WEBSTER CHIROPRACTIC CARE

Similar documents
COMPLAINTS (Briefly describe each complaint by order of severity): HAVE YOU EVER HAD FALLS, AUTO ACCIDENTS OR INJURIES?

WELCOME to the Florence Chiropractic and Wellness Center.

Family First Chiropractic

Family First Chiropractic

Saleeby Chiropractic Centre, P.A.

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

MEDICAL HISTORY QUESTIONNAIRE

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.

New Patient Form Welcome!

PERSONAL INJURY QUESTIONNAIRE

Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No

PATIENT INFORMATION FORM (PLEASE PRINT)

MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED

New Patient Paperwork

Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:

Chiropractic Case History/Patient Information

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

Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:

Type of Patient and/or payment method (circle one)

Patient Name Date of Birth / / Today s Date / /

Who may we thank for referring you?

New Practice Member Application

ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS

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

Patient Information. Preferred Name: Date of Birth: SSN: Address: City: State: Zip: Phone: Cell/Home/Work (please circle one)

Patient Information. Refurredby. Emergency Contact. Have you ever had chiropractic care before? For what problem? No ----

Chiropractic Case History/Patient Information

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

Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State

HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC

PERSONAL INFORMATION. First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip:

Patient Intake Form. I prefer to receive calls at (circle) Home/Work/Cell I am (circle) Under Age18/Single/Married/Divorced/Widowed/Separated

Patient s Name Date: Is today s problem caused by: Auto Accident Workman s Compensation Slip and Fall Other

Chiropractic Case History/Patient Information

3. How Long Has This Been An Issue?

Carriage House Chiropractic and Acupuncture

Physical Evidence Chiropractic 7035 Beracasa Way, Suite 103 Boca Raton Florida, Phone# (561) Fax# (561)

History of Present Problem

History of Present Condition

PLEASE PRINT PLEASE CHECK THE BOX AFTER THE PHONE NUMBER THAT YOU WANT AS YOUR PREFERRED NUMBER

DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT

Name First Middle Initial Last Today s Date. Address Street City State Zip. Primary Phone # Cell # . Your Occupation Employer

Name Date / / Age Male/Female Address City State Zip Phone: Home Cell Carrier (Ex: AT&T, Verizon)

1. What is your chief complaint? Why are you seeking physical therapy treatment? 2. Explain how and when your injury/symptoms occurred:

Chiropractic Health Dr. Art Vanderhoef

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

Patient Intake Form Gray Chiropractic Health Clinic LLC 360 East International Airport Road, Suite #4 Anchorage, Alaska (907)

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

Dr. Brett Whitekettle

Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.

Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone

\ NSMI. The National Sports Medicine InstJtute

Welcome to Medina Family Chiropractic and Acupuncture!

Application for Patient

Pain Relief Recover from Injury Chiropractic Therapeutic Laser Therapy. Release & Balance Method Nutritional Counseling Laboratory Testing & Analysis

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

Address: Street Apt. # City State Zip Code. Phone: ( ) - ( ) - ( ) - Home Mobile Work. Emergency Contact: ( ) - Name Relationship Phone

PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell

New Patient Information and History Form

Rise Chiropractic 239 S. French Broad Ave Asheville, NC

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

Heritage Chiropractic Clinic Geoffrey A. Sandels, D.C Lenora Church Road / Snellville, Georgia / Welcome to our office!

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

HEALTH INFORMATION FORM

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

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

PLEASE NOTE: This file must be saved to your desktop before and after completing!

Welcome to our office!

List anything that caused/contributed to your problem(s) Is this new or Have you ever had these issues before? Yes No if yes, please explain

New Practice Member Paperwork

Who may we thank for referring you? Office Only LIST YOUR HEALTH CONCERNS BELOW. If you had the condition before, when? When did this episode start?

MEDICAL HISTORY FORM

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

Chiropractic Registration and History

NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )

CORNERSTONE PAIN MANAGEMENT

Personal and Family Health History

General Information: (Circle One) (Circle One) Primary Insured's Information Skip if you are primary

Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:

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

Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team

LIST YOUR HEALTH CONCERNS BELOW

Liberty Chiropractic Clinic Scarsdale Blvd., Houston, TX

PAIN DIAGNOSTICS AND INTERVENTIONAL CARE Phone: Internet: Fax:

Home Phone # Cell Phone # Address. Occupation Employer. Work Address Work Phone # Person to Contact in an emergency Phone #

NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE

Notto Chiropractic Health Center Patient Information

Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status

RED-ROSE CHIROPRACTIC CLINIC, P.S NE 85 TH STREET KIRKLAND, WA (425) fax (425)

Pacific Coast Medical Group, PLLC dba Bellevue Pain Institute NE 8th St. Ste. 200 Bellevue, WA

NEW PATIENT REGISTRATION FORM

Family Chiropractic Care Patient Health Questionnaire. Patient Name: Date: What type of regular exercise do you perform? None Light Moderate Strenuous

Matthews Family Chiropractic

Name: (Last) (First) (M.I.) Date: / / Address: City: State: Zip: Home Phone: / / Cell Phone: / / Work Phone: / /

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

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

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

Sports and Spine Physical Therapy

Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone

Transcription:

