Name Date of Birth Social Security # XXX-XX- Address Apt. # City State Zip. Home Ph# Cell Ph# Driver s License #
|
|
|
- Rosalyn Gibson
- 8 years ago
- Views:
Transcription
1 PATIENT INFORMATION Name Date of Birth Social Security # XXX-XX- Address Apt. # City State Zip Home Ph# Cell Ph# Driver s License # address: Race: Afro-American Am-Indian American Asian Black Caucasian Hispanic Other Marital Status: S M D W No. of Children: Gender: F M Emergency Contact: Name: Relation ship: Phone No. How did you hear of us? Internet Billboard Phone Book Friend/Patient Other WORK INFORMATION Name of Company Address City State Zip Phone # Fax # Contact Person INSURANCE INFORMATION Your Health Insurance Co. Phone # Member Name Member ID Group # Date of Onset Have you been treated for this condition? YES/NO Doctor s name Doctor s Location/Phone number Briefly describe your condition PATIENT S SIGNATURE DATE
2 Check any of the following symptoms you have noticed: C: Current P: Past Heart & Vascular C P Mental Health C P Heart Disease Irritability or Depression Dizziness Anxiety Difficulty Breathing Memory Loss Confusion Difficulty Sleeping Shortness of Breath Drug/ Alcohol Abuse Fatigue Headaches Angina Fainting High Blood Pressure Nausea Neuromusculoskeletal C P Vomiting Thrombophlebitis Cold Sweats Light Headedness Severe Sudden Headaches Sudden Weakness/ Numbness of Face, Arm, Leg, Esp. One Side Deep Leg Pain when Walking Neck Pain or Stiffness Shoulder Pain Arm/Hand Numbness/Tingling Arm/Hand Fatigue/Weakness Leg/Foot Numbness/Tingling Leg/Foot Fatigue/Weakness Abdominal Pain Mid Back Pain Systemic Conditions C P Low Back Pain Pneumonia Joint Pain Swelling/ Stiffness Emphysema Pain with Exercise (Activity, Climbing, Stairs, etc) Chest Pain or Cough Paralysis Gall Blander Disease Muscle Weakness Kidney Stones Liver Disease Other C P Blood in Urine or Stool Difficulty or Pain w/ Urination Fatigue or Loss of Energy Seizures Numbness/Tingling Jaw Pain, Clicking or Locking Lumps (where?) Ear, Nose, Throat, Eyes, Skin C P Diarrhea or Constipation Visual or Hearing Disturbance Rashes (Face, Body, Limps) Pain or Difficulty Swallowing Sensitive to Light or Sound Loose of Appetite Abnormal Menstrual Periods INITIALS:
3 MEDICAL HISTORY Have you ever been hospitalized due to an accident or an illness? YES / NO If yes, please explain. List any current or past major medical conditions you have had (cancer, diabetes, heart disease, arthritis, etc.): Have you recently notice any changes in you bodily function? i.e., intestinal/urinary functions, loss of weight, frequent dizziness, fatigue, nausea, vomiting, etc. YES / NO If yes, please explain: List any surgeries (include dates & reason): List any hospitalizations (include dates & reason): List any auto accident injuries before (include dates): List any on the job injuries (include dates): Have you had any broken bones? YES / NO if yes, please list and give dates: Have you ever had done: MRI CT X-Ray Associated with this injury? List all current over-the-counter and prescription medication used (include reason used): List any heath conditions that run in your family (cancer, diabetes, heart disease, etc.): Have you been under physician s care in the past year? YES / NO (Reason) When was your last physical examination? Have you ever been under chiropractic care? YES / NO (DESCRIPTION/REASON) If female, is there a possibility that you are pregnant? YES / NO Are there any other additional health concerns or questions you have? INITIALS:
4 Houston ChiroCare & Rehab Veterans Memorial Dr, Ste G. Houston, TX CONSENT TO EXAMINATION & DIAGNOSTIC PROCEDURES I,, do hereby authorize HOUSTON CHIROCARE & REHAB, doctors, associates, or assistants to perform upon my examination and diagnostic procedures (not limit to but including x-ray examination) arising from any current or presently unforeseen conditions, which HOUSTON CHIROCARE & REHAB, doctors, associates, or assistants may consider necessary or advisable in the course of my health care. I understand and agree that HOUSTON CHIROCARE & REHAB, its doctors, associates, or assistants have the right to refuse to accept me as a patient any time before treatment begins. The taking of a history and conducting of a physical examination are not considered treatment, but are part of the process of information gathering so that the doctors and associates of HOUSTON CHIROCARE & REHAB can determine to accept me as a patient. PATIENT S NAME PATIENT SIGNATURE SIGNATURE OF PATIENT S REPRESENTATIVE SIGNATURE