Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver.
|
|
|
- Aron Alexander
- 8 years ago
- Views:
Transcription
1 Please use the contact information below for questions or concerns. Abraham Lincoln High School Name: Eric Nicholson Phone: Bruce Randolph School Name: Greg Ahrnsbrak Phone: Denver Center for International Studies Name: Mary Lou Miller Phone: George Washington High School Name: Syrae Weikle Phone: Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver. Step 2: Return completed forms to the Fitness Center; forms will be faxed to your physician for approval. Step 3: Schedule a Fitness Center orientation when paperwork is completed with physician s signature. Step 4: Meet Physical Education Teacher to set goals, plan program based on physician s recommendations. Step 5: Start your program and enjoy the results!
2 The First Day of the New You! Registration Form Date: Name Date of Birth / / Gender M F Address City State: Zip Phone Address Emergency? Friend/Relative Phone Physician Phone Please circle your workout location and time choices: Fitness Center Monday Tuesday Wednesday Thursday Friday Abraham Lincoln HS *6:00am8:00 am # 3:30pm5:00pm *6:00am8:00 am # 3:30pm5:00pm *6:00am8:00 am Bruce Randolph * 3:30pm5:15pm * 3:30pm5:15pm * 3:30pm5:15pm *3:30pm 4:15pm Denver Center for International Studies George Washington HS *4:30pm6:30pm *6:00 am8:00am *4:30pm6:30pm *6:00 am8:00am #6:00am7:30am #3:00pm4:30pm #6:00am7:30am #3:00pm5:00pm * Community and Denver Public Schools Employees # Students and Denver Public Schools Employees For school closures call school site. Page 1 12/19/2009
3 Health Appraisal and Medical History Questionnaire Please complete this form carefully. All information will be treated as strictly confidential. When were you last seen by a physician? Reason? May we call him/her? Yes No Phone: Height Weight Blood Pressure Resting Heart Rate (count heart rate wrist location, for one minute while sitting) Please provide the following information about your current health, fitness, or disability: Check all Health Risks that apply: Cat. I Yes No Cat. II Yes No Cat. III Yes No Risk Stratification Results For use by physical education teacher: D NT WRITE IN THIS BX High Risk (13) Moderate Risk (413) Low Risk (1421) Note: 1. Has your doctor ever told you that you have heart disease? 2. Do you currently have diabetes? 3. Do you have asthma or other lung disease? 4. Pain or discomfort in chest, neck, jaw, arms, or other areas caused by partial or total blockage of an arteryischemia. 5. Shortness of breath at rest or with mild exertion. 6. Dizziness or syncope (loss of consciousness). 7. Abnormal awareness of breathing at rest in recumbent position relieved by sitting up or standing. 8. Abnormal awareness of breathing after the onset of sleep. 9. Ankle edema. 10. Rapid beating of heart. 11. Pain in a muscle stressed by exercise with inadequate blood supply. 12. Known heart murmur. 13. Unusual fatigue or shortness of breath with usual activities. 14. Are you a 45 or older male/or a 55 or older female? 15. Family history heart disease father/brother death, before 55 or, or mother/sister death before Do you currently smoke cigarettes or quit within last 6 months, or are exposure to environmental smoke. 17. Sedentary Lifestyle; not participating in minimum of 30 minutes of moderate activity three days of the week for at least three months. 18. besity; body mass index based on weight and height, or waist girth greater than 40 for males and greater than 35 for females. 19. High blood pressure, hypertension 20. Do you know your cholesterol; HDL and LDL level/ or use medication. 21. Prediabetes Page 2 12/19/2009
4 Medical History Have you ever had, or do you currently have, any of the following: Cardiac Disorder Cancer Dizziness Diabetes Abnormal EKG Stomach Problems Irregular heart beats Numbness or tingling in arms, hands, legs High triglycerides Thyroid Condition Asthma Chest pains Shortness of breath Hernia Anemia Hypoglycemia Arthritis Embolism Respiratory Infections High cholesterol Allergies to food, medicines, insects Nerve damage Surgery Emphysema Gout High blood pressure Epilepsy Kidney problems Pulmonary disorder Bone fracture Back Pain ther medicals Please explain and give dates and age of onset for any items checked above: Please list any other medical conditions or chronic illnesses you have or have had: Injury to: Hip or Pelvis Shoulder Knee/Thigh Ankle/Foot Clavicle Back Arm/Elbow Face/Head Wrist/Hand Page 3 12/19/2009
5 Name Date Please list any medications you are currently taking the reasons for taking them: Medication Reason Affects Notes: Do you have any conditions that limit range of motion at nay joint or part of your body that may be aggravated by exercise? Yes No If yes, please describe in detail and give dates of onset. I have answered the preceding questions to the best of my ability. I further understand that thorough and honest responses to these questions are essential to my safety and prudent recommendations and guidance from the physical education instructors and personal trainers at this Denver Public Schools Fitness Center. Instructors are not engaged in rendering medical, health or any other kind of personal professional services. I can consult medical, health, or other competent professionals. The instructors, school personnel, school district specifically disclaim all responsibility for any liability, loss, or risk, personal or otherwise, which is incurred as a consequence, directly or indirectly, of the use and application of any of the exercise equipment. Signature Date Medical Clearance ID Consult Date rientation Date Page 4 12/19/2009
