PATIENT APPLICATION FORM
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- Aron Gibbs
- 6 years ago
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1 PATIENT APPLICATION FORM WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation. These methods have enabled our patients to achieve their optimal health; even when many other systems have failed. Because of this specialized approach, we may not accept you as a patient until we are absolutely certain we know the cause of your condition, that we can perform the necessary tests to establish an optimal rehab program for you, and are completely confident we can help you recover your health. Please know if we do accept you as a patient, we will then make specific recommendations based upon our understanding that your health will become your TOP PRIORITY. Thank you again for applying as a patient in our clinic. Patient name Date ComPleteD
2 Patient Information Name: (Age) Gender: M F Home Address: Home Phone: ( ) City, State, Zip: Work Phone: ( ) Address: Cell Phone: ( ) Birth Date: / / Social Security #: - - Marital Status: S M D W Occupation: Employer Name: Spouse s Name: Work Phone: ( ) Cell Phone: ( ) Spouse s Employer: Occupation: How were you referred to this office? Purpose For This Visit Reason for this visit: Is this related to an accident or specific injury (other than auto or work-related)*? q Yes q No If yes, when: / / *If your symptoms are the result of an auto accident or work-related injury, please ask the front-desk person for the corresponding application. Describe: Please use the General Symptoms Chart on the next page to provide a detailed notation of your symptoms. When did these symptoms begin? / / Are they: q Constant q Intermittent q Activity-related Are they getting worse? q Yes q No Do they interfere with: q Work q Sleep q Hobbies q Daily Routine Explain: What activities aggravate your symptoms? Is there anything that relieves your symptoms? q Yes q No If yes, explain: Have you experienced these symptoms before (if not accident/injury related)? q Yes q No If yes, explain: Have you been treated for this? q Yes q No When were you last treated? / / Who did you see? What treatment was performed? How did you respond? Experience with Chiropractic Have you seen a Chiropractor before? q Yes q No Who? Reason for visit(s): Did your previous chiropractor take before and after x-rays? q Yes q No What was the diagnosis? Did he or she recommend a specific course of treatment? q Yes q No Did they recommend a Home Health Care program? q Yes q No If yes, what? How long were you treated? Last treatment: / / How did you respond? Are you aware of any poor posture habits? q Yes q No Is there any history of spinal problems in your family? q Yes q No If yes, explain:
3 GENERAL SYMPTOMS CHART Please use the following nota ons on the figures below to indicate the type and loca on of your symptoms, as it relates to the purpose of your visit today. A = ACHE B = BURNING P = PINS & NEEDLES G = STABBING M = SPASMS F = STIFFNESS N = NUMBNESS T = TINGLING O = OTHER FRONT BACK If you marked O for Other on any part, please explain below:
4 Health & Lifestyle Do you exercise? q Yes q No How often? day(s) per week; Other: What activities? q Walking q Running/Jogging q Weight Training q Cycling q Yoga q Pilates q Swimming q Other: Do you smoke? q Yes q No How much? / How often? Do you drink alcohol? q Yes q No How much? / How often? Do you drink coffee? q Yes q No How much? / How often? Do you take any supplements (i.e. vitamins, minerals, herbs)? If yes, please list: Health Conditions Your spine is the foundation of health and core strength in your body. Shifts in the vertebrae or sections of the spine will spread ultimately causing weakness and distortion to ALL the areas of the spine. These distortions are reflected in abnormal posture. Research shows abnormal posture leads to chronic pain, disease and possibly a shortened life span. 1 Please answer the following questions accurately so we may determine the full extent of your condition. Cervical Spine (Neck) Misalignment of the individual vertebrae or distortion of the complete cervical curve (neck) originating in the neck or a compensation from postural distortions in other areas of the spine may result in many health conditions. Have you experienced any of these symptoms presently or in the past? Neck Pain Headaches Sinusitis Pain in shoulders/arms/hands Dizziness Allergies/Hay fever Numbness/tingling in arms/hands Visual disturbances Recurrent colds/flu Hearing disturbances Coldness in hands Low Energy/Fatigue Weakness in grip Thyroid conditions TMJ/Pain/Clicking thoracic Spine (upper back) Misalignment of the individual vertebrae or distortion of the upper thoracic curve (upper back) originating in the upper back or a compensation from postural distortions in other areas of the spine may result in many health conditions. Have you experienced any of these symptoms presently or in the past? Heart Palpitations Heart Murmurs Tachycardia Heart Attacks/Angina Recurrent Lung Infections/Bronchitis Asthma/Wheezing Shortness Of Breath Pain On Deep Inspiration/Expiration 1. Postural and Degenerative Kyphosis: Freeman JT. Posture in the Aging and Aged body. JAMA 1957, Oct 19:
5 Health Conditions continued... thoracic Spine (mid back) Misalignment of the individual vertebrae or distortion of the mid thoracic curve (mid back) originating in mid back or a compensation from postural distortions in other areas of the spine may result in many health conditions. Have you experienced any of these symptoms presently or in the past? Mid Back Pain Nausea Diabetes Pain in Ribs/Chest Ulcers/Gastritis Hypoglycemia/Hyperglycemia Indigestion/Heartburn Reflux Tired/Irritable after eating or when not having eaten for a while LUMBAR Spine (LOW back) Misalignment of the individual vertebrae or distortion of the lumbar curve (low back) originating in the low back or a compensation from postural distortions in other areas of the spine may result in many health conditions. Have you experienced any of these symptoms presently or in the past? Pain in hips/legs/feet Weakness/injuries in hips/knees/ankles Low back pain Numbness/tingling in legs/feet Recurrent bladder infections Coldness in legs/feet Frequent/difficulty urinating Muscle cramps in legs/feet Sexual dysfunction Constipation/Diarrhea Menstrual irregularities/cramping (females) OTHER Please list any health conditions not mentioned: Please list any medications (include name, dose, for what condition, and how long you ve been taking it): Please list any surgeries (include type of surgery and date it was performed):
6 Family Health History Have any of your family members ever been diagnosed with the following (please indicate Y for You, and O for Other than you, or both if applicable): Diabetes Varicose Veins Neurological Problems Lung Disease Rheumatic fever Circulatory Problems Stroke Heart Murmur High Blood Pressure Heart Disease Cancer Osteoporosis Kidney Disease Paralysis Migraine Headaches Arthritis Liver Disease Metal Implants Infectious Disease Gall Bladder Broken bones/fractures Appendectomy Tonsillectomy Hernia Pneumonia/Bronchitis Polio Tuberculosis Anemia Whooping Cough Chicken Pox/Shingles Mumps Measles Thyroid Problems Small Pox Influenza Pleurisy Blood Sugar Problems Epilepsy/Seizures Eczema/Psoriasis Lumbago Other: Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual cycle: / / Patient s Signature Date / / Authorization of Care I authorize and agree to allow the doctor and/or his/her designated staff to take x-rays and work with my spine or the spine of the charge I represent through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration of normal bio-mechanical and neurological function. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. The Doctor and/or his/her staff will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another healthcare practitioner, or are not related to the spinal structural conditions diagnosed at this clinic. I also clearly understand that if I do not follow the doctors and/or staff s specific recommendations at this clinic that I will not receive the full benefit from these programs; and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. Patient s Signature Date / / Patient s Name Printed If patient is a legal charge of limited capacity requiring guardianship for treatment, please complete the following: Date Guardianship Awarded County, State of Guardianship I hereby authorize the doctor to administer care as deemed necessary to my charge as appointed to by the courts. Guardian Signature Date / / In Case of Emergency Name Relationship Work Phone ( ) Home Phone ( ) Cell Phone ( )
7 Insurance We may accept assignment of insurance benefits. By signing this policy, you agree to assign your insurance benefits to this clinic. In cases where benefits are not assignable or in any case where your benefit is processed directly to you regardless of assignment, you agree to submit any payments received along with the explanation of benefits to this clinic within 10 days of receipt unless you have paid for the services represented by said payment in full at the time of service. In no case will an assignment alleviate you of your obligation for payment of services received. Your insurance plan is a contract between you and your insurance company. This clinic is not a party to that contract and therefore cannot modify the terms of that contract. Payment for treatment you receive from this clinic is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you provide us with the necessary billing information, assign your benefits to this clinic and agree to permit us to release the necessary medical information required to secure payment. In the event we do accept assignment of benefits we require that you provide a credit card with authorization to bill that account any balance or make other payment arrangements. We will make every effort to ensure that your insurance carrier properly processes your services for payment. In some circumstances we may require your assistance. If your insurance company has not paid your account in full within 60 days and you refuse to assist us in dealing with your carrier, the balance will be automatically be transferred to your credit card or the extended payment plan. DECLARATION I clearly understand that all insurance coverage, whether accident, work related, or general coverage is an arrangement between my insurance carrier and myself. If this office chooses to bill any services to my insurance carrier that they are performing these services are strictly as a convenience