New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, Office: (830) Fax: (830) NewBraunfelsWellness.
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1 New Braunfels Family Wellness Center 1135 West Mill Street New Braunfels TX, Office: (830) Fax: (830) NewBraunfelsWellness.com PATIENT INFORMATION DATE: Legal Name: Nickname: Address: City: State: Zip Code: Date of Birth: Age: SSN: Cell #: Work #: Home #: Occupation: Employer: Address: Marital Status: Married Single Widow Divorced Separated Spouse Name: If you have children, please list their name and age: How did you hear about our office? [] Referred [] Website [] Other If referred, by whom? Please check reasons for pursuing chiropractic care: [] I m continuing ongoing care from another chiropractor. [] I m interested in Wellness and Natural health care. [] I m concerned about my health and I m looking for answers. [] I have a specific condition that concerns me. HEALTH HISTORY Please list your symptoms below in order of importance and give date symptoms began. 1. Date 2. Date 3. Date Is this condition due to: [] Auto Accident [] Work Injury [] Other Accident [] Not Sure 1. Please describe what aggravates your symptom(s): Please describe what alleviates your symptom(s): 2. What is the nature of your symptom(s)? [] Sharp [] Dull Ache [] Burning [] Numb [] Tingling [] Throbbing 3. Does your symptom(s) radiate: [] Up [] Down [] Left [] Right [] Other 4. How often do you experience your symptom(s)? [] Constantly [] Frequently [] Occasionally [] Intermittently 5. Who have you seen for your symptom(s)? [] No One [] Medical Doctor [] Other Chiropractor [] Physical Therapist []Other 1 P a g e
2 6. Have you experienced this symptom(s) before? [] YES [] NO If yes, please tell us when it started and how often since then you have experienced it: 7. What tests have you already had for your symptom(s)? [] X-Rays []MRI [] CT Scan [] Lab Work [] None [] Other 8. Are you currently using any of the following: [] Medications []Drugs []Tobacco []Alcohol []Vitamins/Minerals/Herbs (IF YOU CHECKED ANY OF THESE PLEASE SEE NEXT PAGE TO LIST SPECIFICATIONS) 9. Physical Activity: [] Sitting 50% or more [] Light Labor [] Manual Labor [] Heavy Labor [] Exercise [] Repeated Motion PLEASE CHECK ALL OF THE FOLLOWING THAT APPLY TO YOU: [] HEADACHES/MIGRAINES [] HIGH BLOOD PRESSURE [] ALLERGIES FEMALES: Are you pregnant? [] ASTHMA [] CHOLESTEROL ISSUES [] DIZZINESS [] YES [] NO [] HIV/AIDS [] HEPATITIS A, B, C [] ACID REFLUX Please list below any surgeries you have had in the past: Date of Surgery What kind of surgery was it? What was the reason for this surgery? *If you have, or have had, any diseases please let us know what it is and when it presented itself: MEDICATIONS Please list all medications/vitamins you are currently taking including over the counter drugs. Also, list how long you have taken each drug and the condition for which it is taken. Date of Started Medication/Vitamin Name What is it being taken for? Dosage and how often? PRIMARY CARE PROVIDER Do you have a primary care physician [] Yes [] No. If yes, and your condition requires, we would like to keep your doctor informed about your condition and the care you receive at our office. If you have no objection to this, sign and date. Primary Physician s Name: City: Phone Number: 2 P a g e
3 PAST TRAUMAS The vast majority of our population has been involved in dozens of impacts that could cause vertebral subluxation. We would like to discover some of yours. Auto Accidents: Please list any auto accidents beginning with the most recent. Date Speed Location of Impact Any Treatment Chiropractic Care? Slips, Falls, Strains, or Broken Bones: Please list beginning with the most recent. Type of Trauma Date Describe Any Treatment Chiropractic Care? PEDIATRIC SECTION (Age 11 and younger) 1. Adopted? [] YES [] NO 2. Complications during pregnancy? [] YES [] NO If yes, please describe: 3. Drugs/Cigarette/Alcohol during pregnancy? [] YES [] NO 4. Location of birth? [] Hospital [] Birthing Center [] Home [] Other 5. Check any that apply: [] MOTHER INDUCED [] MOTHER MEDICATED [] CAESARIAN SECTION [] FORCEPS [] VACUUM EXTRACTED [] BABY GIVEN MEDICATION [] NICU STAY REQUIRED [] ICU FOR MOTHER REQUIRED 6. Breastfed? [] YES [] NO 7. Any complications during delivery? [] YES [] NO If yes, please explain: 3 P a g e
4 HOBBIES (past and present): SPORTS (past and present): GOAL QUESTION: If you could accomplish one important thing or mission in your life, what would it be? If chiropractic care works for you, what is something you would like to be able to do that you can t do, or have difficulty doing, now? Please read the following statement. By signing below you acknowledge that you have read and understand your obligations, and have been made aware of your right to privacy (HIPAA) provided by this office. In this document, I and my refer to the patient, and Chiropractor refers to New Braunfels Family Wellness Center. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself, NOT between New Braunfels Family Wellness Center and my insurance company. Furthermore, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for all payments. Payment is due at time of service. Thank you! I understand that the fee paid for x-rays is for analysis only. The film itself is the property of New Braunfels Family Wellness Center. Once films are used for treatment purposes, they cannot be released without proper written request, naming the physician who will have use of the films for two weeks. Patient Signature Guardian/Spouse Signature Date: Thank you for taking the time to fill out this form as accurately as possible. This information is crucial to your case and the doctor will be reviewing it very carefully and correlating this information with your x-ray and exam findings. We look forward to helping you and your family on the journey toward optimal health! 4 P a g e
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Denton Sanger Aubrey Patient Information Patient Registration Information Name: (First) (MI) (Last) Social Security #: Date of Birth: Address: Phone: City: State: Zip: Home Cell Work Alternate Phone: Email
Patient Registration Form
2130 South 17 th Street Suite 100 Lincoln NE 68502 Phone: 402-454-7454 Fax: 1-402-513-6547 (the 1 must be dialed when faxing to our office) Email: admin@genesispsychiatricgroup.com Patient Registration
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
NEW PATIENT CHECKLIST
80 Park Street, Attleboro, Ma 02703 508-223-2300 NEW PATIENT CHECKLIST If you need to see a physical therapist, you want to get the most out of each and every visit. Before you can show up for a visit,
1. PATIENT INFORMATION
Runnels Chiropractic 32 South 9 th Street - Richmond, IN 47374 (765) 96 CHIRO (24476) www.runnelschiro.com 1. PATIENT INFORMATION Today s _ Full Name SSN Age DOB Address City State Zip Height Weight Race
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
Was this the first time you heard of IPT? Therapist: PATIENT INFORMATION Home Phone:
1144 HWY 59 SUITE 3 MANDEVILLE, LA 70448 PH (985) 778-2540 FAX (985) 778-2542 Appt : Who referred you to IPT? Time: Was this the first time you heard of IPT? Therapist: Y N If no, where? Initials & of
New Patient Referral and Insurance Verification Form
New Patient Referral and Insurance Verification Form Today s Date: Prior Patient: Y N How did you hear about our practice? Physician: Dr., Internet:, Family/Friend:, Advertising:, Insurance:, Other:. Patient
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
Welcome to Southwest Diagnostic Center!
Patient Information Form PATIENT INFORMATION Welcome to Southwest Diagnostic Center! Name: Last Name First Name MI Address: City: SS # Email: State: Zip: Sex: M F Age: Birth date: Marital Status: Patient
ADDRESS CITY / STATE / ZIP CODE RACE/ETHNICITY WORK PHONE # ( ) ADDRESS MAY WE CONTACT YOU BY YES NO
PATIENT REGISTRATION Patient Information (please print) PATIENT NAME (last, first, middle) SOCIAL SECURITY # SEX: M F DATE OF BIRTH AGE ADDRESS CITY / STATE / ZIP CODE RACE/ETHNICITY HOME PHONE # CELL