OF WITNESS DATE DATE DATE 2. ASSIGNMENT OF BENEFITS I irrevocably assign to Houston ChiroCare & Rehab all my rights and benefits under any insurance contracts for payment for services rendered to me by Houston ChiroCare & Rehab. I irrevocably authorize all information regarding my benefits under any insurance policy relating to claims by Houston ChiroCare & Rehab to be released to Houston ChiroCare & Rehab. I irrevocably authorize Houston ChiroCare & Rehab to file insurance claims on my behalf for services rendered to me. I irrevocably direct that all such payments go directly to Houston ChiroCare & Rehab. I irrevocably authorize Houston ChiroCare & Rehab to act in my behalf and report my suspected violations of proper claims practices to the proper regulatory authorities. This assignment of benefits has been explained to my full satisfaction and I understand its nature and effect. I authorize the release of any medical or any other information necessary to process any claims for services rendered. I authorize the payment of benefits for services rendered to Houston ChiroCare & Rehab. I authorize a copy of this consent and authorization to be used in all of my insurance submissions. I authorize Houston ChiroCare & Rehab to endorse any checks made payable to me and/or Houston ChiroCare & Rehab for services rendered. DO NOT SIGN UNTIL YOU READ AND UNDERSTAND THE ABOVE Name of Doctor (Print) Doctor s Signature Date Name of Patient (Print) Patient s Signature Date Signature of Patient s Representative (If minor or physically incapacitated) Date
5 PATIENT AGREEMENT Houston ChiroCare & Rehab specialize in the treatment of the spine and associated pain. We perform various treatments consisting of passive modalities, therapeutic interventions and spinal manipulation. The goal of our services is to reduce and/or eliminate your pain, however, as with any chiropractic and/or physical medicine services there are risks associated with the services we provide. As your healthcare provider, we feel that it is crucial that you understand these risks. By informing you of these risks we are striving to more actively involve you in our case as well as further assist you in making well-informed decisions regarding your treatment options. PASSIVE MODALITIES Passive modalities consist of the following treatments: heat/cold agent, ultrasound, electrical stimulation, massage, traction and paraffin. The primary risk associated with the passive modalities is skin irritation due to exposure to heat, cold or agents used in the application of modalities, i.e. lotions, pads and/or paraffin. If you have experienced skin sensitivity to heat, cold temperatures and/or lotions or similar products in the past or are aware of any skin allergies, please inform our staff prior to treatment so proper precautions can be made prior to initiating treatment. THERAPEUTIC INTERVENTIONS Therapeutic interventions consist of the following types of treatments: stretching, flexibility exercises, strengthening exercises, joint mobilizations, trigger point therapy and myofascial release. Therapeutic interventions are generally quite safe though there are risks associated with each of these procedures. The primary risk is potential aggravation of your current condition and/or underlying condition. As with any physical activity and/or exercise there is also the risk of injury. Though this risk is minimal as you are under the direct supervision of experienced clinical staff, it may still exist. Some responses to therapeutic interventions are muscle soreness, muscle fatigue, increased discomfort, overall tiredness and/or joint stiffness and/or pain. It is important that you inform your treating staff member of any of these responses following your treatment and more importantly it is crucial that you continue to attend your appointments as scheduled so your condition can be documented and your symptoms effectively managed. SPINAL MANIPULATION Spinal manipulation consists of adjustments that seek to restore normal function to the spine and other joints. Typically, this involves applying a specific, highly controlled treatment directly to a joint or muscle. This treatment often reduces or eliminates both local and referred pain, allows muscle spasms to relax, and may even release the irritation from the nervous system, which may result in other health benefits. INITIALS