to me. The doctor s office will provide any necessary reports or required information to aid in insurance reimbursement of services, but I understand that insurance carriers may deny my claims and that I am ultimately responsible for any unpaid balances. Any monies received will be credited to my account. I understand there could be some services that my insurance company does not cover, if this is the case are you willing to pay for these services? q Yes q No Patient s Signature Date / / Signature of Person Authorizing Care (if different from patient): Date / / Relationship to Insured Date of Birth / / Employer Primary Insurance Company Policy# Address Phone # ( ) Insured s Name Insured s Social Security #: - - Secondary Insurance Company Policy# Address Phone # ( ) Insured s Name Insured s Social Security #: - -
*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
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PATIENT QUESTIONNAIRE Please fill out this form COMPLETELY using your LEGAL name. Do not leave any blanks. FAMILY PHYSICIAN (First Name, Last Name) PATIENT INFORMATION DATE TO SEE DOCTOR (Name) / / PATIENT
PATIENT REGISTRATION FORM
Today s Date: 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
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
To all of our new patients
ATLAS FAMILY Thank you for choosing Atlas Family Chiropractic. We are committed to providing you with the best possible care and we are pleased to discuss our professional fees with you at any time. Your
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
What to bring to your first visit:
What to bring to your first visit: *Identification (drivers license) *Health Insurance Card *X-Rays (if taken since injury) *Police Report (auto accident) *Auto Insurance Card (yours and the drivers, if
HEALTH QUESTIONNAIRE. Today s Date Date of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No
Name HEALTH QUESTIONNAIRE Today s of Birth Age Referring Physician Occupation Tobacco/Nicotine Use: Yes No If yes, type and amount: Alcohol Use: How many drinks do you have per week? Hand Dominance: Left
Bloink Chiropractic Welcome
Bloink Chiropractic Welcome Today s Date: File No. Patient s Name Preferred Name Birth Date Age Male Female SS# Address City/State/Zip Home Phone Work Phone Cell Phone Preferred Phone to be called: Home
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,
Patient Information. Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name:
Patient Information Referred by: Primary Care Physician: Last Name: First Name: Mr. Mrs. Miss Other Middle Name: Preferred Name: Date of Birth: / / Age: SSN: - - Address: City: County: State: Zip: Email
WELCOME. one ABOUT YOU. Patient File # Today s Date: / / Birth date: / / Age: Social Security #: Mailing Address: City State Zip.
Patient File # WELCOME one ABOUT YOU Today s Date: / / Your Name: LAST FIRST MI Male Female Birth date: / / Age: Social Security #: Mailing Address: City State Zip Home Phone #: Work Phone #: Ext: Mobile
PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Last Name First Name Address City, State, Zip Email Address Home Phone Work Phone Cell Phone SS# Date of Birth Age Sex ( ) Male ( ) Female Marital Status (check one):
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
Villa Medical Arts New Patient Forms
Villa Medical Arts New Patient Forms New Patients, To expedite your check- in process, please print and complete the following pages. If you have access to a fax machine, please fax them along with a copy
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
NEW PATIENT INFORMATION
12101 W. Parmer Lane Ste. 200 Cedar Park, Texas 78613 Phone: 512.363.5178 Fax: 512.339.2664 Welcome!!! Please allow our staff to photocopy your driver s license and insurance or Medicare card (if applicable).
WELCOME TO FETZER FAMILY CHIROPRACTIC
WELCOME TO FETZER FAMILY CHIROPRACTIC Patient Information Thank you for choosing Fetzer Family Chiropractic for your health care needs. Please complete this form in ink. If you have any questions or concerns,
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ
Palmer Center for Natural Healing 8600 E. Shea Blvd. #110, Scottsdale AZ 85260 480-443-2584 www.wellnessdoc.com Date Home Phone Work Phone Cell # Patient e-mail: Last Name First Name Street Address City
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
(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
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: ( )
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
Cell Phone Texting is OK Only call if urgent
WELCOME! Name (Circle title: Dr., Mr., Mrs., Ms., Miss) of Birth Age Social Security Number Single Married Divorced Separated Widowed Sex Male Female E-mail : Please check the best number(s) to reach you:
PATIENT INFORMATION PRIMARY INSURANCE INFORMATION
1001 Medical Plaza Dr. The Woodlands, TX 77380 www.woodlandsretina.com Tel: 281-367-9700 Fax: 281-367-9701 PATIENT INFORMATION Patient s Legal Name: Date of Today s Visit: Social Security # Date of Birth:
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
Georgia Foot & Ankle
Georgia Foot & Ankle PLEASE PRINT CLEARLY Today s Date / / Name Date of birth / / First MI Last SSN Marital Status M S D W Age Weight Height Male Female Address City State Zip Phone (Home) (Work) (Cell)