Acupuncture New Patient Questionnaire
|
|
|
- Gregory Clark
- 7 years ago
- Views:
Transcription
1 Acupuncture New Patient Questionnaire Name Today s Date Address City State Zip address Phone: Home Work Cell Birth date Age Ht Wt Sex M / F Marital Status No. of Children Occupation Emergency Contact: Name Phone Primary Care Practitioner: Is this your first time getting acupuncture? Y / N How did you hear about us? Goals: What would you most like to achieve with acupuncture treatments? Major Symptoms: Please list in order of importance what symptoms are of concern to you. (most concerning to least, along with the duration of the symptom) Are you experiencing pain/discomfort in any area of your body? Y / N Please rate your pain level Use the illustration to indicate painful or distressed areas. Indicate the location of the discomfort by using the symbol that best describes the feeling: X X X Sharp/Stabbing P P P Pins & Needles D D D Dull/Aching N N N Numbness T T T Tightness/Spasms Medical History 1
2 Do you or have you had any of the following conditions? If yes, please indicate date of diagnosis. Date Diagnosed Date Diagnosed Cancer type: HIV Diabetes Mental Illness Heart Disease Seizures Hepatitis Stroke High Blood Pressure Thyroid Disease High Cholesterol Other Please list any surgeries or major injuries with dates. List any medications or supplements you have taken in the last 2 months. Do you have a pacemaker or any metal devices in your body? Y / N Family History Indicate close family members with any of the following. Family member(s) Family Member(s) Cancer (specify type) High Cholesterol Diabetes Mental Illness Heart Disease Stroke High Blood Pressure Alcoholism Lifestyle Habits Do you have an exercise routine? Please describe. How many hours per night do you sleep on average? Do you wake rested? Y / N Nicotine Use: Alcohol Use (#drinks/week and type): Caffeine Use (#drinks/day and type): Water intake (how much/day): Briefly describe your dietary habits (#meals/day and type of food) 2
3 Please check all that apply Energy and Immunity Fatigue Allergies (Specify) Anemia Chronic Fatigue Syndrome Thyroid Problems Tendency to Catch Colds Head, Eye, Ear, Nose, and Throat Eye Dryness Blurry Vision Poor Night Vision Ear Ringing Hearing Difficulties Headaches / Migraines Teeth Grinding / TMJ Sore Throat Chronic Sinus Congestion Dry Mouth Bad Breath Mouth Sores / Bleeding Gums Increase in Thirst Emotions / Sleep Mood Swings Anxious / Worried Depressed Irritable Difficulty Making Decisions Stressed Insomnia Nightmares Difficulty Falling or Staying Asleep Respiratory/Cardiovascular Shortness of Breath Asthma Chest Pain Palpitations / Fluttering Poor Circulation (Cold hands/feet) Chronic Cough Night Sweats Unusual Sweating Hot/Cold Intolerance Gastrointestinal Ulcers Changes in Appetite Nausea / Vomiting Bloating / Pain Gas Heartburn / Acid Reflux Belching Hemorrhoids Diarrhea Constipation Sudden Weight Change Kidney/Urinary Painful Urination Frequent Urinary Tract Infections Frequent / Urgent Urination Edema / Swelling Musculoskeletal Neck / Shoulder Pain Muscle Spasms / Cramps / Weakness Arm Pain Finger Pain / Tingling / Numbness Upper Back Pain Mid Back Pain Low Back Pain Leg / Knee Pain Foot / Ankle Pain Hip / Pelvic Pain Arthritis Neurological Vertigo / Dizziness Numbness / Tingling Difficulty Concentrating / Poor Memory Skin Rashes / Eczema / Hives / Psoriasis Dry Hair or Hair Loss Changes in Skin Color Easy Bruising Acne Dry / Itchy Skin Female Health Irregular Cycle Heavy Flow Light Flow Clots in Menstrual Blood Menstrual Related Moodiness Menstrual Related Breast Tenderness Menstrual Related Bloating Bleeding Between Cycles Painful Periods (Is pain before, during and/or after period? Hot flashes Vaginal Dryness Breast Lumps / Cysts Uterine Fibroids Endometriosis Ovarian Cysts Unusual Vaginal Discharge Odor Frequent Yeast Infections Decreased Libido Male Health Prostate Enlargement Impotence Premature Ejaculation Decreased Libido Groin Pain 3
4 Acupuncture Patient Payment Policies We appreciate that you have chosen to receive acupuncture services with Acupuncture for Balanced Wellness and welcome any questions you might have regarding our policies and services. Outlined below is an overview of our patient payment policies for acupuncture services. 1. Cancellation / Missed Appointments. Please call if you need to cancel an appointment at least 24 hours prior to the time scheduled. If your appointment is not cancelled within the 24 hour timeframe or you miss your appointment, you will be charged a $25 missed appointment fee. 2. Lateness. To maintain a high level of service to our patients, we strive to begin appointments on time. If you arrive late to your appointment, we will do our best to treat you in the remaining time allotted. 