WEBSTER CHIROPRACTIC CARE Name: Address: City: Zip Code: Marital Status: M S Phone: Cell: Age of Birth Email: May we contact you or send helpful health information via Email? Yes or No Would you like E-mail reminders for your appointment. Yes or No Text reminders? Yes or No If yes, cell carrier: How did you hear about our office? Workers Compensation/No Fault : Claim# Soc. Security# Insurance Company: Insurance Phone: Insurance Address: Adjustor Name: Employer when injured: of Injury: s of Missed Work: Names of other treating doctors:

NAME: How did your pain start? pain started? How long have you had this pain? What do you think is causing your pain? What makes the pain better? What makes the pain worse? Can you describe the way your pain feels? What have you done to treat the pain? What current activities would you like to do, that your pain inhibits you from doing? (please list)(ex. Golfing, biking, vacuuming, gardening, walking etc.) How is most of your day spent? Standing Sitting Other Please Circle: Is the pain: Intermittent Continuous Positional W/Activities Is this condition getting progressively worse? Yes No Does this interfere with Sleep? Yes No Have you gained or lost weight unexpectedly? Yes No Have you ever had a similar condition? Yes No Bowel or bladder problems from pain? Yes No Do you currently wear shoe inserts? Yes No

NAME: Primary Physician: Phone: of last: (Circle all that apply) Physical exam: 1-4months 5-9mths 12mths or greater never Blood Work: 1-4months 5-9mths 12mths or greater never Urine: 1-3months 5-9mths 12mths or greater never Bone Density: 1-3months 5-9mths 12mths or greater never Current Height: Current Weight List surgical operations and year performed: Medications/Supplements/Herbs: Have you undergone: (Circle all that apply) Physical Therapy Massage Therapy Acupuncture Injections Have you had Chiropractic Care before? Yes No of Last Treatment: Do you have a chiropractic physician preference in this office? Female Male No Preference In case of an Emergency Contact: Relation Phone

NAME: Have you ever had any of the following? Circle all that apply: Anxiety Osteoporosis Tremors/Shakes Aneurysm Stroke Blood Clots Heart Attack Heart Disease Atrial Fibrillation Chest Pain Jaw Pain Sweating/Night Sweats High Blood Pressure High Cholesterol Acid Reflux Hernia Blood Thinners Rib Disorder Pregnancy Hormone Replacement Birth Control Multiple Sclerosis Rheumatoid Arthritis Diabetes Dizziness Headaches Migraines Sinus Trouble Cancer Prostate Disorder Joint Replacement Pacemaker Heart Surgery Ulcerative Colitis Autoimmune Dz Allergies Crohns Gallbladder Trouble Gout Skin Ulcerations HIV/AIDS Shingles Life Style: Exercise: times a week - month - year. Tobacco: packs per day - week - month - year. Alcohol: drinks a day - week - month - year. Occupation: Family Medical History (first degree relatives only): Circle all that apply: Heart attack Diabetes Stroke Cancer Multiple Sclerosis Rheumatoid Arthritis Autoimmune Dz Signature

AUTHORIZATION OF INSURANCE PAYMENT Webster Chiropractic Care, P.C. I hereby instruct and direct my insurance company to pay by check made out and mailed to: Webster Chiropractic Care Dr. Alaina Keem & Dr. Matthew Keem 1205 Ridge Road Webster, New York 14580 or If my current policy prohibits direct payment to the doctors, I acknowledge that I will make payment to the above mentioned health care provider. For the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This insurance payment along with any required deductible, co-insurance, or co-payment will be accepted as payment in full. A photocopy of this Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize the doctors to initiate a complaint to the Insurance Commissioner for any reason on my behalf. Signature of Policyholder or Patient Name of Policyholder or Patient (Print) Witness

HIPAA Release Webster Chiropractic Care, P.C. Patient consent for use and disclosure of protected health information (HIPAA) for Webster Chiropractic Care I hereby give my consent for Alaina Keem DC, Matthew Keem DC, or any other personnel of Webster Chiropractic Care to use and disclose protected health information (PHI) about me in order to carry out treatment, payment and healthcare operations (TPO). With this consent, Alaina Keem DC, Matthew Keem DC, or other personnel of Webster Chiropractic Care may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent, Webster Chiropractic Care may mail to my home or other alternative location any item that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With this consent, Webster Chiropractic Care may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Webster Chiropractic Care restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Webster Chiropractic Care to use and disclose my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Webster Chiropractic Care may decline to provide treatment to me. Patient s Name (PRINT) Patient s Signature

Pain Diagram and Pain Rating Name: : INSTRUCTIONS: Please use the diagram below to indicate the symptoms you have experienced over the past 24 hours. Use the key to indicate the type of symptoms. KEY: Pins and Needles = 000000 Stabbing = / / / / / / Burning = xxxxxx Deep Ache =zzzzzz Please rate your current level of pain on the following scale (check one): 0 1 2 3 4 5 6 7 8 9 10 (no pain) (worst imaginable pain) Please rate your worst level of pain in the last 24 hours on the following scale: 0 1 2 3 4 5 6 7 8 9 10 Please rate your best level of pain in the last 24 hours on the following scale: 0 1 2 3 4 5 6 7 8 9 10

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