Welcome to Chirosports Coogee
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- Francis Preston Park
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1 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 s own natural ability to function and heal itself. The body loses its ability to self heal when there are problems with: + STRUCTURE (joint misalignment, nerve irritation, muscle spasm) + EMOTIONS (stress and past trauma) + NUTRITION (insufficiency, malabsorption, toxicity) Therefore it is important when filling in the history form to be as thorough and specific as possible with all areas of your health. At Chirosports we define HEALTH as a state of optimal physical, mental and social wellbeing, not merely the absence of disease or pain. We specialise in correcting JOINT SUBLUXATION, which is a misalignment of one or more joints, causing alteration of nerve function flow. Altered nerve function can lead to pain and organ dysfunction. Some CAUSES OF SUBLUXATIONS include the birth process, accidents, falls, faulty posture and ergonomics, stress, significant emotional trauma, sleeping habits and dietary factors. We correct subluxations with an ADJUSTMENT by applying gentle specific forces. During your Chiropractic history, examination, x-rays (if required) and continued chiropractic care, we may become aware of health issues beyond the scope of our expertise. If this is the case we have an extensive network of health professionals that we work closely with to ensure the best individual health results are achieved for you. Please feel free to ask as many questions as you like. Our team is here to serve you.
2 PAGE 2 OF 6 Office Fee Schedule and Financial Policy SERVICE FEES CONCESSION Initial Consultation & Examination $137 $112 Report of Findings $87 $82 Long Consultations $87 $82 X-Rays (Private Health Fund rebates may apply) $104 $104 Standard Adjustment $70 $62 Foot Scan & Adjustment $70 $82 10 Pack Pre Pay $630 $580 FINANCIAL POLICY AND CHIROPRACTIC CARE PLANS We are committed to providing you with the best chiropractic care possible in a caring environment and have established our financial policies to achieve that goal. You will be expected to pay for your chiropractic care at the time the service is rendered unless you arrange a Chiropractic 10 Pack plan in advance. 10 PACK To save time and your money, we offer our 10 Pack option of 10 pre-paid visits at a 10% reduced fee. These plans are designed to be the most cost and time effective way for you and your family. Details of these plans will be discussed with you during your chiropractic report. For insurance claiming purposes, at every 10th visit you will receive a statement for the previous 10 visits to submit to your health fund. They pay claims on care already received, not in advance. If you wish to discontinue care at any time, we will happily refund your payment minus the care already received at the full fee per visit. PRIVATE INSURANCE If you have private health insurance that covers chiropractic, and you are choosing to pay as you go, you can utilise our HICAPS facility to receive instant rebates. The GAP payment can be made with credit cards, EFTPOS, cheques or cash. Most health funds in Australia contribute between $300-$400 per year to your Chiropractic care. Please contact your private health insurer for details on your policy. I, (name) have read and I understand the above policies. Patient signature Date / /
3 PAGE 3 OF 6 Confidential Patient Information Thank you for allowing us to be involved in the improvement of your health and wellbeing! It is essential that you complete the following questions to the best of your ability. These questions are all relevant to your health and our proposed Chiropractic Care Plan. Who may we thank for referring you? YOUR DETAILS Your name Date / / Address Suburb Post Code address Mobile phone Home Work Date of birth / / Occupation Marital status M S D W Pregnant Yes No Partners name Names & ages of children Private Health Fund Doctors name & address YOUR HEALTH PROFILE What is your presenting complaint? When did this problem begin? How did it begin? What makes it better? What makes it worse? Have you had it before? Yes No How many times? Last time: What caused the problem in the past? Is the problem stopping you from doing anything? Yes No If so, please list: Have you seen anyone else for this problem? Yes No If so, whom and what was the outcome:
4 PAGE 4 OF 6 Please indicate on the diagram where you feel your discomfort: R L L R List any medication/vitamins you are taking and what they are for? List any operation, surgical procedures, major tests you have had, with dates: 1. Type When? 2. Type When? List any past accidents, injuries, broken bones you have had, with dates: 1. Type When? 2. Type When? List any past X-rays, CT s, MRI s you have had, what part of the body? Where and when? Do you exercise regularly? Yes No If so, what type/how often? Do you have a personal trainer or go to a fitness class? (pilates, yoga, group training) Yes No Contact details of Trainer Coach Teacher Do you smoke? Yes No Do you drink alcohol? Yes No if so, how much/often? Do you wear orthotics or heel lifts? Yes No Please indicate on the following scale how you are feeling at the moment: 1 being BEST ever felt 10 being WORST ever felt Presenting Symptoms Pain Level General Wellbeing Quality of Sleep Energy Levels Overall, how do you feel?