3. Insurance. We may accept insurance for payment for acupuncture services if your insurance policy includes acupuncture benefits. We can also provide an itemized paperwork that you can submit to your insurance company for reimbursement if you wish to pay for services at the time of treatment. We do recommend that you verify your acupuncture insurance benefits by contacting your insurance company, but we can also help you verify benefits at our office. Assignment and Release (if using insurance) I, the undersigned, certify that I (or my dependent) have insurance coverage with and assign directly to City Center Chiropractic and Rehabilitation all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Signature of Insured Relationship to patient Date 4. Forms of Payment. If not using insurance, payment for acupuncture services is expected at the time service is provided. We accept cash, check, Visa, Mastercard, American Express, or Discover for payment. 5. Flexible Spending Accounts (FSA). If you have a corporate FSA that covers acupuncture services, we still expect full payment at the time of service. We will provide you with the itemized paperwork necessary for reimbursement. Please check with your human resources representative for details. By signing below, you acknowledge that you understand the above information and agree to the policies on this form. Patient s Signature Date 4
5 Patient Informed Consent for Acupuncture I,, hereby voluntarily consent to be treated with acupuncture and other associated forms of therapy which include, but are not limited to, cupping, gua sha, heat therapy, tui na (oriental bodywork), electrical simulation, nutritional counseling, and herbal therapy administered by Angie Ng, hereinafter referred to as Practitioner. I understand that the acupuncture is performed by the insertion of fine, pre-sterilized, disposable acupuncture needles (with or without the addition of electric current) through the skin, or the application of heat to the skin, or both, at certain points on the body, in an attempt to improve the body function and/or relieve pain. I acknowledge that although rare, certain side effects may result from acupuncture. These include bruising, mild pain or discomfort, a feeling of weakness, fainting, nausea, and a temporary aggravation of symptoms. These effects are unusual and of short duration. I accept the fact that no guarantee is made concerning the use and effects of acupuncture or its adjunctive therapies mentioned above. I understand that I may stop treatment at any time. I further understand that the evaluation given to me is an energetic assessment of the acupuncture meridian network, and in no way purports to be, or replaces a western medical examination and diagnosis. In the course of the evaluation, there may be reference to the state of various organs such as heart, liver, spleen, kidneys, etc., which actually refers to energetic channels of the same name. I acknowledge the fact that Practitioner is not and does not profess to be a western-trained medical doctor and does not use or advise on the use of medically-prescribed pharmaceuticals or medical treatments, nor does Practitioner give any substances by injection. I acknowledge that Practitioner has completed a minimum of three academic years of training in Acupuncture, is National Board Certified (NCCAOM0 and a Licensed Acupuncturist (L.Ac.) in the State of Illinois. Signature: Date: Witnessed by: Date: Angie Ng, L.Ac. Dipl.Ac. 5
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)
REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE
412 Holistic Health, LLC Maura Schuster, L.OM 412.841.2065 Practitioner of Oriental Medicine NEW PATIENT INTAKE PATIENT INFORMATION Date Name Address City State Zip Age Birthdate Occupation Company name
Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient
PATIENT INFORMATION Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address Emp. Phone Spouse/Partner
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
Dr. Ann Zee R.Ac. DTCM Acupuncture/Traditional Chinese Medicine PATIENT INFORMATION
Dr. Ann Zee R.Ac. DTCM PATIENT INFORMATION Date: Surname: First Name: Middle Initial: Date of Birth (M/D/Y) Age: Sex: M F Address: City: Province: Postal Code: Family Doctor (Required): Business Employer:
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************
CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE
Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE Name: Date: Street: City: State: Zip: Cell Phone: Home Phone: Occupation: Marital Status: Date of Birth: Age: Gender: M F Height:
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
Patient Intake Form. Patient Information. How did you find out about our office?
