PATIENT CASE HISTORY
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- Laurence McDowell
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1 Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM PATIENT CASE HISTORY Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Address: Occupation: of Birth: List any Allergies: Animals Aspirin Bees Chocolate Dairy Dust Eggs Latex Molds Penicillin Ragweed/Pollen Rubber Seasonal Allergies Shellfish Soaps Wheat X-Ray Dye Other: List any Surgeries with dates: Back Brain Elbow Foot Hip Knee Neck Neurological Shoulder Wrist Other: List ALL Past Medical History conditions: Ankle Pain Arm Pain Arthritis Asthma Back Pain Broken Bones Cancer Chest Pain Depression Diabetes Dizziness Elbow Pain Epilepsy Eye/Vision Problems Fainting Fatigue Foot Pain Genetic Spinal Condition Hand Pain Headaches Hearing Problems Hepatitis High Blood Pressure Hip Pain HIV Jaw Pain Joint Stiffness Knee Pain Leg Pain Menstrual Problems Mid-Back Pain Minor Heart Problem Multiple Sclerosis Neck Pain Neurological Problems Pacemaker Parkinson s Polio Prostate Problems Shoulder Pain Significant Weight Change Spinal Cord Injury Sprain/Strain Stroke/Heart Attack Other: List Medications you are taking: List your Family History: Arthritis Asthma Back Pain Cancer Depression Diabetes Epilepsy Genetic Spinal Condition High Blood Pressure Heart Problems Multiple Sclerosis Neurological Problems Parkinson s Polio Prostate Problems Stroke/Heart Attack Other: 1
2 Have you had any auto or other accidents? No Yes Describe: of last physical examination: Do you smoke? No Yes Do you drink alcohol? No Yes - how many per day? Do you drink caffeine? No Yes - how many per day? Do you exercise? No Yes (what forms and how often): What is your major complaint? How did this problem begin (falling, lifting, etc.)? How is your condition changing? GETTING BETTER GETTING WORSE NOT CHANGING Have you had this condition in the past? YES - NO What happened? How often do you experience your symptoms? Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Describe the nature of your symptoms: Sharp Dull Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing Other: Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain) How do your symptoms affect your ability to perform daily activities such as working or driving? (0= no effect and 10= can t perform activities) What activities aggravate your condition (working, exercise, etc)? What makes your pain better (ice, heat, massage, etc)? 2
3 Do you have a secondary complaint? How and when did this problem begin (falling, lifting, etc.)? How is your condition changing? GETTING BETTER GETTING WORSE NOT CHANGING Have you had this condition in the past? YES - NO What happened? How often do you experience your symptoms? Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Describe the nature of your symptoms: Sharp Dull Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing Other: Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain) How do your symptoms affect your ability to perform daily activities such as working or driving? (0= no effect and 10= can t perform activities) What activities aggravate your condition (working, exercise, etc)? What makes your pain better (ice, heat, massage, etc)? How did you find us? I authorize this office to release any information necessary to expedite insurance claims. I understand that I am responsible for all charges, regardless of insurance coverage. Patient, Parent, or Guardian printed name as signature /s/ Have you ever had chiropractic care? When? Why? Where? When was your last adjustment? 3
4 FINANCIAL POLICY OF THE FAMILY CHIROPRACTIC CENTER OF SANTA FE Thank you for choosing us as your health provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment.. PAYMENT IS EXPECTED AT TIME OF VISIT UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE The following is a statement of our Financial Policy which we require that you read and sign prior to treatment. REGARDING INSURANCE We will accept assignment of benefits from an insurance policy that is in force at the time of treatment and that covers the treatment provided by this office. You will be responsible for payment at the time of visit for what has been determined to be your portion of the bill. We cannot bill your insurance company unless you provide us with all insurance information. Please understand that your insurance policy is a contract between you and your insurance company. Please be aware that some or perhaps all of the services provided may be non-covered services and not considered reasonable and necessary under your policy. We will do our best to verify and determine your coverage benefits so that you will know in advance just what is covered. The bottom line is that you are ultimately responsible for payment of all charges incurred by you at this office. In the case of managed care plans, we will accept the contracted