5 PAGE 5 OF 6 Please tick if you have suffered any of the following recently or on a regular basis: Dizziness Unexplained Weight Loss Headaches Fainting High Blood Pressure Migraines Difficulty Swallowing Fatigue Back Pain Visual Problems Sleeping Problems Loss of Balance Nausea Depression Stomach Problems Numbness Loss of Smell Heart Burn Pins and Needles Buzzing / Ringing in ears Ulcers Difficulty Talking Neck Pain / Stiffness Menstrual Problems Night Sweats Constipation Hot Flushes Inflammatory Arthritis Diarrhoea Frequent Coughs / Colds Asthma Allergies Frequent Ear Infections Scoliosis Seizures Tonsillitis STRESSORS Because accumulation of stress affects our health and ability to heal please list your top three stresses (you have ever had) in each category: 1. Physical stress (falls, accidents, work postures, etc.) a. b. c. 2. Bio-chemical stress (smoke, unhealthy foods, missed meals, don t drink enough water, drugs/alcohol, etc.) a. b. c. 3. Psychological or mental/emotional stress (work, relationships, finances, self-esteem, etc.) a. b. c. What are your short term health goals? What are your long term health goals?
6 PAGE 6 OF 6 YOUR CONSENT At Chirosports we aim to provide the highest quality care. Part of this care may involve cervical (neck) manipulation. We feel it is important that you are aware that as with any health care procedure there is some risk associated with cervical manipulation. This risk is currently estimated at 1 in 1,000,000 for stroke or stroke like symptoms. This is a rare and unpredictable event. Other risks that can be associated with spinal adjustments include disc injuries, rib fractures, sprains/strains or pre-existing conditions may be aggravated. We take every precaution to ensure that this risk is minimized through thorough testing, examination and the use of gentle and specific techniques. If you have any concerns, please let your chiropractor know. I acknowledge that I have been informed of the risks involved and understand that if at any time I have concerns they can be discussed with my chiropractor. I appreciate that I will receive the best care possible at CHIROSPORTS but that results cannot be guaranteed. I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems necessary. I understand that any fee for service rendered is due at the time of service and cannot be deferred to a later date. Patients Signature Date / / Chirosports provides an appointment reminder service by SMS and may also communicate with you by SMS and from time to time. All clients are automatically enrolled in this service. If you do not wish to have this service please indicate: Please do not send me appointment reminders by SMS Please do not send me communications by
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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
Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center
Thank you for choosing ALTITUDE PHYSICAL THERAPY, a Member of the P3 Network - PT-MD Kinect LLC & Partners in Health Healing Center Below is some information you may find helpful regarding your benefits
PATIENT INFORMATION GUARANTOR INFORMATION. for patients under 18 years of age INSURANCE INFORMATION
Welcome to ChiroSport Specialists of Dallas. We would like to thank you for coming to our office and taking the first step to achieving a pain-free and healthy lifestyle. Please fill out the questionnaire
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
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
Therapeutic Massage .(W). Chiropractor
Therapeutic Massage Please take a moment to answer the following questions. The information you provide will be used to customize your session to your needs and exclude any techniques that may be medically
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):
Preventing & Treating Low Back Pain
Preventing & Treating Low Back Pain An Introduction to Low Back Pain Low back pain is the number two reason that Americans see a health care practitioner second only to colds and flu. While most people
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
Workers' Compensation History
Workers' Compensation History 3025 N. Taft Avenue, Suite A Loveland, Colorado 80538 Phone: 970.203.0621 Fax: 970.461.2462 Name: Age: Date: Sex: M / F Address: City: State: Zip: Social Security Number:
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
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
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
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:
Auto Accident Questionnaire. Auto Insurance Information (please present a copy of your auto insurance card)
Auto Accident Questionnaire name today s date date of accident date of birth age gender marital status # of children address street city state zip home phone cell phone email occupation company name city
New Patient Form Please print clearly
New Patient Form Today s Date: Name: Last First MI Preferred name to be called: Email: Address: Street City State Zip DOB: Age: Sex: SSN#: - - Please check a box for the preferred # to call to confirm
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.
LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS: