NEW PATIENT INTAKE FORM Patient Name: Date:
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- Elaine Harmon
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1 NEW PATIENT INTAKE FORM Patient Name: Date: 1. Is today's problem caused by: Auto Accident Workman's Compensation 2. Indicate on the drawings below where you have pain/symptoms 3. How often do you experience your symptoms? Constantly (76-100% of the time) Occasionally (26-50% of the time) Frequently (51-75% of the time) Intermittently (1-25% of the time) 4. How would you describe the type of pain? Sharp Numb Dull Tingly Diffuse Sharp with motion Achy Shooting with motion Burning Stabbing with motion Shooting Electric like with motion Stiff Other: 5. How are your symptoms changing with time? Getting Worse Staying the Same Getting Better 6. Using a scale from 0-10 (10 being the worst), how would you rate your problem? (Please circle) 7. How much has the problem interfered with your work? Not at all A little bit Moderately Quite a bit Extremely 8. How much has the problem interfered with your social activities? Not at all A little bit Moderately Quite a bit Extremely 9. Who else have you seen for your problem? Chiropractor Neurologist Primary Care Physician ER physician Orthopedist Other: Massage Therapist Physical Therapist No one 10. How long have you had this problem? 11. How do you think your problem began? Insidious Posture Auto Accident Work Injury Fall Other 12. Do you consider this problem to be severe? Yes Yes, at times No 13. What makes your problem Worse? Better? 14. What concerns you the most about your problem; what does it prevent you from doing?
2 15. What is your: Height Weight Date of Birth Occupation 16. How would you rate your overall Health? Excellent Very Good Good Fair Poor 17. What type of exercise do you do? Stenuous Moderate Light None 18. Indicate if you have any immediate family members with any of the following: Rheumatoid Arthritis Diabetes Lupus Heart Problems Cancer ALS 19. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column. Past Present Past Present Past Present Headaches High Blood Pressure Diabetes Neck Pain Heart Attack Excessive Thirst Upper Back Pain Chest Pains Frequent Urination Mid Back Pain Stroke Smoking/Tobacco Use Low Back Pain Angina Drug/Alcohol Dependance Shoulder Pain Kidney Stones Allergies Elbow/Upper Arm Pain Kidney Disorders Depression Wrist Pain Bladder Infection Systemic Lupus Hand Pain Painful Urination Epilepsy Hip Pain Loss of Bladder Control Dermatitis/Eczema/Rash Upper Leg Pain Prostate Problems HIV/AIDS Knee Pain Abnormal Weight Gain/Loss Ankle/Foot Pain Loss of Appetite For Females Only Jaw Pain Abdominal Pain Birth Control Pills Joint Pain/Stiffness Ulcer Hormonal Replacement Arthritis Hepatitis Pregnancy Rheumatoid Arthritis Liver/Gall Bladder Disorder Cancer General Fatigue Tumor Muscular Incoordination Asthma Visual Disturbances Chronic Sinusitis Dizziness Other: 20. List all prescription medications you are currently taking: 21. List all of the vitamins and/or supplements you are currently taking: 22. List all surgical procedures you have had: 23. What activities do you do at work? Sit: Most of the day Half the day A little of the day Stand: Most of the day Half the day A little of the day Computer work: Most of the day Half the day A little of the day On the phone: Most of the day Half of the day A little of the day 24. What activities do you do outside of work? 25. Have you ever been hospitalized? No Yes if yes, why 26. Have you ever seen a chiropractor before? No Yes if yes, how long ago? How were the results? Great Good Average Poor 27. Have you had significant past trauma? No Yes 28. Anything else pertinent to your visit today? Patient Signature Date:
3 ABOUT THE ACCIDENT 1. What was the date of the accident? 2. What time did the accident occur? 3. How many vehicles were involved in the accident? 4. What was the estimated damage to the vehicle you were in? 5. What state did the accident occur in? 6. What city did the accident occur in? 7. What street or intersection were you on when the accident occurred? 8. What direction were you traveling in? 9. What type of impact was the auto accident? 10. Did your vehicle hit anything after the accident? if yes, please describe 11. Where were you sitting in the vehicle during the accident? 12. Did you know the accident was coming? 13. What type of vehicle were you in? 14. What type of vehicle impacted yours? 15. At the time of the impact, how fast was your vehicle moving? 16. At the time of impact, how fast was the other vehicle moving? 17. During and after the crash what happened to your vehicle? (circle all that apply) - kept going straight - spun around - kept going straight hitting a car in front - spun around and hit a stationary object - was hit by another vehicle - hit a stationary object 18. Did you lose consciousness during the accident? -yes - no 19. How was your head positioned during the accident? 20. How was your torso positioned during the accident? 21. How were your hands positioned during the accident? 22. Did your head hit anything during the accident? -no - yes, please describe 23. Did your face hit anything during the accident? -no - yes, please describe 24. Did your shoulders hit anything during the accident? -no - yes, please describe 25. Did your neck hit anything during the accident? -no - yes, please describe