6 Name Date Goal Inventory/Health Habits Do you regard yourself as verweight Underweight ptimal Weight Do you think of yourself as Sedentary Somewhat Active Very Active Do you think of yourself as Unfit Somewhat Fit Very Fit Do you think of yourself as Very Stressed Somewhat Stressed Without Stress Do you think of yourself as Unhealthy Somewhat Healthy Very Healthy Do you think of yourself as Always Fatigued ccasionally fatigued Energetic How many times per week do you currently engage in physical activity of at least a 10 minute duration? Type of Activity Frequency (Days/Week) Intensity (mild/moderate/intense) Please describe the type of exercises/physical activities that you enjoy the most: Are there any exercises/ physical activities you would be interested in trying with this program? Notes: Page 5 12/19/2009
7 Name Date To be completed during consult time. 1. What I want to accomplish in the Sound Body Sound Mind Fitness Program: Short Term (semester) Goals: Long Term Goals: 2. Why I want to accomplish these goals: These goals are very important to me because: How will we measure your success? How will you feel when you accomplish your goals? 3. I will do almost anything, except What do you consider to the greatest barrier to your participation in an exercise program? 4. What are your concerns regarding participation in an exercise program? How can we keep you motivated? Do you feel like you are able to accomplish your goals? Why or why not? What will your personal rewards be for achieving your goals? Page 6 12/19/2009
Personal Training Health Screening Questionnaire
Personal Training Health Screening Questionnaire Personal Information Today s date: Title: Dr. Mr. Mrs. Ms. Name: / Birth date: Last name First name Age: Address: Phone: (home) City: Phone: (work) Province:
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
Pittsfield Family YMCA: Personal Training Services
Pittsfield Family YMCA: Personal Training Services I would like to purchase the following Client s Name personal training package with personal trainer : Trainer s Name 1 Session, $40 2 Sessions, $80 5
Personal Training Client Policies and Procedures
Personal Training Client Policies and Procedures General Information Personal Trainers are certified through a nationally recognized personal training certification (ACSM, NSCA, ACE, AFAA, ISSA or equivalent).
PERSONAL TRAINING PACKET. Revised: 6/24/15
PERSONAL TRAINING PACKET Revised: 6/24/15 Packages and Prices Advanced Trainer Rates: Advanced trainers are experienced trainers who hold a degree in Exercise/Fitness Science and/ or are certified though
NEW STUDENT-ATHLETE MEDICAL HISTORY FORM
Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency
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:
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
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM
NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a
CARDIAC OR PULMONARY HISTORY
Name: Last First M Gender: M / F DOB: / / Age: Email Address: Address: City State Zip Preferred Contact Number: ( ) - Alternative Contact Number: ( ) - Emergency Contact: Relationship: Name Emergency Contact
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
PERSONAL TRAINING FITNESS ASSESSMENT
PERSONAL TRAINING FITNESS ASSESSMENT A fitness assessment is a great way to evaluate your current fitness level. It includes a series of measurements that help determine physical fitness and are a great
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
Texas Association of Private and Parochial Schools
Texas Association of Private and Parochial Schools P.O. Box 1039 601 N. Main Salado, Texas 76571 Date: April 1, 2014 254-947-9268 254-947-9368 (Fax) To: Head Administrators Athletic Directors Coaches Parents
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 ( )
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
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.
PERSONAL TRAINING CLIENT INFORMATION PACKAGE
PERSONAL TRAINING CLIENT INFORMATION PACKAGE At West Vancouver Community Services, our approach to health and fitness is balanced. Being healthy means adopting a lifestyle that strengthens the body and
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
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
HOW DID YOU HEAR ABOUT THE FITNESS CENTER? Personal Training Walking Program Strength Training Cardiovascular Conditioning
FORM 1 ABOUT YOU DATE COMPLETED FIRST NAME LAST NAME EMPLOYEE ID # DATE OF BIRTH GENDER WORK EMAIL BUSINESS SUITE NUMBER WORK PHONE HOME PHONE HOME ADDRESS CITY/ZIP PRIMARY PHYSICIAN PHYSICIAN PHONE PHYSICIAN
RAM Personal Training
WEST CHESTER UNIVERSITY RAM Personal Training Division of Student Affairs Campus Recreation Dear MEMBER, Thank you for taking the first step towards better overall health and allowing the West Chester
USC RECREATIONAL SPORTS
USC RECREATIONAL SPORTS PERSONAL TRAINING INFORMATION PACKET WELCOME TO USC REC SPORTS PERSONAL TRAINING GETTING STARTED The information included in this packet is everything you need to get started with
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance INSTRUCTIONS - Please print all answers If required, retain a photocopy for your files. 1a) Plan contract number(s)
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
NAME: (PRINT) First Last. College M#:
SPORT (s): NAME: (PRINT) First Last College M#: MONTGOMERY COLLEGE SPORTS MEDICINE PACKET INSTRUCTIONS: - 7/11 - DO NOT remove any papers this includes the four physical exam pages! - If downloading from
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.