amounts and you will be responsible for your copayments. You will not be charged the difference between our usual and customary rates and the contracted rates set by the managed care plans. We accept assignment for Medicare claims and will bill them for payment. Your only charge will be to meet your deductible and any co-insurance, if applicable. PERSONAL INJURY POLICY If you have been injured in an auto accident, we will look first to the MedPay part of your auto insurance to pay for services, regardless of who was at fault. If you do not have that coverage, or if you ve been injured in another type of accident, you will either pay for services as they are incurred or contract with a personal injury attorney who will provide us with a Letter of Protection, stating that we will be paid by the attorney after settlement of your case. All fees incurred for treatment at this office will be due and payable following settlement. You will be ultimately responsible for payment of all treatment costs if the attorney fails to do so. MISSED MASSAGE THERAPY APPOINTMENTS Unless canceled 24 hours in advance, our policy is to charge the entire amount due for the massage appointment at the rate of $38.00 per half hour. You will not be charged if an emergency prevents you from keeping your appointment. An emergency is defined as a sudden, urgent, usually unexpected occurrence requiring immediate action. Using our voice mail or will enable you to leave a message when our office is closed. Thank you for reading and understanding our Financial Policy. Please let us know if you have any questions. I have read the above Financial Policy. I understand and agree to this Financial Policy. /s/ Patient Printed Name as Signature /s/ Guardian/Responsible Party Printed Name as Signature
5 To Stephen Perlstein, DC/Family Chiropractic Center of Santa Fe, in consideration of your undertaking to treat me, I agree to the following: AUTHORIZATION AND ASSIGNMENT FOR INSURANCE You are authorized to release any information you deem appropriate concerning my physical condition to my insurance company in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequence thereof. I also authorize my insurance company to direct payment of these charges to you as per my policy agreements. DATED: PATIENT: /s/ AUTHORIZATION AND ASSIGNMENT FOR ATTORNEY You are authorized to release any information you deem appropriate concerning my physical condition to my attorney in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequence thereof. I also authorize my attorney to direct payment to you of these charges interimly or at the time of settlement of my case, as per agreement between you and my attorney. DATED: PATIENT: /s/ ACKNOWLEDGMENT AND UNDERSTANDING INSURANCE I hereby acknowledge that I am ultimately responsible for payment of any charges incurred by me at the Family Chiropractic Center of Santa Fe. If my insurance company refuses to pay for charges and/or services for which reimbursement is anticipated, I will pay these charges immediately upon notification. DATED: PATIENT: /s/ ATTORNEY I hereby acknowledge that I am ultimately responsible for payment of any charges incurred by me at the Family Chiropractic Center of Santa Fe. If my attorney is unable to accomplish a satisfactory settlement of my case and only has funds to partially reimburse all charges incurred, or if my attorney refuses to reimburse for all charges incurred, I will pay these charges immediately upon notification. DATED: PATIENT: /s/
6 FAMILY CHIROPRACTIC CENTER OF SANTA FE 2019 GALISTEO ST. STE M6 SANTA FE, NM PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION The Family Chiropractic Center of Santa Fe (FCC) is committed to maintaining the privacy of your protected health information (PHI), which includes information about your health condition and the care and treatment you receive from the FCC. This Notice details how your PHI may be used an disclosed to third parties, as well as your rights. CONSENT: The FCC may use and/or disclose your PHI (provided that it first obtains a valid Consent signed by you) for the purposes of treatment (providing it to other physicians by request) and payment (to insurers for billing purposes). NO CONSENT REQUIRED: The FCC may use and/or disclose your PHI without your consent based on the orders of another healthcare provider, in an emergency, as required by law, if there is a barrier to communicating with you, or by court order. FAMILY/FRIENDS: The FCC may disclose your PHI to a family member or close personal friend identified by you. YOUR RIGHTS: You have the right to revoke any consent, request PHI usage restrictions except in an emergency, inspect and copy your PHI, amend your PHI as provided by law, complain to the FCC if your privacy rights have been violated, and receive a copy of this Privacy Notice/Patient Consent. FCC S REQUIREMENTS: The FCC will maintain the privacy and confidentiality of your PHI as by law, reserves the right to change the terms of this notice for maximum PHI effectiveness, and will not retaliate against you for filing a complaint. PATIENT CONSENT: The patient agrees that the above has been read and agreed to, that the FCC can change its privacy practices by law, that the FCC can use and/or disclose my PHI for purposes of treatment or obtaining payment, that I can request that the FCC restrict how my PHI is used and/or disclosed, that this consent is valid for 7 years, that the FCC can refuse to treat me if I refuse to sign below or revoke this consent. This notice is effective as of. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice. /s/ Printed name as Signature If you are a minor, or if you are being represented by another party: /s/ Parent/Guardian/Represenative Printed name as Signature
7 Family Chiropractic Center of Santa Fe 2019 Galisteo St. Suite M6 Santa Fe, NM NOTICE REGARDING YOUR SIGNATURE All paper documents that you fill out in this office that constitute part of your patient record will be scanned and entered into the office computer system. All documents that you sign on the Family Chiropractic Center of Santa Fe website with your printed name will be deemed your signature and will make what you are signing legal and binding. The following statements below determine the legality of those signed documents: Photocopies, facsimiles, electronic, or other copies of documents which you have signed shall have the same effect for all purposes as an ink-signed original. All signature lines in all Family Chiropractic Center of Santa Fe documents on the Family Chiropractic Center of Santa Fe website will be preceded with the notation: /s/ which shall signify that the printed name of the signer shall be the legal and binding signature of the signer. By signing below, I certify that I have read and agree with the above statements. /s/ Patient, Parent, or Legal Guardian Signature (Print if online, signature if on paper)
Hun Chiropractic 1 Creekview Ct, Suite B Greenville, SC P: F:
1 Creekview Ct, Suite B Greenville, SC 29615 Personal Information Last Name: First Name: Middle Initial: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: Age: Social
Patient Case History
Patient Case History Name: Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Email Address: Preferred Contact: Home Phone Cell Work E-mail Employer & Occupation: Date of Birth:
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
PS CHIROPRACTIC PATIENT CASE HISTORY
PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security
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:
Welcome PATIENT INFORMATION NAME DATE SOCIAL SECURITY# HOME PHONE CELL PHONE NUMBER CELL PHONE PROVIDER MARRIED WIDOWED SINGLE DIVORCED OTHER
Welcome PATIENT INFORMATION NAME DATE SOCIAL SECURITY# STREET ADDRESS CITY P.O. BOX (street address also needed) ZIP DO YOU PREFER PHONE CALLS AT: HOME WORK NO PREFERENCE BEST TIME TO CALL HOME PHONE CELL
Integrated Spinal Solutions Patient Information
Integrated Spinal Solutions Patient Information Patient Name: City/State/Zip: Today s Date: Home Telephone: Work Telephone: Birth Date: Age: Cellular Telephone: Height: Weight: Employer s Name: Social
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: ( )
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
Patient Name (Last) (First) Date
PATIENT INFORMATION Patient Name (Last) (First) (Middle) Social Security # Driver s License # State Date of Birth: Age: Sex: M F Marital Status: S M D W SEP Address: City State Zip Mailing Address: City
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):
WALL FAMILY CHIROPRACTIC CENTER
WALL FAMILY CHIROPRACTIC CENTER Dr. Michael L. Wall, D.C. 13412 Pacific Avenue Tacoma, WA, 98444 Office: (253) 531-5242 Fax: 253-537-7293 About the Patient Name: Address: City: State: Zip: Home Phone:
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
CHIROPRACTIC PATIENT REGISTRATION AND HISTORY
CHIROPRACTIC PATIENT REGISTRATION AND HISTORY Today s Date: / / Date Symptoms began: / / Is your condition due to an accident? Yes No Type: Auto Work Home Other Name : Address: Last First Middle Street
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 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
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):
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
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
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
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
W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By
W E L C O M E PATIENT INFORMATION Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By Date of Birth Social Security # - - Gender: Male Female Marital Status (please circle):
AUTO ACCIDENT INTAKE FORM