6 As with any healthcare service there are potential reactions and risks, however, as with any healthcare intervention, it is hoped that the expected benefits of spinal manipulation exceed the expected risks. These are unavoidable risks of spinal manipulation which, though rare, can occur. DISK HERNIATION The occurrence of disk herniation during spinal manipulation is highly unlikely. In fact, average disks withstand an average of 23 degrees of rotation and degenerated disks an average of 14 degrees of rotation before failure occurs. Furthermore, given the fact that during manipulation posterior facet joints limit rotation to a maximum of 2-3 degrees, this joint would have to fracture to allow any further rotation to occur. CAUDA EQUINA SYNDROME It is estimated that the rate of occurrence of the cauda equine syndrome as a complication of lumbar spinal manipulation is about one case per 100 million manipulations. It is probably higher in patients with a herniated nucleus pulposus, and lower in patients without this anatomic abnormality. VERTEBROBASILAR ARTERY COMPROMISE Serious complication of cervical spine manipulation are also rare (none having been reported in any of the clinical trials), but appear to be more common and severe than complication of lumbar manipulation. The most serious complication of the cervical spine manipulation is related to compromise of the vertebrobasilar artery, leading to stroke or death. The risk is higher for manipulation involving rotation plus extension of the cervical spine than for other types of manipulation, and those persons who have suffered manipulation-related vertebrobasilar artery compromise due to atherosclerotic disease. The best estimate of the incidence of vertebrobasilar artery compromise related to cervical spine manipulation is that it occurs one in 1 million manipulations (Hurwitz, 1996; McGregor, 1995). PATIENT UNDERSTANDING AND ACCEPTANCE OF RISKS ASSOCIATED WITH TREATMENT As your doctor it is our responsibility to inform you of the potential risks and benefits of your treatment, but we also want to assure you that we strive to minimize these risks by providing thorough clinical examinations and by performing diagnostics as clinically indicated. Furthermore, we continually review medical literature pertaining to current trends within our profession as well as throughout the entire medical community to ensure the safest and most effective care. I have reviewed the information provided regarding the benefits and risks of treatment provided at Houston ChiroCare & Rehab. I have been given the opportunity to discuss my questions and/or concerns and by signing below I acknowledge that I understand and accept the risks associated with my treatment. Patient Signature Date Guardian s Signature Date
7 (Please list all body parts separately: neck, back, low back, left leg, right hand, left thumb etc.) 1. Body part/ system When did it start? Level of pain? Slight Severe How often does it bother you? Intermittent Constant Describe pain: Sharp Dull Throbbing Burning Achy Excruciating Any lost of sensation? Yes / No If yes, where at? Does the pain radiate? Yes / No If yes, where to? What aggravates the symptoms? Bending Lifting Sitting Walking Exercise Moving Sneezing Coughing Other What helps the symptoms? Medicine Hot Showers Rest Other: Any lost of sleep due to this condition? Yes / No Stress cause by condition? Yes / No Similar conditions in the past? Yes / No 2. Body part/ system When did it start? Level of pain? Slight Severe How often does it bother you? Intermittent Constant Describe pain: Sharp Dull Throbbing Burning Achy Excruciating Any lost of sensation? Yes / No If yes, where at? Does the pain radiate? Yes / No If yes, where to? What aggravates the symptoms? Bending Lifting Sitting Walking Exercise Moving Sneezing Coughing Other What helps the symptoms? Medicine Hot Showers Rest Other: Any lost of sleep due to this condition? Yes / No Stress cause by condition? Yes / No Similar conditions in the past? Yes / No 3. Body part/ system When did it start? Level of pain? Slight Severe How often does it bother you? Intermittent Constant Describe pain: Sharp Dull Throbbing Burning Achy Excruciating Any lost of sensation? Yes / No If yes, where at? Does the pain radiate? Yes / No If yes, where to? What aggravates the symptoms? Bending Lifting Sitting Walking Exercise Moving Sneezing Coughing Other What helps the symptoms? Medicine Hot Showers Rest Other: Any lost of sleep due to this condition? Yes / No Stress cause by condition? Yes / No Similar conditions in the past? Yes / No INITIALS:
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?