4 26. Did your chest hit anything during the accident? -no - yes, please describe 27. Did your hips hit anything during the accident? -no - yes, please describe 28. Did your knees hit anything during the accident? -no - yes, please describe 29. Did your feet hit anything during the accident? -no - yes, please describe 30. What kind of headrest was in your vehicle? - movable fixed headrest - nonmovable fixed headrest - no headrest 31. Where was the headrest positioned on your head? 32. Did you have your seatbelt on during the accident? - yes -no 33. Did you slide out of your seatbelt during the accident? 34. What was damaged in your vehicle? (Circle all that apply) - windshield - rear bumper - mirror - steering wheel - front bumper - knee bolster - dashboard - trunk - back right door - seat frame - front left door - completely totaled - side window - front right door - rear window - back left door 35. Choose the items that dented inward - floorboards - side door - dashboard 36. Choose the doors that would not open as a result of the accident - front left - front right - rear left - rear right 37. Did you go to the hospital? (If no, why and do not answer 38-43) 38. How did get to the hospital? 39. What was the name of the hospital? 40. Were you hospitalized over night? 41. Circle what you were prescribed at the hospital - pain medication - muscle relaxors - neck brace 42. Did you receive any stitches for any cuts at the hospital? 43. Were X-Rays, MRI OR Cat Scans taken at the hospital? If yes, which area was taken? Person Completing: Signature: Date:
5 LifeStyle Health & Fitness Center 5351 Neroly Road, Suite B Oakley, California BACK 3 rd PARTY AND ATTORNEY ACKNOWLEDGMENT AND UNDERSTANDING (TO BE SIGNED BY PATIENT) I hereby acknowledge that I am receiving (or about to receive) health care services from Dr. Rick Junnila or Dr. Brenda Ramos. I have been advised that the doctor providing services to me is willing to wait for payment for these services, providing that there be a reasonable chance that payment will be made either by insurance reimbursement or of the settlement of a liability claim or law suit. I understand that if it is determined: 1, That there is no insurance company obligated to pay for these services, or if the insurance company involved refuses to acknowledge an assignment to the doctor or make other provisions for the protection of the doctor s charges, or 2. If a liability claim exists, and my current attorney or any new attorney I may retain at a later date refuses to agree to protect the interest of the doctor by signing a lien agreement, or 3. If I do not engage the services of an attorney, I agree to pay for all services rendered to me on a current basis and any remaining balance owing on my account will be paid in full as soon as my liability claim is settled or within three months from the date of last treatment, which ever occurs first. On all accounts referred to collections or litigation all reasonable collection fees, attorney fees, court costs, and/or interest fees will be paid by patient/guarantor. Furthermore I agree to make a good faith payment of $ on my account on or by the day each month. I agree that I will continue to make these payments on my account regardless of treatment status and until my case has been settled and the balance is paid in full. Patient s Name Patient Signature Witness Signature Patient Date of Injury Date Date