AUTO ACCIDENT INTAKE FORM Last First Middle Birthdate / / Address City State Zip Phone Number (cell) (home) Today s Date / / Email Occupation Employer Spouse s Name Spouse s Phone Number Who may we thank
Spencer Family Chiropractic
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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:
List any past surgeries that you have had throughout your lifetime (if none, circle NONE):
New Patient Mobility Intake Form NAME: DATE OF BIRTH: Address City State Zip Code Phone Gender Male Female Height Weight Social Security Number Email address Primary Insurance Group # -- Secondary Insurance
PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
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
New Patient Registration
New Patient Registration Personal Information Last Name: First Name: Middle initial: Street Address: City: State: Zip: Birth date: Age: Sex: M F Social Security Number : Home phone: ( ) Work phone: ( )
For Motor Vehicle Accidents: Passenger name(s):
Insurance Coverage Information Page 2 Medical Insurance Insurance Carrier: Phone: Policy Holder Name: Policy Number: Group Number: For Motor Vehicle Accidents: Passenger name(s): Were you: Driver / Passenger
NEW PATIENT INFORMATION
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THE BIOMECHANICS Physical Therapy and Sports Medicine Patient Information: Last Name First Middle Date of Birth / / / Employer s Name School
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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
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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
Chiropractic Case History / Patient Information
Chiropractic Case History / Patient Information Date: Name: Social Security #: Home Phone:( ) Address: City: State: Zip: E mail address: Cell Phone:( ) Age: Birth Date: / / Marital Status: M S W D Occupation:
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
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
Chiropractic Case History/Patient Information
1 Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E. Chiropractic Case History/Patient Information 100 Ridgeway St., Suite 8 Hot Springs, Arkansas 71901 P 501-463-9477 F 501-463-9478 Date: Patient # Doctor:
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
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:
First Name: Last Name: Initial:
Patient Information Sheet Please complete the entire form First Name: Last Name: Initial: Address: City: State: Florida Zip Code: Home: ( ) Work: ( ) Cell: ( ) 420 South Dixie Hwy, Suite 4D Email: Gender:
entral Chiropractic Center
Patient Information Date: Name Sex M F Birthdate last middle initial first Address street/p.o. box city state zip Marital Status Single Married Widowed Separated Divorced Social Security # Occupation Primary
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757
Christos Vasakiris, D.C.,D.A.C.A.N. 350 West Montauk Highway Lindenhurst, N.Y, 11757 PLEASE PRINT Patient Name SS# Address City State Zip Code Birth Date / / Age Circle one: Marital Status: S/M/D/W/P How
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
Patient Registration. D. INSURANCE (if applicable)
Patient Registration A. PATIENT Account #: Address: City: State Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone DOB: SSN #: Gender: Male Female E-MAIL: Check here to receive Electronic
*Married *Widowed *Single *Minor *Separated *Divorced *Partnered for years
Name Last Name First Name M.I. Address City State Zip E-mail Birthdate Age Sex *M *F Occupation Employer/School Employer/School Address Employer/School Phone ( ) *Married *Widowed *Single *Minor *Separated
ACKNOWLEDGMENT OF RECEIPT OF HIPAA PRIVACY NOTICE
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Informed Consent for Physical Therapy Services
Informed Consent for Physical Therapy Services The purpose of physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis, and intervention by use of rehabilitative
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
Medical Information Sheet
Please use this guide as a tool to identify where you want to head with your recovery and identify areas or pieces that may be missing in your wellness. Simply check the answers that best apply to you
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
NEW PATIENT INTAKE FORM Patient Name: Date:
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
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
Name: Date: DOB: / / Age: Nickname (if applicable): Height: Weight: Hand Dominance: R / L
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Medical Information Sheet
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1150 Prairie Parkway Suite 102 Dr. Heidi Western, D.C. West Fargo, ND (701)
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New Patient Referral and Insurance Verification Form
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Welcome! And thank you for choosing Advanced Physical Therapy, Inc.