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
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
SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)
SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey
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
RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
Height FT IN Weight Married? Y / N Employed? Y / N
Name Patient # (PLEASE PRINT) Signature Date Height FT IN Weight Married? Y / N Employed? Y / N Previous Illnesses: Check all that apply AIDS, HIV, STD Epilepsy Pacemaker Alcoholism Eye/vision problems
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
Dear Alderson Broaddus Student-Athlete:
Dear Alderson Broaddus Student-Athlete: Welcome back for another exciting year at Alderson Broaddus University! In preparation for the beginning of the academic year, and your participation in intercollegiate
Cardiac Rehabilitation
Cardiac Rehabilitation Introduction Experiencing heart disease should be the beginning of a new, healthier lifestyle. Cardiac rehabilitation helps you in two ways. First, it helps your heart recover through
Mind-Body Stress Reduction Program. Masterpeace Studios
STUDIO ADDRESS Arden Mead Youth and Community Center 17 Selma Ave. Webster Groves, MO 63119 MAILING ADDRESS 171 Hull Ave. Webster Groves, MO 63119 314-918-7747 www.masterpeacestudios.org mail@masterpeacestudios.org
West Florida Rehabilitation Institute Wellness Program
West Florida Rehabilitation Institute Wellness Program Thank you for your interest in our Wellness Program! As a member, you will enjoy the benefits of our modern Fitness Center and/or warm water pool.
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
Personal Training Pre-Participation Packet
Client name: W# Personal Trainer: Returning Client: YES or NO Personal Training Pre-Participation Packet Dear Client, Welcome to the Personal Training Program. We are excited that you have chosen to participate
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
Patient History Information
Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:
City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:
Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: 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:
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
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 ( )
Portland State University Sports Medicine Returning Student Athlete Health Report Form
Portland State University Sports Medicine Returning Student Athlete Health Report Form All the following forms must be completed and submitted to the Sports Medicine Department annually. It needs to be
Mountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION
Mountain View Natural Medicine Lorilee Schoenbeck ND, PC Jessica Stadtmauer ND Dana Dabransky ND Sara Norris ND 185 Tilley Dr. Suite 51 S. Burlington, VT 05403 Phone: (802) 860-3366 Fax: (866) 440-8220
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
Name: Last First MI. Mailing Address: City State Zip. Email Address: Phone# (H) (W) (M)
Chart #: Patient Information Name: Last First MI Mailing Address: City State Zip Email Address: Phone# (H) (W) (M) Date of Birth: Sex: Male Female SS#: Marital Status: Single Married Divorced Widowed Separated
PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:
PATIENT INFORMATION: TODAY S DATE: HOW DID YOU HEAR ABOUT US?: LAST NAME: FIRST NAME: STREET CITY: STATE: ZIP: EMAIL MARTIAL STATUS: SINGLE MARRIED DIVORCED WIDOWED SEPARATED BIRTHDATE: AGE: SEX: MALE
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
WICOMICO COUNTY ATHLETIC PACKET
Emergency Form and Medical History LAST NAME: FIRST: M.I. SEX: MALE FEMALE Date of Birth: / / Sports: Grade: School: SSN: Parent/Guardian Home Phone Cell Phone Work Phone Emergency Contact-In the event
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:
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
Sun Life and Health Insurance Company (U.S.)
Sun Life and Health Insurance Company (U.S.) One Sun Life Executive Park, Wellesley Hills, MA 02481] [800-247-6875 Evidence of Insurability Cover Page Employer Instructions Complete this cover page and
The insurance company checked above (Company) is responsible for the obligation and payment of benefits under any policy that it may issue.
American International Life Assurance Company of New York* Home Office: 80 Pine Street, New York, NY 10005 The United States Life Insurance Company in the City of New York* Home Office: 830 Third Avenue,
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
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
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
HEALTH MANAGEMENT PLAN PROGRAMME
HEALTH MANAGEMENT PLAN PROGRAMME Medical Controls for Referees and Candidates The FIVB believes that Referees and Referees Candidates health is very important therefore in accordance with the Medical and
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
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
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:
Application for Employment
POSITION SOUGHT Application for Employment Please complete both the front and back of this form (if you have already submitted your resume or are enclosing you do not need to complete the section on page
Please complete the Consent Form and the Respirator Certification Questionnaire.