Patient Intake. Insurance Information
Patient Intake First Name: Last Name: Initial: Home Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email: Social Security #: Birth Date: Age: Sex: Male Female Occupation: Employer s Name:
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
First Name, Nick Name _. Last Name Middle Name Suffix _. Address1. Address 2. City State, Zip Code _. Primary Phone Secondary Phone _.
and Sports Injuries Patient Health History Today's Date 1 1 1 _ Signature of Patient _ Patient Title: (check one) D Mr. D Mrs. D Ms. D Miss D Dr. D Prof. D Rev. First Name, Nick Name _ Last Name Middle
Accident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked
Work Injury Information Continued
Welcomes You Full Name: Today s Date: DOB: M / F Social Security #: DL# Address: City: State: Zip Code: Home # : Cell #: Occupation: Employer: Employer Address: Employer Phone: Employer Fax: Emergency
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
BOYER CHIROPRACTIC INC
Patient Name: Birthdate: Sex: M / F Address: City: State: Zip: Telephone: Social Security #: Driver Lic. #: Occupation: Employer: Work Phone: Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber
PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM
Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If
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:
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
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.
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
Injury Center of Houston An Affiliate of ICH Healthcare, P.A. Case History & Patient Information
+ Case History & Patient Information Name: Driver Lic #: _ Address: City: State: Zip Code: Phone: Home ( ) Cell ( ) Work ( ) S/S #: Age: Birth date: / / Sex: M / F Status: M S W D Your Email: Occupation:
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
Patient Questionnaire Auto-Collision
Patient Questionnaire Auto-Collision Patient Name: (First) (Middle) (Last) (Suffix) Today's Date: / / Birth Date: / / Age: SSN: Gender: (circle) F M Height: ft in Weight: lbs (circle one) Right handed
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
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
Electronic Health Records Intake Form
Dr. Sam Yoder, D.C. 101 Winston Way Ste B Campbellsville, KY 42718 Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Address: Last
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 INFORMATION. Age: Street address: Email: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.
(Please Print) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Birth date: Age: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Sex: M F Street address:
Lighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY.
Lighthouse Chiropractic IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY. Your Auto Insurance Company Name Address Policy
CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.
VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different
(STREET) (CITY) (STATE) (ZIP) DOB: / / Soc. Sec # : - - Employer Address: (STREET) (CITY) (STATE) (ZIP)
PATIENT INFO Name: Address: (LAST) (MI) (FIRST) (STREET) (CITY) (STATE) (ZIP) Home Phone: Work Phone: Cell Phone: Email Address: DOB: / / Soc. Sec # : - - Driver s License #: State: Marital Status: S M
Cervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER
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
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
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.
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
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
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 #:
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
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional
New Patient Evaluation
What area hurts you the most? (Please choose one) When did this pain start? Neck Other: Back How did this pain start? How often do you experience this pain? Describe what this pain feels like. What makes
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
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
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
Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone: ( )
Patient Information Date: First Name: Address: Surname: City: Postal Code: Home Phone#: Mobile #: Email Address: Sex: M F Date of Birth (mm/dd/yyyy): / / Name of Emergency Contact: Relationship: Home Phone:
PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart. OOB Age _
PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart Patient Name: Date: OOB Age Address City, State, Zip Home Phone Work Phone Other em ail address M or F Marital --~------- Status
Personal Injury Questionnaire
Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer
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
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
Medical Massage Client Intake Form Medical Massage Client Intake Form
Medical Massage Client Intake Form Medical Massage Client Intake Form Client Name: Date: Please note: The more information you are able to provide, the better equipped our therapists will be to help you.
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.)