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Patient Information. Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other
Patient Information Date: Name: Birth Date: Age: Marital: M S W D Address: City: State: Zip: E-mail address: Phone: Occupation: Employer: Spouse: Occupation: Employer: How many children? Names and ages
PATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth Date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
WELCOME TO FETZER FAMILY CHIROPRACTIC
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PATIENT INFORMATION. Social Security Number: - - Home Phone: ( ) Work Phone: ( ) Cell: ( ) Nearest Relative: Phone: ( ) Employer Address:
PATIENT INFORMATION PERSONAL INFORMATION Today s Date: Check the type of care desired: Temporary Relief Lasting Correction Name: Social Security Number: - - Date of Birth: - - Age: Height: Weight: Check
Patient Registration. D. INSURANCE (if applicable)
A. PATIENT Please Print Legibly Account #: Address: City: State: Zip: Preferred Contact Method: Home Phone Work Phone Cell Phone Patient Registration DOB: SSN #: Gender: Male Female E-MAIL: Check here
Financial Polic SIGNATURE OF PATIENT (OR PARENT IF PATIENT IS A MINOR) X DATE PATIENT NAME PRINTED
PATIENT INFORMATION NAME HOME PHONE ADDRESS WORK PHONE CITY/STATE ZIP CODE CELLPHONE DRIVER'S LICENSE# EMAIL ADDRESS DATE OF BIRTH PATIENT'S GENDER EMPLOYER EMPLOYER ADDRESS EMERGENCY CONTACT EMERG. CONTACT
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HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information
Patient Information Name birth date Address (street) apt. # (town, state, zip) Telephone: home cell phone Guardian (if a minor) work e-mail relationship Address (if different) telephone Employer Occupation
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
Personal Insurance Intake Form
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
Patient Demographic Sheet Please use Black ink only & print clearly Referred by:
, TX 78613 Patient Demographic Sheet Please use Black ink only & print clearly Referred by: Last Name: First Name: Mailing Address: Apt/Ste: City: State: Zip: Gender: Marital Status: Employer: Occupation:
DATE: / / ABOUT YOU: Employer Data Name: Position: Address line 1: Address line 2: City: St. Zip Code:
DATE: / / ABOUT YOU: First Name: Middle Initial: Last Name: Preferred to be called: Date of birth: / / Address line 1: Address line 2: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone:
If patient is under 18 y/o, name of Parent/Guardian: Relationship to Patient: Address: (street) (city/state) (zip code)
At both New Tampa Foot & Ankle AND South Tampa Foot & Ankle, we are committed to getting you back on your feet free of pain and injury so that you can get back to your activities and back into life! We
Joint Chiropractic Case History/Patient Information
1 Joint Chiropractic Case History/Patient Information Name: Date: Social Security # Birth Date: Race: Marital Status: M S W D Address: City: State: Zip: E-mail address: Cell: Home: Work Occupation: Employer:
Name: Social Security: Address: City: State: Zip: Birthdate: Age: address: Cell Telephone: ( ) Fax: ( )
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will
KINETIC FOOT AND ANKLE CLINIC Marc House, DPM
Patient Information KINETIC FOOT AND ANKLE CLINIC Marc House, DPM Patient s Name (Last) (First) (MI) Dr. Mr. Mrs. Ms. Miss Address City, State, Zip E-Mail Address Date of Birth / / Sex Male Female SSN:
Worker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information Date of Birth: / / Social Security: - - Address: Street City State Zip Email Address: Home Phone: Cell Phone: Gender: Height: Weight: lbs Marital Status:
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
PHYSICAL THERAPY CENTRAL
PHYSICAL THERAPY CENTRAL PATIENT INFORMATION Patient Name: Address: City: State: Zip: Employer: Birthdate: Age: Home Phone: Cell Phone: Work Phone: Preferred Contact Method for Appointment Reminders: Home
PATIENT REGISTRATION FORM
Today s PATIENT REGISTRATION FORM PATIENT INFORMATION Last Name: First: Mi. Init: DOB: Age: SSN: Gen: M F Marital Status: S M D W Race: African American American Indian Asian Caucasian Hispanic Pacific
Welcome to Phillips Family Chiropractic
Welcome to Phillips Family Chiropractic Name: Age: DOB: / / SS# / / Address: City: State: Zip Code: Phone: ( ) - Employer: Occupation: Circle One: Single / Married Number of Children: Email: Spouse: Employer:
Patient Information. Insurance Information
Date Name (LAST NAME) (FIRST NAME) (MIDDLE INITIAL) Address City State Zip Phone (HOME) Patient Information (CELL) Email Birthdate Age Sex: M F Social Security # Occupation Employer Do you have health
ProAdjuster Chiropractic Clinic
Please list all of your doctors- fill out as much as you can below It is extremely important that your doctors receive your office notes to coordinate your treatment. General Physician OB Gynecologist
COLLINS CHIROPRACTIC CLINIC
Welcome to Collins Chiropractic We are pleased that you have chosen our practice for your chiropractic needs. Caring for you is our privilege. Enclosed are several informational items that will acquaint
Northwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR
rthwest Functional Neurology Dr. Glen Zielinski DC, DACNB, FACFN 4035 SW Mercantile Dr., Suite 112 Lake Oswego OR 97035 503-850-4526 DEMOGRAPHCS Last Name: First Name: MI: Date of Birth / / Gender: SS#:
PATIENT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Ronald M. Yarab, Jr., M.D. Michael T. Engle, M.D. Sean T. McGrath, M.D. Patient s First Name: M.I. Last: Mr. Mrs. Miss Ms. Marital status: (circle one) Single / Married / Divorced Separated
Patient Information TO BE COMPLETED BY PARENT/GUARDIAN ACCIDENT INFORMATION. Date SSN/HIC/Patient ID # Patient Name
1 Date SSN/HIC/Patient ID # Patient Name Address PATIENT INFORMATION Best time/place to contact you? E-mail Sex M F Age Date of Birth Married Widowed Single Separated Divorced Minor Patient Employer/School
PATIENT INFORMATION Patient Demographics and Insurance
PATIENT INFORMATION Patient Demographics and Insurance PERSONAL INFORMATION Last First MI Suffix Social Security # Date of Birth Sex Marital Status Primary Phone Alternate Phone Email Address Address City
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:
Carter Family Dentistry
Carter Family Dentistry General Dentistry Patient Information Patient Name: Date: Last First MI Occupation: Employer: Title/Pos. 1 Male 1 Female 1 Single 1 Married 1 Child 1 Other Spouse s Name Social
PATIENT INFORMATION. Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex:
PATIENT INTAKE FORM (Please Print or Type. Once complete, either fax to 949-553-3561, email to Stacie@thephysiofix.com or bring with you during your first session!) Today s date: PATIENT INFORMATION Patient
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
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
Prairie Life Chiropractic 1224 S. Main Ave. Sioux Center, IA 51250
Patient Information Name Birth Date Guardian s Name (If applicable) Address City State Zip Home Phone ( ) Cell ( ) Email Sex: Age SS# Race: Ethnicity: Occupation Employer Employer City Employer Phone(
APM PATIENT INFORMATION. Date of Birth / / SS# - - Sex: q Male q Female. Address: City State Zip. Employer Phone # ( ) Occupation
APM PATIENT INFORMATION Date: / / Name: / / (Last) (First) (MI) Date of Birth / / SS# - - Sex: q Male q Female Address: City State Zip Home Phone # ( ) Work Phone # ( ) Circle preferred number for communication
Welcome to our office!
2007 Rainbow Drive Gadsden, AL 35901 Ph: 256-543-0009 Fax: 256-549-1221 Patient Information Page 1of 2 Welcome to our office! Dr. Shan Tian, D. C. Patient Information Please complete all questions. Today