Similar documents
Shallotte Vision Care J. Mark Saunders, OD PA 4637 Main Street Shallotte NC Patient Demographic Information

WELCOME to the Florence Chiropractic and Wellness Center.

The Impact of Tiered Co-Pays A Survey of Patients and Pharmacists

Over. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:

Preferred Name: First Name: Last Name: Middle Initial: Mailing Address: City: State: Zip: Alternate number: address:

PLEASE FILL OUT & RETURN

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

New Patient Information

Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005

Counseling Associates, Inc.

2013 National Treatment Survey. Immune Deficiency Foundation

How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all

Health Care Callback Survey Topline August 2001

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

Feil & Oppenheimer Psychological Services

PATIENT REGISTRATION FORM. Last Name: First Name: Initial: Address: City: State: Zip Code: Date of Birth: / / Social: - - address:

Medical Questionnaire

Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address:

History & Review of Systems Screening. Medical History

Naturopathic Medicine Intake Form

Carriage House Chiropractic and Acupuncture

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C

Welcome to Medina Family Chiropractic and Acupuncture!

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

Health History Questionnaire

SLEEP SCREENING QUESTIONNAIRE

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

PATIENT REGISTRATION

Please return the questionnaire in the enclosed pre-paid envelope

In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed.

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

3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:

Providence Medical Group

Outpatient Registration Form

LECOM Health Ophthalmology

Welcome to the Healthplex!

George M. Salib, M.D., Inc.

c o m m u n i t y o u t r e a c h

Additional details about you What is your ethnic group? Name of next of kin \ Emergency contact

New Patient Form Welcome!

PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT

PATIENT HEALTH HISTORY

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

Patient Intake Form for Allegany Ear, Nose, & Throat

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

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

ADULT INFORMATION SHEET

Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address

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.

Adult Neuropsychological Questionnaire

Patient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:

PATIENT INFORMATION FORM

ITG Diet Health Status Intake Form

Anesthesia Preoperative Patient History

Cost-Motivated Treatment Changes in Commercial Claims:

New Patient Paperwork

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

Sincerely, Michael R. Probstfeld, M.D., FACS Southern Arizona Laser & Vein Institute A MESSAGE ABOUT OUR PATIENT HISTORY FORM

Primary Care Physician: If Yes, where? Current work status: Full-Time Part-Time Self-Employed Unemployed Disability Retired

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

Diabetes Program Enrollment Questionnaire Please complete this questionnaire with as much information as possible

Evolve180 / Ideal Northwest Health Profile

Who is filling out this intake form? Self Spouse Parent Guardian

New Patient Information

MGH Beacon Hill Primary Care New Patient Form

Adult Naturopathic Medicine Intake Form

DOCTOR REFERRAL LETTER

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

MEDICAL HISTORY. Previous Nephrologist. Medication taken Insulin Oral Both. Who manages your diabetes? Blindness Yes No Hearing Problems Yes No

SURVEY ABOUT YOUR PRESCRIPTION CHOICES

SCHNEIDER MEDICAL GROUP, PA History Intake Form (Please Print)

Male New Patient Questionnaire

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

THE RELATIONSHIP BETWEEN ACTIVITIES OF DAILY LIVING AND MULTIMORBIDITY. A VIEW FROM TELECARE

PATIENT INFORMATION Please print clearly and complete all blanks

FROST FAMILY MEDICINE

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

Patient Name Date of Birth Age. Other phone ( ) . Other

Dr. Hall New Patient Paperwork Please fill out these forms completely

PATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?

New Patient Paperwork

DATE OF BIRTH: MELANOMA INTAKE

Medicare Annual Wellness Visit Patient History

Outpatient Registration Form

Welcome to About Women by Women

I choose not to specify

Initial Patient Health Assessment Form

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

Laser Vein Center Thomas Wright MD Page 1 of 4

Patient Registration Form

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

Name: (Last) (First) (Middle) Address: (City) (State) (Zip) Home: ( ) Work: ( ) Cell: ( ) Age: DOB: SS#: Height: Weight: Occupation:

History of Present Condition

Name (Last Name, First Name): SSN #: Date of Birth: Age: Sex: M F Other. Address: Home phone: Work phone: Cell phone:

PATIENT DEMOGRAPHIC INFORMATION

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

Patient s name Patient s phone numbers Emergency contact name Emergency contact phone number Relationship to patient