The Occupational Safety and Health Administration (OSHA) Respiratory Protection Standard requires an employee to complete a questionnaire if the employee is required to wear a respirator. You have been
Guest Profile. Smart Start
1111 Bagby St. Houston, TX 77002 713-651-0075 hfitness@plusone.com Monday Thursday: 5:30AM 9:00PM Friday: 5:30AM 8:00PM Saturday: Closed Sunday: Closed Guest Profile Mr. Ms. First Name: Last Name: of Birth:
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):
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
KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION
KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION 1 *Participant: *Name of School: *Name of Coach: *Camper/Commuter: Check One: June Cheer Camp June Dance
MVA Accident Questionnaire
MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK
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
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
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
MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.
MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:
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
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:
If yes, you are not eligible to participate in this program)
Patient Name: Date: Address: City: St: Zip: Email Address: Ok to send email: Yes No Phone: Date Of Birth: How did you find out about our weight loss program? Are you currently pregnant, breast feeding,
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.
SLEEP DISORDER ADULT QUESTIONNAIRE
SLEEP DISORDER ADULT QUESTIONNAIRE Name: Date: Date of Birth (month/day/year): / / Gender: ο Male ο Female Marital Status: ο Never Married ο Married ο Divorced ο Widowed Home Address: City: Zip: Daytime
1. NAME 2. SOCIAL SECURITY NUMBER # 4. PRESENT OCCUPATION 5. PLANT 6. ADDRESS 8. TELEPHONE NUMBER 9. INTERVIEWER
ASBESTOS INITIAL MEDICAL QUESTIONNAIRE 1. NAME 2. SOCIAL SECURITY NUMBER # 3. CLOCK NUMBER 4. PRESENT OCCUPATION 5. PLANT 6. ADDRESS 7. (Zip Code) 8. TELEPHONE NUMBER 9. INTERVIEWER 10. DATE 11. Date of
Personal Training Information and Pricing
Personal Training Information and Pricing Client 1 Name: Preferred Trainer: Client 2 Name: (if applicable) Male Female No preference Referred By: What are your preferred workout times? Day Mon. Tues. Wed.
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.
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology
Otis R. Washington, D.D.S., M.S., P.A. Diplomate of the American Board of Periodontology 2310 Myron Drive Raleigh, North Carolina 27607 P: (919) 782-9536 F: (855) 787-8025 Name: SSN: Date of Birth (mmddyy):
Welcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.
Welcome! We want to thank you for allowing us the opportunity to provide you with the highest level of quality rehabilitation services possible. We are committed to providing you with a comfortable, friendly
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
REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
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
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS
NURSING STUDENT HEALTH & IMMUNIZATION RECORDS *********************************** COMPLETE THE ATTACHED HEALTH PACKET AND SUBMIT TO THE NURSING DEPARTMENT NO LATER THAN THE ASN ORIENTATION. **************************************
PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date:
WORKERS COMPENSATION HISTORY PLEASE FILL IN THE FORM AS COMPLETELY AS POSSIBLE. NOTIFY OUR STAFF IF YOU HAVE ANY QUESTIONS; THEY WILL BE GLAD TO HELP YOU. Patient s Name: Date: Address: City: State: Zip:
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
Clinical Care Program
Clinical Care Program Therapy for the Cardiac Patient What s CHF? Not a kind of heart disease o Heart disease is called cardiomyopathy o Heart failure occurs when the heart can t pump enough blood to meet
AON Physical Therapy & Wellness
AON Physical Therapy & Wellness PATIENT REGISTRATION Patients First and Last Name Intake Taken By- Appointment Date / Therapist Date- Date of Birth: Is the patient Under 18? If so, who is the guarantor?
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,
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:
OSHA INITIAL ASBESTOS MEDICAL QUESTIONNAIRE
OSHA INITIAL ASBESTOS MEDICAL QUESTIONNAIRE 1. NAME 2. SOCIAL SECURITY NUMBER # 3. CLOCK NUMBER FULL TIME PART TIME 4. PRESENT OCCUPATION 5. PLANT / Department 6. ADDRESS (City, ST Zip) 8. TELEPHONE NUMBER
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
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:
How To Get A Membership At Angelina Rehabilitation Center
APPLICATION FOR MEMBERSHIP.. Member Information Referring Physician Name:,, (Last) (First) (Middle) Driver s License #: Sex: M /F: Date of Birth: Social Security #: Email Address: Home Address: City: State: