Welcome to Align Chiropractic Wellness Center!
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- Vernon Arnold
- 5 years ago
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1 Welcome to Align Chiropractic Wellness Center! Many of the health challenges that people will face originate from stressors experienced during developmental years (including gestation and birth). These stressors (traumas) may be emotional, physical, or chemical. This health record is designed to help us understand the stressors your child might have already experienced and to maximize your child s health and wellness. Name DOB Age Address City State Zip Code Parent/Guardian Phone Number: Parent/Guardian Name(s): Who may we thank for referring you and your child to our office: Name of your Pediatrician: Phone Number: When was their last visit: Current Height/Length: Current Weight: Reason for today s office visit: When did it begin: Please explain symptoms or presentation of this condition: What methods or remedies have you tried: Were they successful: Have you consulted with your Pediatrician or a Specialist for this reason? If Yes, Who: Current Medications or Supplements: I hereby authorize and consent to the chiropractic evaluation and care of my child. Parent/Guardian Signature Date
2 The Pregnancy Process During the pregnancy process, did the mother: O Take medications? Type O Smoke or consume alcohol or drugs? O Experience any illness? Type O Undergo a lot of stress? O Receive ultrasounds or other radiation The Birthing Process Birthplace: O Home O Hospital O Birthing Center Type of Birth: O Vaginal O C-Section O Cephalic (head first) O Breech (feet first) Procedures: O Forceps O Vacuum Extraction Birth Assistants: O M.D. O Midwife O Doula What was the child s gestational age at birth? How long did labor & delivery last? hours How long did you push? hours What was the child s birth weight? How many inches long? Final APGAR score: What was the mother s position during labor? O Back O Side O Sitting O Standing Did the mother have an episiotomy? O Yes O No Was labor chemically induced? O Yes O No Was your child Fed O Breast Milk O Formula O Cow s Milk Were any drugs administered during the labor process (IV, epidural)? O Yes O No Was your child subjected to any of the following? O Silver Nitrate eye drops O Incubation (how long?) O Vitamin K injection O Hepatitis injection O Separation from mother (how long?)
3 Vaccinations Have you chosen to vaccinate your child? O Yes O No Is your child on the recommended vaccine schedule or on a delayed schedule: Please check all vaccinations received: O DPT O MMR O Polio O Chicken Pox O Hepatitis O Flu O Other Describe any reactions to the vaccine(s): Growth and Development At what age did your child perform the following: Follow an object Respond to sound Hold up head Vocalize Sit unassisted Teethe Crawl Walk Prior accidents or trauma Is your child accident-prone? Has your child: Been hospitalized/surgery? O No O Yes: Had a severe fall? O No O Yes: Been in a car accident? O No O Yes: Any child traumas resulting in bruises, fractures, or stitches? Social History Average number of hours your child watches television, plays on the computer, or plays electronic games each week, if any? Approximate hours of playtime each week Any sports participation and age began? Do you feel that your child s social and emotional development is normal for their age? (Please explain) Average hours of sleep per night: Any night terrors, sleep walking, difficulty sleeping? Is a school backpack used? (Heavy or Light)
4 Dietary History Does your child consume?: O fruits (organic is best) O vegetables (organic is best) O lean meats and fish O nuts O omega 3 fatty acid supplement O probiotics O caffeine O soda O sugar O artificial sweetener O fast food O processed foods Health History Has your child experienced any of the following? O vision problems O irritability O pink eye O attention problems O constipation O hyperactivity O headaches O skin problems O ear problems O frequent colds O asthma O bedwetting O sleeping difficulty O breathing problems O tubes in the ears O digestive problems O colic O other
5 Patient HIPAA Consent Form Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to de ne situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its sta. I authorize the use of my full name for the purpose of greeting me, announcing me into a room, or around the office in the presence of others. This is effective as of April 14, 2003 and remains in effect until further notice. I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician s certificates. I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and disclosed. Signature Date Insurance Policy 1. The privilege of insurance is conditional on receiving all of the necessary information to process claims. 2. Deductible payments must be made directly to Align Chiropractic Wellness Center for chiropractic services rendered until deductible is met. 3. All co-payments are due at the time of service. If co-insurance payments are indicated on an Explanation of Benefits, the co-insurance is due at the time of notification. A co-payment is the amount an insurer may require to be paid per visit out- of- pocket from the subscriber (patient). A co-insurance is a percentage amount of the office fee to be paid by the subscriber (patient) to the provider, 4. Align Chiropractic Wellness Center, LLC will verify benefits at the patient s request. Verification of benefits is not a guarantee of payment for services. 5. The office will submit insurance claims directly to your insurance company. 6. The insurance policy is a contract between the patient (subscriber) and the insurer. If our office (the provider) has difficulty with your insurer we will require your assistance to obtain details and information. If information is not forthcoming then the privilege of accepting assignment will be terminated. 7. There is no promise of payment by an insurance company made by this office. Any services not paid by the insurance company will be transferred to the patient. As reimbursement rates and coverage of policies tend to vary from month to month, we cannot be responsible for changes in your coverage. 8. It is the goal of the office to provide you with the finest quality chiropractic care possible. However, insurance policies accommodate only symptom care and corrective care. They do not cover maintenance care. Care beyond correction of posture or symptom care is frequently considered maintenance by insurers. This will become patient responsibility for payment. 9. Certain insurers may reject claims or coverage stating a lack of medical necessity or no coverage for children or certain diagnosis. The patient will then be held responsible for these unpaid charges. Signature Date
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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
David L. Rothman, dds Pediatric Dentistry
Complete forms, print out and sign. Bring completed forms to your office visit. 1/7 pages Name: nickname: Sex: Male Female Birthdate: age: School: Is this your child s first dental visit? Yes No Is this
IDENTIFYING INFORMATION
IDENTIFYING INFORMATION Child s Name: Date of Birth: Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Mother s Name: Father s Name: Email Address: Siblings: Languages Spoken at Home: Caretaker
Patient s Name: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip:
PATIENT INFORMATION: Patient s D.O.B: Age: Social Security: Height: Weight: Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: Home Phone: Cell Phone: Work Phone: Email
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 #: (
PHARMACY INFORMATION
NAAMAN CLINIC TODAY S DATE: Prefix Mr. Mrs. Miss Ms. Dr. Preferred Name: Patient s Name Address: First Middle Last Street & Apt # City State Zip SS# Birthdate Age: Sex: Female Male Marital Status: Single
PATIENT INFORMATION. First:
PATIENT INFORMATION Patients last name: First: MI: Street Address: PO Box: Birth date: / / City: State: Zip Code: Marital status: Sex: Male or Female Social Security: 1st phone: 2nd phone: Email address:
MACRI DENTAL LLC 4380 S. Syracuse St. Suite 502 Denver, CO Patient Registration Form
Personal Information Patient Registration Form Responsible Party First Name Initial Last Name Patient First Name Initial Last Name Address City State Zip Home Phone Work Cell Birthday Social Security Email
PATIENT REGISTRATION / INFORMATION SHEET
PATIENT REGISTRATION / INFORMATION SHEET Name: LAST FIRST MIDDLE Date of Birth: Gender: M F Marital Status: Social Security Number: Email Address*: Street Address: City: State: Zip: Home Phone: Cell Phone:
New Patient Registration Form
New Patient Registration Form PATIENT INFORMATION Last name: First Name: Middle Initial: Marital Status: Single Married Divorced Other Social Security #: Birth Sex: M F Street Address: City: State/Zip
PATIENT INFORMATION. Child s Name: DOB: Address: Phone: Zip: School: Emergency Contact: Phone: Relationship to Patient:
PATIENT INFORMATION Child s Name: DOB: Address: Phone: Zip: School: Father s Name: Occupation: Phone: (work) Email Address: Mother s Name: Occupation: Phone: (work) Email Address: DOB: Social Security
*PLEASE PROVIDE COPIES OF YOUR DENTAL ID CARD AND DRIVERS LICENSE*
DR. MILES MAZZAWI DR. ANTHEA DREW MAZZAWI DR. NIRALI PROCTER 205 Waleska Rd. Suite 2-B Canton, GA 30114 (770) 479-1717 Today s Date: / / We are so pleased to welcome you and your child to our practice!
Winthrop Orthopaedic Associates, PC
Pediatric Demographic and Insurance Information Form PATIENT INFORMATION: Child s Name: Date of Birth: Age: Sex: Social Security #: Phone Number: Reason for office visit: Referred by: Child s pediatrician:
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