Atlanta Injury and Wellness Center 2740 Greenbriar Parkway Suite A 3 Atlanta, GA 30331 404 629 9999 Patient Intake Form Welcome to our office of chiropractic. Thank you for taking a moment to fill in our
Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Pharmacy: Pharmacy Phone #:
PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally
71 Spit Brook Road, Suite 407 Nashua, NH 03060
71 Spit Brook Road, Suite 407 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to serve you better.
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
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
New England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
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
MEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
traditional medicine for modern times tm Laura Gabbé, LAc, MS Acupuncture & Herbs
traditional medicine for modern times tm Laura Gabbé, LAc, MS Acupuncture & Herbs FIRST NAME LAST NAME ADDRESS CITY STATE ZIP HOME PHONE OTHER PHONE EMAIL OCCUPATION INSURANCE CO. INSURER S NAME SELF SPOUSE
WORKERS COMPENSATION INFORMATION
WORKERS COMPENSATION INFORMATION PATIENT REGISTRATION INFORMATION 15215 Shady Grove Rd. # 100 Patient Name: Last First MI Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Primary Doctor:
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792 1 PAIN MANAGEMENT SERVICES New Patient Questionnaire Date: Primary MD: Referring
General Internal Medicine Clinic New Patient Questionnaire
General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:
Disclosure Form. Memberships: National Certification Commission for Acupuncture and Oriental Medicine (Dipl. Acup.)
Consent Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental materia medica Matt Hillman, L.Ac. I understand that acupuncturists practicing
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
PATIENT REGISTRATION
PATIENT REGISTRATION Patient s Last Name: Patient s First Name: MI: Address: City, State Zip code: Patient s Date of Birth: Patient s Social Security: Best Number to contact: Secondary Number: Marital
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History
THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History Name DOB Date Age Occupation Email Address Home address City State Zip Home phone Cell Phone Referred By Physician Physician Phone Please
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
Aspen Chiropractic & Wellness
WELCOME TO OUR OFFICE We are committed to providing you the best of care and are pleased to discuss our professional fees with you at any time. Please ask any questions you may have regarding our fees
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD
CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD DATE PATIENT INFORMATION OUR DOCTOR CHART NO. LAST NAME FIRST NAME MIDDLE INITIAL MAIDEN NAME Are you
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
Medical History Questionnaire
Medical History Questionnaire Name: Date: Allergies (including latex): List all medications that you are currently taking, either prescription or non- prescription. Please specify dosage and length of
319 Airport Road Hackettstown, NJ 07840 Ph: 908-850-0888 / FAX: 908-850-1005
319 Airport Road Hackettstown, NJ 07840 Ph: 908-850-0888 / FAX: 908-850-1005 Dear New Patient: Thank you for choosing Holistic Family Healthcare as your holistic healthcare provider. Our goal is to help
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
Rehabilitation Medicine Clinic. New Patient Questionnaire
Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
How To Get A Medical Checkup From A Doctor
Welcome to Schoonman Chiropractic. We look forward to providing you the best possible care. Please fill out the following information for our records: Name: Name of Parent (If Minor): Address: Phone Number:
Male New Patient Package
Male New Patient Package The contents of this package are your first step to restore your vitality. Please take time to read this carefully and answer all the questions as completely as possible. Thank
Patient Information Form Pain Management Center at Phoebe
Patient Information Form Pain Management Center at Phoebe Please complete the following form, so that we may facilitate your visit Occupation: or (circle) Retired, Disabled Homemaker, Full time student
PAST MEDICAL HISTORY REVIEW OF SYSTEMS
SOUTHEASTERN SPORTS MEDICINE Page 1 of 6 21 Turtle Creek Drive Asheville, NC 28803 DATE PATIENT INFORMATION PATIENT NAME: Last First Middle ( ) Child ( ) Single ( ) Married ( ) Widow(er) ( ) Divorced Address
CHRONIC FATIGUE SYNDROME/FIBROMYALGIA SYMPTOM CHECKLIST (c) 1997 Katrina Berne, Ph.D., Mesa, AZ www.livingwithillness.com
CHRONIC FATIGUE SYNDROME/FIBROMYALGIA SYMPTOM CHECKLIST (c) 1997 Katrina Berne, Ph.D., Mesa, AZ www.livingwithillness.com Please indicate on a scale of 1 to 10, with 10 being the most severe, the severity
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
Mary R. Hunter, RN, BSN, LMT Clinical Herbalist Certified Nutritionist
Mary R. Hunter, RN, BSN, LMT Clinical Herbalist Certified Nutritionist Responsibility for Payment 1. Fees Office Visit $1.00/minute First visit usually 90 minutes $90.00 2. The client is responsible for
Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:
Welcome to Avenstar Pain Specialists! Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM
INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable
AGREEMENT AND INFORMATION
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS
DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with
Patient Information. Name: Soc Security #: Date of Birth: Age: Male / Female. LOCAL Address: Street City State Zip. Phone: Home: Cell / Work:
Patient Information PERSONAL INFORMATION (Please Print Clearly) Name: Soc Security #: Date of Birth: Age: Male / Female LOCAL Address: Street City State Zip Phone: Home: Cell / Work: Email Address: Out
A Caveat - Be Aware Of Quiz-Limitations
Hypothyroidism Progressive Treatment Quiz Think you may have a sluggish thyroid or what medicine calls hypothyroidism? Have you seen the doctors, but your blood tests keep coming back normal? Or did the
CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
NEW PATIENT HISTORY Mark L. Prasarn, M.D.