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
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION
DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single
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
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
Personal Information
REHABILITATION Personal Information Date: First Name: Last Name: Initial: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Email: Social Security #: Birth Date: Age: Sex: M F Occupation:
AUTO ACCIDENT QUESTIONNAIRE
AUTO ACCIDENT QUESTIONNAIRE Patient s Name Today s of Accident Time of Accident AM PM Location of Accident Were you the: Driver / Passenger (circle one) Were you wearing a seat belt? Yes No With a shoulder
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
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
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
MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE
A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital
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:
20. Please describe any pain or symptoms: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d.
Name Date of Birth Phone Address City State Zip Email: Employer s Name Employer s Address Your Ins. Co. Claim # Claims Adjustors Name Driver/Owner Have you retained an attorney? ( ) Yes ( ) No If yes attorney
*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM
Oasis Chiropractic Injury/ Auto Accident/ Slip & Fall Form First Name: Last Name: Title: (check one) Mr. Mrs. Ms. Miss Dr. Other Patient ID#: Single Married Widowed Under 18 (Minor) Separated Divorced
REASON FOR SEEKING CHIROPRACTIC CARE HEALTH CARE PRACTITIONER HISTORY
Well Beings Chiropractic Family Health 1990 Wadsworth Blvd. Ste #2, Lakewood, CO 80214 Phone (303) 238-6500 www.wellbeingschiropractic.com Please fill out this form as completely and accurately as possible.
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
Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )
Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Last Name First Name Middle Initial Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Home Phone ( ) Mobile
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. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
O CONNOR REHAB & WELLNESS CLINIC. Patient Information Record
Patient Information Record Date: Patient s Name: Last First MI Address: Street City Province Postal Code Home Phone ( ) Work ( ) Cellular( ) (Please circle best number to reach you during the day) E-Mail
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
Gary Seghi, D.C. 1613 W. 6 th Street, Austin, TX 78703
Referred by: _ Office Use Only: Patient Account Number Today s _ Age _ Full Name _ Birth _ Address _ SS# _ City _ Race _ State _ Sex _ Zip Code _ Marital Status _ Telephone _ Age of Children _ Occupation
Sciatica Yuliya Mutsa PTA 236
Sciatica Yuliya Mutsa PTA 236 Sciatica is a common type of pain affecting the sciatic nerve, which extends from the lower back all the way through the back of the thigh and down through the leg. Depending
Welcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
Herniated Disk. This reference summary explains herniated disks. It discusses symptoms and causes of the condition, as well as treatment options.
Herniated Disk Introduction Your backbone, or spine, has 24 moveable vertebrae made of bone. Between the bones are soft disks filled with a jelly-like substance. These disks cushion the vertebrae and keep
Full version is >>> HERE ***************PATIENT INFORMATION****************
SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE:
Horn Family Chiropractic Non-Surgical Spinal Decompression Application For Admission
Horn Family Chiropractic Non-Surgical Spinal Decompression Application For Admission Non surgical Spinal Care for Severe Neck, Shoulder, Low Back & Leg Pain If you are reading this you have been fortunate
Herniated Cervical Disc
Herniated Cervical Disc North American Spine Society Public Education Series What Is a Herniated Disc? The backbone, or spine, is composed of a series of connected bones called vertebrae. The vertebrae
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:
ACCIDENT HISTORY QUESTIONNAIRE
ACCIDENT HISTORY QUESTIONNAIRE PATIENT INFORMATION Name Date Address City State Zip Code DOB Age SS# Marital Status Sex Male Female How did you hear about the office? Home Phone Work Phone Employer Occupation
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081 PLEASE COMPLETE ALL OF THE INFORMATION. REFERRED BY: LAST NAME MIDDLE FIRST STREET ADDRESS CITY STATE ZIP CODE HOME PHONE ( ) - WORK ( )
Orthopedic Initial Questionnaire
Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
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
Interventional Spine Care New Patient History and Intake Form
Interventional Spine Care New Patient Introduction You have been referred to Dr. Hamburger/Dr. Olson. Our focus is the evaluation and management of low back pain, and other disorders of the spine. Our
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
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:
PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
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
Atlantis Physical Therapy Associates
Atlantis Physical Therapy Associates Date Called/Walk-In: Appointment Date: Time: PT/OT: Diagnosis/ICD9/Body Parts: Frequency & Duration: X Referring Doctor: Dr. Phone#: Fax: NPI: Addresss: Ins Type: (Circle
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
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
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
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation that helps our patients
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:
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
Motor Vehicle Accident - New Patient
Motor Vehicle Accident - New Patient Today's Date: Patient Name: Auto Insurance Company of Car You Were In: Phone: Insurance Agent: Phone Was A Police Report Made? Have You Informed Your Agent of Your
Potomac Valley Chiropractic Personal Injury
Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------
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. 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