6 AUTO ACCIDENT INSURANCE POLICY *You may pay for your care by using one of these three methods: 1) MED-PAY Your auto insurance Med-Pay coverage will pay for your care in full, regardless of fault. Med-Pay is a set amount of funds, usually $1,000, $5,000 or $10,000, which is put aside to pay your medical bills in case of an accident. You pay extra for this benefit, so use it. Your insurance rates are not affected by the cost of health expense, unless you were at fault. It is your responsibility to notify your claims office that you are being treated in this office and have them send any necessary paperwork directly to us. In the event your auto insurance DENIES that you hold insurance, REFUSES payment, DOE NOT HAVE Med-Pay Coverage, or you have EXHAUSTED your Med-Pay coverage, charges for services are due and payable. 2) GROUP HEALTH INSURANCE Your group health insurance can be billed for your care. If you have an accident rider on your policy, it may be covered at 100%. You pay your deductible and co-payments as required and we will wait for the balance from the insurance company. 3) PATIENT PAYMENT You can pay for your care as you go or we can arrange a convenient monthly payment plan for you. We will prepare billings for you to submit to your attorney, third party, etc. ********************************************************************** You are considered a cash patient until all the required information is submitted to our billing office. The only circumstance in which we will accept a lien is when all the above options are exhausted and you are making personal payments on your account. In this case, a lien may be accepted as a promise to pay the remaining portion of your bill. We will bill your auto or health insurance and have you assign payment to us. In the event that your insurance company sends a check directly to you, be sure or bring it in, along with the attached stub, within three days. Otherwise, we may re-bill in error, which will delay future payments. If the insurance company fails to pay a portion of your bill after 90 days, that balance will be due and payable by you. ******************************************************************** Policyholder s Name: Your Auto Insurance Company s Name: Policy# Claim #: Med-Pay Coverage?:(yes) (no) Amount: $ Adjustor s Name: Phone#: Claims Office Address:
7 Family Chiropractic Health and Fitness Center New Patient Information Welcome to our office! Please complete all questions. Name: Date: Address: City/State/Zip Home Phone Cell Phone Work Phone Date of Birth Sex: M F CA Drivers License #: Employer Occupation Marital Status: S M W D Current Health Complaints 1) 2) 3) 4) 5) 6) Have you ever seen a chiropractor before? ( ) Y ( ) N How did you hear about our office? Please Select One ( ) Yes I would like a copy of the 6 page HIPAA form to Sign and Read (Medical Privacy - National Standards to Protect the Privacy of Personal Health Information). ( ) No I understand my HIPAA privacy rights and with my signature below I acknowledge this: Patient Signature:
First Name MI Last Name. Address. City State ZIP. Phone (H) (W) (Cell) (Please circle the preferred contact number) Address
Date of Birth Social Security Number - - First Name MI Last Name Address City State ZIP Phone (H) (W) (Cell) (Please circle the preferred contact number) Email Address Occupation Full Time/Part Time Employer
NEW PATIENT INFORMATION. Name: (Last) (First) (Middle) DOB: Address: City: State: Zip: Home #: Work #: Cell#: -
NEW PATIENT INFORMATION Name: (Last) (First) (Middle) DOB: Address: City: State: Zip: Home #: Work #: Cell#: E-Mail- SS#: Marital Status (S-M-Sep-D-W) Sex: (Male/Female) Age: Employer: Work Title: Name
Patient Information. Insurance Information Who is responsible for this account? Relationship to Patient. Insurance Co: Member ID:
Patient Information Today s Date: Birth Date: SS#: First Name: M. I.: Last Name: Address: City: State: Zip: Sex: M F Age: Email: Cell: ( ) Home: ( ) Emergency Contact: Relationship: Cell: ( ) Home: ( )
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Date. D Light D Moderate D Strenuous
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Family First Chiropractic & Wellness Center 9445 Farnham Street, Suite 104 San Diego, CA 92123
PATIENT NAME: ADDRESS: CITY: STATE/ZIP CODE: HOME PHONE NUMBER: CELL PHONE NUMBER: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: GENDER: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMPLOYER NAME:
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New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, Office: (830) Fax: (830) NewBraunfelsWellness.
New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, 78130 Office: (830)625-9255 Fax: (830)643-9255 NewBraunfelsWellness.com PATIENT INFORMATION DATE: Legal Name: Nickname: Address:
South Lake Pain Institute
Welcome to South Lake Pain Institute We are honored that you have chosen us as your health care provider. Our goal is to provide the highest quality care for all of our patients in a timely and respectful
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HEALTH ASSESSMENT PERSONAL ** Please provide the front desk with your Driver s License or a Valid I.D., Auto Insurance Policy page and Health Insurance : How did you hear about Dr. Dilo (Who referred you)?:
Have you had Chiropractic Care Before? When? Where? What is your current complaint (be specific)?