NEW PATIENT HISTORY Mark L. Prasarn, M.D. Date: Name: Age: Height: Weight: Pharmacy: Phar. Phone#: Primary Care M.D. Referring M.D.: What is your Chief Complaint? What makes the pain better? Neck Pain
Paul Kempisty L.Ac. Acupuncture. Chinese herbs. Reiki. Aromatherapy. Patient Information. Please answer questions to the best of your knowledge
Paul Kempisty L.Ac. Acupuncture. Chinese herbs. Reiki. Aromatherapy. Patient Information Please answer questions to the best of your knowledge Name Date Address_ City State Zip Home Phone Other Phone Fax
Cancellation/No Show Policy
Cancellation/No Show Policy If you are unable to keep your scheduled appointment we require a 24 hour advance notice. Failure to provide this notice will result in a $50.00 cancellation/no show fee. You
Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)
Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:
Home Phone Work Cell Email
Dr. Jerrid Goebel Licensed Acupuncturist 824 1 st Street Dr. Stuart Johnson Sturgis, South Dakota, 57785 Dr. Al Gunderson Telephone (605) 347-4003 Todays date: Patient s Name Date of Birth age Address
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
Galerie Dental Care. Patient Information. Emergency Contact Relationship: Phone:
Galerie Dental Care Patient Information Date: Patient Name: Last First Middle Initial (Preferred Name) Gender: Birth Date: Marital/Family Status Address: Street Apartment # City Province Postal Code Phone
Male Patient Questionnaire & History
Male Patient Questionnaire & History Name: Today s Date: (Last) (First) (Middle) Date of Birth: Age: Occupation: Home Address: City: State: Zip: E- Mail Address: May we contact you via E- Mail? ( ) YES
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 An important part of the helping relationship is understanding the expectations of the relationship.
Welcome to Chirosports Coogee
PAGE 1 OF 6 Welcome to Chirosports Coogee At Chirosports our goal is to optimise your health and increase your quality of life. Chiropractic is an approach to health and wellbeing that assists the body
Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip
Texas Sinus Center PATIENT REGISTRATION 1. PATIENT INFORMATION Name Birth date Soc Sec# Address City/State Zip Home Phone Work Phone Cell Phone Marital Status S / M / W / D Student FT / PT Male / Female
SPINE PATIENT HISTORY FORM
Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print
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
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
SLEEP DISORDERS CENTER SLEEP CLINIC PATIENT QUESTIONNAIRE. Please bring this completed questionnaire with you to your sleep clinic appointment.
SLEEP DISORDERS CENTER Please bring this completed questionnaire with you to your sleep clinic appointment. Patient s Name: Date: Referring Physician: Clinic Location: 1. Why are you being seen in the
New Patient Registration Form
New Patient Registration Form Welcome to Bayside Dental Care! We look forward to giving you the best dental experience possible. Please complete both sides of this form. Let us know if you need any assistance
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #:
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
NEW PATIENT INFORMATION FORM
Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D. 303-762-DISC (3472) NEW PATIENT INFORMATION FORM Please print all information. By fully completing this form, you allow us to serve you quickly and efficiently.
PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
Relation Address City State Zip Code
To enable us to provide you with the best possible care, please complete the following: Date: Name Social Security # First Full Middle Last Address City Zip Code_ Telephone (home) (work) Date of Birth
Welcome! Please fill out this Patient Registration
Welcome! Please fill out this Patient Registration Personal: (Please Print Clearly, Sign ALL pages and be Complete) Last Name First Name Middle Street City State Zip Home Phone #: ( ) Work / Cell Phone
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION
PREMIER PAIN CARE PA Carlos J Garcia MD 2435 W. Oak Street # 103 Denton, TX 76201 Phone 940-323-9404 Fax 940-323-9422 PATIENT REGISTRATION Last Name First Name MI Mailing Address City Zip code Home Phone
PATIENT DEMOGRAPHICS:
PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?
WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
HIRSHFIELD DENTAL CARE 50 NORTH ST. MEDFIELD, MA 02052 Today s date WELCOME Thank you for taking the time to fill out this form. It will enable us to provide quality, personalized dental care for you.
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician: