Patient History Form
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- Brett Bishop
- 5 years ago
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1 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 or problems: 4 Please rate the quality of pain between mild moderate extreme pain 5 Please indicates painful areas by shading the models to the right: 6 Which of the following describes your pain: (check all that apply) Sharp Dull Numb Constant Aching Tingling Variable Radiating 7 How did your problem start? : 8 Are there any positions or activities that make your pain worse? 9 Are there any positions or activities that lessen your pain? 10 Please list any medication(s) you are taking for this problem: 11 What tests or treatment have you received for this problem?
2 Past Medical History 12 Have you ever had any of the following? Heart / Vascular Disease General Medical Conditions Congestive Heart Failure High Blood Pressure / Hypertension Heart Attacks Stroke / TIA Pacemaker Atherosclerotic Disease (CAD) Angioplasty Valve Disease Arrythmia Bypass Graft (CABG) Angina Lung Disease Chronic Obstructive Disease (COPD) Recent Pneumonia Asthma Acquired Respiratory Distress Syndrome Emphysema Arthritis (rheumatoid/osteo) Allergies Neurological Conditions (MS, Parkinson s, etc) Headaches Gastrointestinal Disease (ulcers, hernia, IBS, Crohns, liver/gall baldder) Visual Impairments Back Pain (neck, back, disc disease, etc) Hepatitis HIV / AIDS Osteoporosis Depression Kidney / Bladder / Prostate issues Incontinence Hearing Impairments Sleep Dysfunction Prosthesis Implants (metal, etc) Cancer (active / remission) Diabetes Previous Surgeries (please write down 13 Do you have metal anywhere in your body (other than teeth)? If so, where? 14 Are you pregnant? If yes, how many weeks/months? 15 List all allergies you have: 16 Have you ever had physical therapy treatments? If yes, when and for what? 17 Have you had any physical/occupational/chiropractic/speech therapy this year? If yes, how many treatments? (Other therapies this year may limit your allowed number of PT visits with us) To the best of my knowledge, the stated medical information is true and correct Signature:
3 PHYSICAL THERAPY HIPAA Privacy Authorization Form Authorization for Use or disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164) 1 Authorization I authorize I do not authorize SPECIALIZED ORTHOPEDIC SOLUTIONS PHYSICAL/OCCUPATIONAL THERAPY to use and disclose the protected health information described below to individual/healthcare Providers seeking the information 2 Extent of Authorization I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) OR I authorized the release of my complete health record with the exception of the following information: Mental health records Communicable diseases (including HIV and AIDS) Alcohol / drug abuse treatment Other (please specify: 3 This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct 4 This authorization shall be in force and effect until (date or event), at which time this authorization expires 5 I understand that I have the right to revoke this authorization, in writing, at any time I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim 6 I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization 7 I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law Signature of patient or personal representative Printed name of patient or personal representative and his or her relationship to patient
4 Physical Therapy AUTHORIZATION TO PAY PHYSICAL THERAPY PROVIDER / FINANCIAL AGREEMENT I hereby authorize SPECIALIZED ORTHOPEDIC SOLUTIONS to charge my insurance company for services rendered including, but not limited to, manual therapy, modalities for pain management, and therapeutic exercise for flexibility and strengthening I further authorize SPECIALIZED ORTHOPEDIC SOLUTIONS to furnish my insurance company my treatment records upon request I authorize and instruct services by payment going to: insurance company to pay for my SPECIALIZED ORTHOPEDIC SOLUTIONS 9259 ETON AVE CHATSWORTH, CA Please read the following and sign below 1 This payment will not excuse my indebtedness to SPECIALIZED ORTHOPEDIC SOLUTIONS 2 I understand that my insurance will on average be billed weekly I agree that if my insurance does not pay within 60 days of being billed that it will then be my responsibility to make payment on any outstanding balance due 3 I agree that any balance of said charges over and above those which have been paid by my insurance will be paid by me 4 I agree that charges that are past due over 90 days will incur a finance charge of 5% of the unpaid balance I understand and agree that balances past 120 days will be turned over to a collection, and any additional collection fees and finance charges will be paid by me 5 I understand that there is a $25 fee for cancellations made on day of my set appointments I also understand that there is a $25 fee for failure to show for any scheduled appointments I acknowledge that this $25 fee, if accrued, is to be paid by me, separate from charges made by my insurance Patients Signature:
5 Physical Therapy CONSENT TO TREAT I,, hereby consent to routine Physical Therapy services as provided by SPECIALIZED ORTHOPEDIC SOLUTIONS and his staff under his supervision This will be done according to the general instructions of the referring physician (if applicable) I acknowledge that the treatment may include any number of modalities and/or procedures that will be rendered according to the general guidelines of my physician (if applicable) and the physical therapist Patients Signature:
Before your first visit there are a few things we would like you to be aware of:
I would like to personally thank you for choosing us to serve you for your physical therapy needs. Our team takes pride in offering a professional and friendly environment for you to rehabilitate. Our
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Patient Name Patient SS# DOB Home City State Zip Home Cell Email Would you like appointment reminders (email/voice/text)? Yes No Would you like your home exercise plan emailed
3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:
Eaton Chiropractic & Rehab Center 1 Patient Information Name: First Initial Last Address: Home: Work: Cell: DOB: Male Sex: Female SSN: Email: Single Divorced Marital Status: Married Separated Widowed Full
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in
The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in Patient Information Thank you for choosing our practice for your chiropractic needs. Please
EMERGENCY CONTACT Name of relative/friend not living with you. Home Phone Cell INSURANCE
DATE PATIENT INFORMATION Name Date of Birth Home# Work# Cell# Do you receive text messages? Address City State Zip SS# email Sex Marital Status Employer If Student, what school? Spouse s Name Who may we
Name of Policyholder. Current Address of Policyholder City State ZIP Telephone No. Former Address of Policyholder City State ZIP Name of Employer
REQUEST FOR ADDITIONS/APPLICATION FOR REINSTATEMENT ACCIDENT-ONLY INSURANCE FOR A-34000 SERIES American Family Life Assurance Company of Columbus (AFLAC) Worldwide Headquarters: Columbus, GA 31999 For
Commerce Primary Care
Patient Name: DOB: Commerce Primary Care Patient Information Sheet Gender: Male Female Marital Status : Single Divorced Married Race: American Indian/Alaska Native Asian Black/African American White Other
Name of Policyholder. Current Address of Policyholder. City State ZIP Telephone No. Former Address of Policyholder City State ZIP Name of Employer
Name of Policyholder Policy Number Current Address of Policyholder REQUEST FOR ADDITIONS/APPLICATION FOR REINSTATEMENT OFF-THE-JOB ACCIDENT-ONLY INSURANCE FOR A-34000 SERIES American Family Life Assurance
uqua 6560 Greenback Lane, Citrus Heights, CA (916) Fax (916)
NOTICE OF PATIENT INFORMATION PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION PLEASE REVIEW IT CAREFULLY FUQUA PHYSICAL
For your convenience, please schedule your appointments two weeks in advance.
Welcome! Welcome to Rebound Physical Therapy. We are pleased you have selected us for your physical therapy services. We will bring you back to a healthy functional and recreational level and educate you
Thank you again for choosing CrossRoads for your care. We hope to exceed your expectations.
BELIEVE! COMMIT! ACHIEVE Dear New Patient, The staff at CrossRoads Physical Therapy and I are delighted that you have chosen our facility for your therapy. Our goal is to provide you with a premium level
Has a family member been a patient in our office? Yes No
Patient Information *Please complete all pages First Name M.I. Last Address Sex M / F Age City State Zip Code Date of Birth Social Security Marital Status S M W D Primary Phone Alternate Phone E-mail Physician
PATIENT INFORMATION : Please present insurance cards to receptionist. INSURANCE: Please fill out only if you re NOT the subscriber
PATIENT INFORMATION : Please present insurance cards to receptionist First Name: Last Name: Date of Birth: - - Sex: Male Female Address: City: Cell Phone #: ( ) - M.I.: APT: State: Zip Code: Home #: (
Patient Registration & Health History
Patient Registration & Health History Today s Date: / / How did you hear about us? Legal Name: How do you prefer to be addressed? Address: City: State: Zip: Date of Birth / / Age: Gender: M / F Marital
Name (Last, First, MI): Date of Birth: / /
Name (Last, First, MI): Address: Age: City: State: Zip: Sex: Male / Female Phone #: (Home): (Cell): (Work): Personal Email: Social Security #: Race: Ethnicity: Hispanic/Latino Non-Hispanic/Latino Other
Patient Health Questionnaire
Patient Health Questionnaire Account # Patient Name DOB / / 1. Describe your symptoms/complaints or limitations: 2. Please describe how your problem began: 3. When did your symptoms begin/specific date
Patient Registration Form
Patient Registration Form Patient Information Account # : Address: Primary Phone: Please indicate the best number for your appointment reminder calls: Home Cell Text Alternate Phone: Email: May we contact
Name:,, SS#: Last First Middle initial
Patient Intake Form Date: Name:,, SS#: Last First Middle initial Address: City: State: Zip: DOB: Male Female Height: Weight: Please check preferred phone number for contact: Home Phone: Cell Phone: Work
Welcome to the ACCESS OMNICARE NEW INJURY PATIENT Your Occupational Medicine partner in Health and Safety
A. Patient Information Please complete this document and return it with your Driver s License LAST NAME: FIRST NAME: MIDDLE NAME: PREFERRED NAME: SEX: DATE OF BIRTH: SOCIAL SECURITY NUMBER: FORMER LAST
Secondary Insurance Co. Name & Address: Subscriber s Name: Subscriber Soc. Sec. No. Group number:
M a u r i c i o R o n d e r o s, D D S, M S, M P H I. PATIENT INFORMATION: Last Name: First Name: MI: Mr. Mrs. Ms. Male Female Birth date (M/D/Y): Marital status: Dr. Other: Address: City, State: Zip:
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
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014 Patient name: Account# Ear, Nose and Throat Associates, PC, believes that in the interest of good health care practices,
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
Stark County Surgeons, Inc Patient Information. Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - -
Today s Date: / / Patient Information Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - - Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Other phone: ( ) - E-Mail
Chong S Kim, MD ENT and Facial Plastic Surgeon
Chong S Kim, MD ENT and Facial Plastic Surgeon 100 Commons Way, Suite 701 300 Perrine Rd., Suite 301 Holmdel, NJ 07733 Old Bridge, N.J 08857 Phone: 732-796-0182 Phone: 732-727-1355 Fax: 732-796-0186 Fax:
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
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History
AristidisPontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Email Address Street Address City State Zip Social Security Number Cell Phone Home
(Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION. If not, what is your legal name? (Former name): Birth date:
Today s date: (Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION Last name: First: MI: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your
entral Chiropractic Center
Patient Information Date: Name Sex M F Birthdate last middle initial first Address Marital Status Single Married Widowed Separated Divorced Social Security # Occupation Primary Phone Secondary Phone Emergency
BARIATRIC PATIENT INFORMATION PACKET
David C. Treen, Jr., MD, FACS Michelle M. Treen, RN Nurse Coordinator BARIATRIC PATIENT INFORMATION PACKET Patient Name: Address City State Zip Home Phone Work Cell Fax Birth Date Gender (M, F) Social
Please feel free to ask questions about this document. I have read the above guidelines and agree to the terms set forth by A Joint Effort PT.
Please arrive to your initial appointment at least 15 minutes early. For all following appointments, please arrive 5 minutes prior to you scheduled appointment time. To avoid waiting unnecessarily remember
-Dr. Noreen Goldwire, DDS-
-- Patient Registration Name of Patient First Middle Last Nickname Birth Social Security # Person Responsible for Account Relationship to Patient Home Address Street City State Zip Email Address Home Phone
The Prudential Insurance Company of America
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Name: Date: DOB: / / Age: Nickname (if applicable): Height: Weight: Hand Dominance: R / L
Medical History Name: Date: DOB: / / Age: Nickname (if applicable): Height: Weight: Hand Dominance: R / L Allergies (medications and/or metals): NKDA / PCN / Sulfa / Latex Occupation (if retired, what
PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION
PATIENT INFORMATION FORM PLEASE COMPLETE THE FOLLOWING INFORMATION DATE Please Print All Information LAST NAME FIRST NAME MI ADDRESS CITY ST ZIP PHONE EMPLOYER WORK PHONE DATE OF BIRTH AGE SEX SOC. SEC.
Name Relationship Phone #
Patient Name: Preferred Name: Last First Middle Gender: Male Female Other Date of Birth (dd/mm/yyyy): Occupation: Home Address: City: Postal Code: Were you injured at work? Is this an ICBC case? If so,
PHYSICAL THERAPY CENTRAL
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NEW PATIENT REGISTRATION
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Welcome to MARTIN CHIROPRACTIC
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PATIENT REGISTRATION
PATIENT REGISTRATION Last / First / M.I. Patient Information Address / APT# City / State / Zip Phone # SSN: DOB Male Female Marital Status: Occupation Patient Email Address Assignment and Release I hereby
4) Address: City, State, Zip Code 5) Gender: Male Female 6) Date of Birth (DOB): / /
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: Male Female 6) Date of Birth (DOB):
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:
FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C. PHYSICAL THERAPY INSTITUTE PATIENT INFORMATION SHEET
PATIENT INFORMATION SHEET Chart #: Today s : FOA Initials: PATIENT INFORMATION Last Name, First Name, MI: Home Phone: Cell Phone: SSN: Birth (MM/DD/YYYY): Age: Sex: Marital Status: Single Separated Male
Date. D Light D Moderate D Strenuous
FAMILY CHIROPRACTIC CARE PATIENT HEALTH QUESTIONNAIRE Patient Name What type of regular exercise do you perform? D None Date D Light D Moderate D Strenuous What are your overall health goals? D Weight
Chirohealth 825 NE. 7 th St Grants pass OR Patient Information. Occupation: Employer s Address: Alternate contact person: name
825 NE. 7 th St Grants pass OR 97526 Dr. David Ray D.C. FNP Dr. Todd Harris D.C. Eve Ledesma PT Patient Information Name: Date: Address: Birth Date: City, State, Zip: Male / female Home Phone: Cell Phone:
Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
NAME AGE BIRTHDATE HT WT SEX ADDRESS CITY STATE ZIP Phone: Home Work Ext Cell PROFESSION MARITAL STATUS: S M W D Sep.