Welcome to Rizzo Chiropractic Holistic Health and Wellness Center Check the following services you are interested in: Chiropractic Physical Rehabilitation Nutritional Analysis (Hair, Blood & Urine) Detox
Motor Vehicle Accident Questionnaire
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WELCOME TO WINDROSE CHIROPRACTIC
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Patient Health Information Consent Form
Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any
BenchMark Rehab Partners Welcome to
BenchMark Rehab Partners Welcome to At BenchMark Rehab Partners we believe communication is essential to achieving the best possible patient outcomes. Understanding your needs and expectations is essential
GIVE US STRENGTH PHYSICAL THERAPY
GIVE US STRENGTH PHYSICAL THERAPY Thank you for choosing Give Us Strength Physical Therapy for your rehabilitation needs. PATIENT INFORMATION: Name (Last, First, Middle Initial): DOB: Social Security Number:
LENNOX SPECIALTY GROUP
LENNOX SPECIALTY GROUP Great expectations, Great results New Patient Intake Forms Your completed intake paperwork helps our physicians and other providers get to know you and your medical history better.
Physical Therapy Services of Ottawa County Patient Registration Form
Physical Therapy Services of Ottawa County Patient Registration Form Personal Information Name Age Sex Date of birth Single Married Widowed Address City State Zip Home phone Cell phone Work phone Email
PLEASE NOTE: This file must be saved to your desktop before and after completing!
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IF WE NEED TO CONTACT YOU ASAP FOR SCHEDULE CHANGES, WHAT NUMBER SHOULD
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REASON FOR TODAYS VISIT Is this injury / condition related to your..
DATE: PATIENT INFORMATION Patient Name: First Middle Last Male Female Address: City: State: Zip: Home phone: Cell: Date of Birth: Marital Status: married single other Soc Sec #: Drivers Lic. # Email Address:
PRINT CLEARLY. Name: (first) (last) (m.i) Address: City: State: Zip:
PRINT CLEARLY NEW PATIENT FORM Name: (first) (last) (m.i) Address: City: State: Zip: Email: Sex: Male Female Student Yes No Home Ph: Cell Ph: Work Ph: Fax: Age: Of Birth: Statement Preference: E-mail Fax
(Formerly AFCN Physical Medicine) A member of the Arkansas Family Care Network, P.A.
Page 1 of 8 (Formerly AFCN Physical Medicine) A member of the Arkansas Family Care Network, P.A. If you have a problem with vision, hearing, speech or communication, please let our front desk personnel
TO ALL OF OUR NEW PATIENTS
Wiles 2310 Mildred St. W, #100C, WA 98466 Thank you for choosing Wiles Chiropractic! We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Address:
PATIENT INFORMATION Today s Date: Last Name: First Name: Middle Initial: Address: STREET CITY STATE ZIP CODE Gender: Male Female Social Security #: Date of Birth: Home Phone: Cell Phone Work Phone: E-mail:
Stinnett Chiropractic we correct pinched nerves
Stinnett Chiropractic we correct pinched nerves Date: First Name: Last Name: Address: City: State: Zip: Home Phone: Cell Phone: Gender: Male Female Birth Date: Marital Status: Single Married Divorced Widowed
Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX (972)
Kirwan Chiropractic Centre 4708 W. Plano Pkwy., Ste. 300, Plano, TX 75093 (972) 265-8100 Name: Date: Address: City State Zip E-mail: Cell #: Home #: Work #: Birth Date: S.S.#: Single Married Divorced Widowed
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APPOINTMENT POLICY FOR FLORIDA SPINE ASSOCIATES
PATIENT INFORMATION PLEASE PRINT Last Name: First Name: MI: Address: City: State: Zip Code: Email: Home Phone: ( ) - Cellphone: ( ) - Work Phone: ( ) - of Birth: Age: Sex: M / F Social Security: - - Race:
Patient Register. Name: Social Security # Birth date: Occupation: Employer:
Patient Register Name: Age: Date: Address: City: State: Zip Code: Alternate Address: City: State: Zip Code: Cell Phone: Home Phone: Male: Female: Social Security # Birth date: Occupation: Employer: Email:
221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:
221 Madison Ave Morristown, New Jersey 07960 (973) 538 4444 Fax (973) 538 0420 PATIENT INFORMATION Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal
Chief Complaint Form: Patient Name: Age: DOB: Occupation: Employer: Referring Physician: Town: Primary Care Physician: Town: Y N
Chief Complaint Form: Patient Name: Date: First MI Last Preferred Name Age: DOB: Occupation: Employer: Send Note? Referring Physician: Town: Y N Primary Care Physician: Town: Y N Coach/ Trainer/ Team Doctor:
Patient History Form
Patient History Form Name: Sex: Male Female Age: Height: ft in Weight lbs 1 Are you currently working? Yes No (last day worked: ) 2 Please give your occupation and physical demands: 3 List your complaints