ALF Boss's ALF Cheat Sheet For ADRC's Phone Interview For Long Term Care

Transcription:

http://results.harrispollonline.com/surveyresults/default.asp?file=page1.html In general, how would you describe your own health? 16% 34% 29% 13% 7% Excellent Very good Good Fair Poor

http://results.harrispollonline.com/surveyresults/default.asp?file=page2.html Overall, how satisfied are you with the health care services you have received in the past 12 months? 53% 35% 7% 3% Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied

http://results.harrispollonline.com/surveyresults/default.asp?file=page3.html This is a list of the different kinds of health plans or health insurance people have, including those provided by the government. Please indicate what type of coverage, if any, you currently have. Health care coverage through your work or union 49% Health care coverage through someone else's work or union 18% Medicare or a Medicare HMO 19% Some other type of health plan or coverage 11% Medicaid, a Medicaid HMO, Medi-Cal or Public Aid 6% Health care coverage through some other group which you buy directly 5% No health insurance coverage 9%

http://results.harrispollonline.com/surveyresults/default.asp?file=page4.html The list below describes actions people sometimes take with regard to their health plans. In the past two years, have you done any of the following things? Asked for info about covered treatments 37% Changed plans due to switching jobs or coverage 13% Called or written with a complaint 18% Challenged a decision regarding care 14% Changed plans due to dissatisfaction with coverage 6% Requested info about how to stay healthy 4% None of these 45%

http://results.harrispollonline.com/surveyresults/default.asp?file=page5.html How would you rate your health plan or health insurer, overall? Thinking about all your own experiences with that plan, overall, what grade would you give it? 26% 41% 22% 6% 3% A B C D F

http://results.harrispollonline.com/surveyresults/default.asp?file=page6.html Please indicate below if you have ever been told by a doctor or another health professional that you have any of the following medical conditions. 44% 28% 14% 6% 6% 24% 15% Allergies Arthritis Asthma Blindness/ Vision impairments Cancer Cholesterol Chronic back problems continued on next page

http://results.harrispollonline.com/surveyresults/default.asp?file=page7.html Please indicate below if you have ever been told by a doctor or another health professional that you have any of the following medical conditions. 6% 8% 2% 20% 4% 1% 10% Chronic bronchitis Chronic sinusitis COPD Depression Other mental health condition Developmental disability Diabetes continued on next page

http://results.harrispollonline.com/surveyresults/default.asp?file=page8.html Harris Poll Online: Please indicate below if you have ever been told by a doctor or another health professional that you have any of the following medical conditions. 12% Digestive/ Gastrointestinal disorder 1% 2% 3% 3% Epilepsy Emphysema ED -- Erectile Dysfunction 9% 8% Fibromyalgia Gynecological condition Hearing impairmen continued on next page

http://results.harrispollonline.com/surveyresults/default.asp?file=page9.html Harris Poll Online: Please indicate below if you have ever been told by a doctor or another health professional that you have any of the following medical conditions. 23% 8% 1% 1% 1% 1% 9% Heart disease Hepatitis C Hypertension or high blood pressure Kidney disease Liver disease, including cirrhosis Lupus Menopaus continued on next page

http://results.harrispollonline.com/surveyresults/default.asp?file=page10.html Please indicate below if you have ever been told by a doctor or another health professional that you have any of the following medical conditions. 15% 1% 4% 12% 1% 8% Migraine Multiple Sclerosis Osteoporosis Skin condition Stroke Thyroid condition

http://results.harrispollonline.com/surveyresults/default.asp?file=page11.html How often do you look for information online about health topics? 47% 16% 24% 13% Often Sometimes Hardly ever Never

http://results.harrispollonline.com/surveyresults/default.asp?file=page12.html Which sources have you used to get health-related information off the Internet? Health pages created by online services 64% Academic or research institutions 34% Medical journals 30% Patient support groups 28% Pharmaceutical companies 22% The media 20% Government sponsored sites 19% Your health insurance company or managed care plan 17%

http://results.harrispollonline.com/surveyresults/default.asp?file=page13.html Overall, do you feel that the health-related information you get from the Internet has had a major impact, minor impact, or no impact at all on how you communicate with your doctor? 23% 44% 33% Major impact Minor impact No impact at all

http://results.harrispollonline.com/surveyresults/default.asp?file=page14.html Overall, do you feel that the health-related information you get from the Internet has had a major impact, minor impact, or no impact at all on the extent to which you understand any health problems you may have? 43% 44% 14% Major impact Minor impact No impact at all

http://results.harrispollonline.com/surveyresults/default.asp?file=page15.html In the past twelve months, how many times have you talked to your doctor about healthrelated information you have seen on the Internet? 37% 17% 16% Never Once Twice 11% Three to Five Times 3% Six or More Times

http://results.harrispollonline.com/surveyresults/default.asp?file=page16.html Do you ever send email messages to your doctor? 97% 3% Yes No

http://results.harrispollonline.com/surveyresults/default.asp?file=page17.html In the past 12 months, have you asked your doctor to prescribe a generic instead of a brand name drug, or not? 45% 54% Yes No

http://results.harrispollonline.com/surveyresults/default.asp?file=page18.html In the past 12 months, have you asked your doctor to prescribe a specific brand name prescription drug, or not? 75% 24% Yes No