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Palm Valley Oral and Maxillofacial Surgery
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The Prudential Insurance Company of America
The Prudential Insurance Company of America 751 Broad Street, Newark NJ 07102 State Bar of Texas 47080 Please print all answers using black ink. Request for LTD Coverage Form Return this completed form
PATIENT REGISTRATION
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Social Security No. Male Female Age Street Address City State ZIP+4 Home Address
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New patient Registration
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Personal Insurance Intake Form
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PATIENT INITIAL EVALUATION INFORMATION (Adult) DATE Patient Name Date of Birth / / First Middle Last Month Day Year Mailing Address Street City State Zip Home Phone Work Phone Cell Phone **The Dermatology
PLEASE MAKE THE FOLLOWING CHANGES TO MY POLICY:
REQUEST FOR ADDITIONS/APPLICATION FOR REINSTATEMENT ACCIDENT-ONLY INSURANCE FOR A35000 SERIES American Family Life Assurance Company of Columbus (Aflac) Worldwide Headquarters: Columbus, GA 31999 For information,
Hun Chiropractic 1 Creekview Ct, Suite B Greenville, SC P: F:
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Patient Register. Name: Social Security # Birth date: Occupation: Employer:
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New Patient Registration
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Multi-Specialty Musculoskeletal Pain Relief Center
Name Social Security # Age Birthdate Date Home Tel Address City State Zip Work Tel Cell Number Email Address Marital Status: M S W D # Children Spouse s Name Your Occupation Emergency Contact Name and
Street Address City State Zip. Preferred Number? Home Cell Work Check if we may leave messages? Home Cell Work
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APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation
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Welcome! And thank you for choosing Advanced Physical Therapy, Inc.
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PATIENT RECORD Please fill out completely. Thank you. Referring Physician. Last Name Legal First Name MI
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Patient Name: Address: Date of Birth: Age: Marital Status: S M D W. Mailing Address: Home Phone #: Cell Phone #:
Patient Information Patient Name: E-Mail Address: Sex: M F Date of Birth: Age: Marital Status: S M D W Mailing Address: Home Phone #: Employer/School: Cell Phone #: Occupation: How were you referred to
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Patient Intake Form Patient Information
Patient Intake Form Patient Information Full Name: First MI Last Date: Address: City: State: Zip: Age: Birth Date: Female: Male: Email Address: Home Phone: Work Phone: Cell/Other: I prefer to receive calls
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice.
LEGAL NOTICE/DISCLAIMER The information contained in this document does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only
Thank you again for choosing Haymarket Chiropractic. We hope to exceed your expectations.
Dear New Patient, The Staff at Haymarket Chiropractic & Rehabilitation (HCR) and I are delighted that you have chosen our facility for your therapy. Our goal is to provide you with a premium level of care
CHIROPRACTIC HEALTH QUESTIONNAIRE
CHIROPRACTIC HEALTH QUESTIONNAIRE Name: SS#: Today s Date: / / Address: City: State: Zip: What you prefer to be called: Age: Birthdate: / / Handedness: Height: Weight: Number of Children: Male Female Marital
Today s Date: Name: Birthdate: / / SS#: Home #: Work #: Cell #: Best Time to Contact You:
Today s : Name: Nickname: Male Female Birthdate: / / SS#: Email: Home #: Work #: Cell #: Best Time to Contact You: Preferred Method of Contact: Please choose all that apply. Home Work Cell Text Email Address:
Acknowledgement of Receipt of Privacy Notice Documentation of Attempt to Obtain Written Acknowledgment
Acknowledgement of Receipt of Privacy Notice Documentation of Attempt to Obtain Written Acknowledgment As required by the Health Insurance Portability and Accountability Act of 1996, we document compliance
SHEDDON PHYSIOTHERAPY AND SPORTS CLINIC
Patient Name: Date of Birth: / / Last First Day Month Year Address: City: Home Tel: Other Tel: Postal Code: *E-mail: Family Physician: Do you have a Doctors referral? How did you hear about us? If so,
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP
GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP 34 Long Pond Road Plymouth, MA 02360 (508) 747-1434 New Patient Intake Form Patient Information Thank you for choosing our practice for your chiropractic