Climbing Ladder Reaching Walking Driving Repetitive Work Writing Lifting floor to waist Lifting waist to shoulder Keyboarding/Computer use Car/ vehicle accident(s): Minor (no medical attention) Minor (some medical attention/ x-rayed) Major (injury/ hospitalization) Surgeries: Back Neck Joint Replacement Gall Bladder Appendix Tonsils Hernia Heart Other Significant Injuries (Broken bones, sprains, falls): Serious illnesses/ hospitalizations: Childhood Illnesses: Chicken Pox Mumps Measles Rheumatic Fever Polio Scarlet Fever Whooping Cough Rubella (German Measles) Other Other health problems (e.g. Diabetes, arthritis, heart/ stroke): Please list any X-rays you have had within the past 5 years: LIFESTYLE Height Weight Pregnant Yes No Due Date Regular Exercise Yes No Walking (usual distance) Running (usual distance) Sports (please list) Diet Satisfied with diet Dissatisfied with diet Weight Satisfied with weight Dissatisfied with weight Stress Low Moderate High Why high stress? Sleep Good Poor Why poor sleep? Intake (Indicate amount) Coffee (cups/ day) Tea (cups/ day) Soft Drink (Cola) (cups/day) Alcohol Cigarettes Soft Drink (non-cola) (cups/day) If you stopped smoking, when did you stop?

REGULAR ACTIVITY HISTORY I am... Full Time Part Time Not Working Retired Student DAILY ACTIVITIES (including work, hobbies, etc.): My daily activities include... Prolonged Standing Extensive Walking Bending / Twisting Reaching Repetitive Movements Heavy Lifting (over 20 lbs) Telephone Use Extensive Sitting Prolonged Driving Care of Children Computer Use My Work is... Home based Farm Work Factory Setting Trades Office Setting Traveling Retail / Food Services Other My drive to/from work is... Less than 30 minutes 1/2-1 hour Over 1 hour No driving Walk/Bicycle The vehicle I typically drive is... Small Car Large Car Bicycle Horse-drawn vehicle Van Truck Other OTHER REGULAR ACTIVITIES Gardening Sports Biking Hiking/Walking Swimming Other (please list) FAMILY HISTORY Does anyone in your family have (or had) a history of the following? Please indicate the relationship. 1. Heart Attack 2. Stroke 3. High Blood Pressure 4. Cancer:(Type) 5 Cancer:(Type) 6. Cancer: (Type) 7. Tuberculosis 8. Kidney Disease 9. Anemia 10. Epilepsy 11. Alcohol / Drug Addiction 12. HIV / AIDS 13. Arthritis 14. Diabetes 15. Scoliosis Other (please name)

PERSONAL HISTORY Please check any of the following you have had in the past 2 years. Muscles / Joints Neck pain Back pain Elbow pain Hand Trouble Wrist pain Hip pain Knee pain Ankle pain Foot Trouble Weakness Swollen joints Painful Tailbone Shoulder pain General stiffness Pain between shoulders Difficulty chewing Clicking jaw Other (please name) General Headaches Blackouts Dizziness Insomnia Skin problems Rashes Nervousness Sweats Fainting Abnormal weight gain Abnormal weight loss Loss of consciousness Allergies (please list) Depression Anxiety Convulsions Cardiovascular High blood pressure Angina Poor circulation Heart pain Heart / blood disease Bleeding disorder Hardened arteries Irregular heartbeat Cold/tingling -arms/legs Digestion Diarrhea Vomiting Poor appetite Nausea Constipation Jaundice Indigestion Stomach pain Food Intolerances Heartburn Gas/bloating after meals Black/bloody stool Colitis Painful bowel movement Weight trouble Cramping Gallbladder problems Liver problems Respiration Chronic cough Chest pain Spitting/Coughing blood Painful breathing Asthma Difficulty breathing Genitourinary Trouble urinating Blood in urine Painful urination Bladder infection Bedwetting Kidney infection MALE Prostate trouble FEMALE Painful menstruation Excessive flow Cramping Hot flashes Irregular cycle Breast problems Eyes, Ears, Nose, Throat Speech difficulty Earaches Frequent colds Noises (e.g. ringing) in ears Sinus infections Enlarged glands Difficulty swallowing Thyroid problems Eye/Vision problems Sore throat Hearing loss Ear infections Other

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