Infant / Child New Patient Information Package Dr. Anne M. Desneiges - Chiropractor
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1 Dr. Anne Desneiges Inner Waves Centre for Well~Being Infant / Child New Patient Information Package Dr. Anne M. Desneiges - Chiropractor Name: Address: Postal code: street city Telephone: home: ( ) work: ( ) ext: cell:( ) Date of Birth: / / Day Month Year Primary Health Care Physician: Date of last physical exam? How did you learn about us: Birth Information Length of Pregnancy: Quality of Pregnancy: Physically (pain, energy level, ) good difficult Emotionally Chemical sensitivities / hormones Neurological (nausea, balance, ) Any complications: Length of Labor: Labor Difficulty: easy very difficult Any interventions &/or drugs utilized: Any complications: Health of Child at Birth: Health of Child at present: Physical poor good excellent Mental poor good excellent Emotional poor good excellent Infant Illnesses colic measles viral infections jaundice diarrhea bacterial infections respiratory difficulties vomiting cerebral palsy Childhood Illnesses measles tubes in ears whooping cough mumps chicken pox meningitis ear infections mumps rheumatic fever
2 Primary Complaint Details What is the primary concern or symptom: What happened to bring this on? When did this happen or start? How would you describe the symptom or problem? In frequency (how often): In quality (sharp, dull, achy, throbbing,...): What makes it feel better? What makes it feel worse? Have you sought any treatment for it? YES NO If yes, what kind and did it help? Has the child had any tests, x-rays, CAT scans, MRI s or blood work done for this issue? YES NO What were the results? Hospitalization & Surgeries Injures list all major injuries, car / bicycle accidents, any traumas, dates and related symptoms Vaccines / Medication -current and any major past medication, dosage and condition treated Activity -please list current activities and approximate number of hours/week. 2
3 If applicable: Check PRESENT symptoms ; underline PAST conditions; Circle specifics ex: knee / foot General Symptoms Headaches / Migraine Fever / Chills Night Sweats / Sweats Night Pain Weight Loss Loss of sleep Clumsiness Cardiovascular Heart murmur Heart disease History of heart attack High / Low blood pressure Bleeding disorders Swelling Poor circulation G.U. for Girls Menstruation: -painful -heavy / scant -irregular -cramps / backache Breast swollen / painful E.E.N.T. Blurred or loss of vision Eye pain Contacts Ringing in the ears Earache Deafness Speech problems Sore throat Difficulty swallowing Muscles & Joints (stiff/pain) Neck Back: upper / lower Shoulder Elbow Wrist / Hand Hip Knee Ankle / Foot Arthritis RA / OA Swollen joints Fractures Jaw problems Respiratory Chronic cough Spitting up phlegm / blood Chest pain Difficulty breathing Bronchitis Asthma Sinus problems Gastrointestinal Poor appetite Cravings: sweets/ starch/ other Indigestion Stomach pain Ulcer Nausea Vomiting / blood Belching / gas / bloating Constipation Diarrhea Hemorrhoids Gall bladder trouble Hiatus / inguinal hernia Crohn s / Colitis Irritable Bowel Genitourinary Painful urination Difficulty urinating Blood in urine Kidney / bladder infection Stones Bed wetting Skin Sensitive Rashes/itching Bruise easily Dryness Boils / hives Contagious condition Herpes / Cold sores Systemic conditions (indicate child or any family member) Diabetes Cancer Heart disease / Stroke Hypo / Hyper thyroid Gout Liver disease/ problems Epilepsy Hepatitis Tuberculosis Osteoporosis Immune system Colds / Flu often Allergies Sensitive to environment Slow to heal HIV + / AIDS Psychosocial Daily Stress mild / moderate / extreme Emotional crisis Depression/Anxiety Psychiatric/Psychological care Addictions: Other Health Care Chiropractic Massage therapy Naturopath/Homeopath Craniosacral Physiotherapy/Osteopathy Acupuncture / pressure Nutrition Other: 3
4 Informed Consent to Spinal Care Dr. Desneiges incorporates different techniques to uniquely care for you as a whole person. They are the following: Chiropractic (traditional) Network Spinal Analysis (non-force Chiropractic) Activator Chiropractic Technique (utilizing a small tool for chiropractic adjustments) Cranio-sacral Therapy Nutrition I hereby request and consent to receiving care by Dr. Anne M. Desneiges. I will have an opportunity to discuss with her, the nature and purpose of any of the procedures. I understand that the results are not guaranteed. I further understand and am informed that in the practice of chiropractic and these additional therapies, there are some possible physical, emotional and mental side effects that may occur. I do not expect the doctor to be able to anticipate and explain all risks and complications. I rely on the doctor to exercise her judgment during the course of the procedure, which she feels at the time, based upon the facts then known, is in my best interest. Due to the utilization of other gentle methods, she does not normally implement manual adjustments and would ask for your consent if one were required. The alternative methods and their side effects are described on the next page. I have read the above consent. I have had an opportunity to ask questions about its content, and by signing below, I agree to the included procedures. I intend this consent form to cover the entire course of my treatment plan. TO BE COMPLETED BY PATIENT: Print Patient s Name Signature of Patient (or parent / guardian) Date Signed 4
5 Please CIRCLE clearly if there is a technique you do NOT wish to receive 1) Network Spinal Analysis: An alternative chiropractic technique. A gentle non-manipulative technique based on releasing tension and optimizing communication within your nervous system. With small finger contact (mostly to the neck and pelvis), the brain is triggered to pay attention to the stored tension/symptom and act upon it. As tension and stress leave the body, the person may experience physical, emotional and chemical side effects. 2) Chiropractic Activator Technique: a technique utilizing a small tool that delivers a small direct force. Used to correct joint dysfunctions instead of spinal manipulative adjustments. Used most often on extremities (ex: wrists and feet). See chiropractic for risks. 3) Chiropractic: a century old hands on healing therapy and philosophy that is now a scientifically supported and approved profession. Doctors of Chiropractic are recognized Health Professionals by the Government of Canada, and are covered by most health insurance plans. Unique to chiropractic is the spinal manipulative adjustment, which has very slight risks to treatment, including, but not limited to muscle strains, disc injuries, and stroke (1 in 1 million). *Note: Dr. Desneiges does not perform neck manipulations 4) Cranio-sacral Therapy: a gentle, hands-on approach to balancing and re-optimizing the craniosacral rhythm which is the rhythm of the cerebrospinal fluid along the nervous system and brain. In addition, work with fascia (connective tissues), scars and viscera (abdomen) are often performed. Possible side effects are similar to NSA physical, emotional and chemical releases may allow for relief or discomfort. 5) Nutrition: Dr. Desneiges may provide nutritional guidance. Following directions given by her are to your advantage, although at your discretion. 5
6 Dr. Anne Desneiges Fees CHILDREN (0 12yrs) New Patient Visit $50.00 Regular Visits $25.00 Special appointments such as Re-examinations; SRI visits or special extended visits have different fees. Please check with the front desk. **We accept cash, cheque, Visa, MasterCard, Amex and debit. I understand that the fee above pertains to me and I agree to pay it upon receipt of my sessions. Signature Date 6
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Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
Patient Information. Patient s First and Last name: Preferred Name: Mailing Address: City: State: Zip Code: Date of Birth: Gender:
Patient Information: Patient Information Patient s First and Last name: Preferred Name: Mailing Address: Date of Birth: Gender: Best Number to Confirm Your Appointments: Alternate Phone Number: Social
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
PATIENT APPLICATION FORM: CHILD
PATIENT APPLICATION FORM: CHILD WELCOME and THANK YOU for trusting us with your child/children applying as patient(s) in our clinic. We are a very unique team specializing in researched, evidence-based,
PERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE NAME: PHONE: ( ) ADDRESS: CITY/STATE/ZIP: AGE: BIRTHDATE: SEX: SS # EMPLOYER'S NAME/ADDRESS: YOUR INSURANCE CO: POLICY #: AGENT'S NAME & PHONE: NAME ON POLICY (IF OTHER THAN
Insurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM (Please Print) Name: LAST FIRST Ml Street Address: STREET APT CITY STATE ZIP Home Phone #: ( ) ) Cell Phone #: ( ) ) Social Security #: Birth date: Age: Sex: M ; F Marital Status:
Cornerstone Family Practice REGISTRATION FORM (Please Print)
Cornerstone Family Practice REGISTRATION FORM (Please Print) Today s Date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status: Single Mar Div Sep Wid Language
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
2015 Medical Requirement Forms
PLEASE RETAIN A COPY OF THE COMPLETED HEALTH FORMS FOR YOUR OWN RECORDS 2015 Medical Requirement Forms Ontario Public Health regulations and St. Clair College Policy require health screening for all persons
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
Welcome to Active Care Atlanta
Welcome to Active Care Atlanta Name Birth Date Age Male Female Cell # Home # Work # Address City, State & Zip Email Occupation Employer Social Security # - - Marital Status Single Married Divorce Other
BRENTWOOD EAST FAMILY MEDICINE Patient Registration Form (ecw)
BRENTWOOD EAST FAMILY MEDICINE Patient Registration Form (ecw) PATIENT INFORMATION Dr. Miss Mr. Mrs. Ms. Sir Patient s Name (Last) (First) (MI) Previous Name Address Line 1 City, State ZIP Pharmacy Pharmacy
Danita Thomas Heagy, DC, LLC 4425 US 1 South, Suite 109 St Augustine FL 32086-3127 904-797-5100 www.drdanita.com
WELCOME! Thank you for choosing this office to assist you with your health care. Once the exam is complete, I will present my findings and recommendations to you briefly. At the Health Dialogue, we will
Zabel Chiropractic Application For Care
Zabel Chiropractic Application For Care The following information is needed in order to better serve you. Please complete all questions. If you need help please ask the receptionist. PLEASE PRINT. Today
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine