Patient Health Summary
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- Alicia Anderson
- 5 years ago
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1 Patient Health Summary Patient Name: Birthdate: / / Sex: M F Address: City: State: Zip: CIRCLE which telephone # to leave appointment reminders or health related messages: Home: Work: Cell: Do you give permission to: Leave Health Related Messages? Send Text Messages? Married Single Partner Widow/Widower Number of kids Address: Parent/Guardian/Caregiver Name (for minor patient): Phone: Insurance Carrier(s): Policyholder s Employer: Policyholder s Name: Policyholder s Birthdate: Emergency Contact Name: Phone Number: Primary Care Physician: PCP Phone: Have you had chiropractic care before? Yes No If yes, for what issue? Whom can we thank for referring you to this office? Date Symptoms Began: Describe your current problem and how it began: Do you perform any repetitive movement in your work, sports, or hobby? Yes No If yes, please describe Is Your Current Problem? : Work Related Auto Accident Related Personal Injury None Current Pain Level TODAY (0 = No Pain and 10 = Unbearable Pain): In the past week, how much has your pain interfered with your daily activities (work, social activities, household chores)? (0= No interference to 10 = unable to carry on any activities): Do you exercise? Yes No What & How Much? Do you drink Alcohol? Yes No How many per day? How many ounces of water do you drink per day? Do you drink Caffeinated Beverages? Yes No How many per day? Family History: Cancer Diabetes High Blood Pressure Heart/Stroke Rheumatoid Arthritis Other:
2 Please list ALL MAJOR past illness/injuries (concussions, head injuries, cancer, broken bones, high blood pressure, car accidents, work related, etc.) you have had which did or did not require hospitalization, please include dates: Please list ALL major surgeries/operations. List when and where done and the name of the surgeon and if you have any remaining problems associated with these procedures. Please list ALL medications & nutritional supplements (including birth control pills, aspirin, vitamins, minerals) even if only occasionally. Include how often, dosage and how long you have been taking it. Please check any condition listed that applies to you: Contagious Skin Condition Open Sores/Wounds Easy Bruising Decreased Sensation Phlebitis Blood Clots Headaches/Migraines Sprains/Strains Swollen Glands Osteoarthritis Tendonitis Varicose Veins Fibromyalgia Fever Atherosclerosis Are you allergic to anything (medications, food, oil, lotion, etc.)? Yes No If yes, what? Do you smoke? Yes How much? How Long? No Women only: Are you pregnant or think you might be pregnant? Date of last menstrual period: Do you or have you suffered from any menstrual disorders? Yes No If yes, please describe:
3 Notice of Privacy Practices (HIPAA) and Release Authorization We would like to make you aware of how your Patient Health Information (PHI) is going to be used in this office, and your rights concerning that information and your health records. A full and complete Notice of Privacy Practices is posted on our practice website or can be requested from the office. 1) You, the patient, agree to allow our office to use your PHI for the purposes of treatment, payment, healthcare operations, and coordination of care. Examples include but are not limited to submission of PHI to third party insurance payers, and referring physicians. Our office will limit the release of all PHI to the minimum required information necessary. 2) You, the patient, have the right to examine and obtain a copy of your own health record at any time and request corrections. You may request to know what disclosures have been made and submit in writing any restrictions on the use of your PHI. Our office is not obligated to agree to those restrictions. 3) Your, the patient s, written request shall only need to be obtained one time for all subsequent care given from this date forward in this office. 4) You, the patient, may provide a written request to revoke consent at any time during care. This would be applicable from the date the request was received forward, but not to dates prior. 5) All staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce these procedures in the office. We have taken all precaution to insure your records are not readily available to those who do not need them. 6) You, the patient, have a right to file a formal complaint with Stelmack Pinpoint Health Care about any possible violations of these policies and procedures. 7) If you, the patient, refuse to sign this consent for the purposes of treatment, payment and healthcare office operations, our office has the right to refuse care. Authorization to Release Information: I authorize Stelmack Pinpoint Health Care to release any information including diagnosis and records of examination or treatment rendered to me to third party payers and/or health practitioners. Stelmack Pinpoint Health Care and/or members of the staff may contact me regarding appointments reminders, information regarding treatment alternatives, or other health related information. If contact is made by telephone, a message may be left on the voice mail or answering machine. I authorize and request my insurance carrier to pay directly to the chiropractor any insurance benefits otherwise payable to me unless other arrangements have been made with the doctor or staff (i.e. Medicare patients). I agree to be responsible for payment of all services rendered to me (or my dependent). I certify that I have read and understand the above information and agree to these policies and procedures. / / Signature Relationship to Patient Date
4 600 Hillgrove Ave Suite # 3 Western Springs, IL T: F: FINANCIAL POLICY Thank you for choosing Stelmack Pinpoint Health Care as your chiropractic physician office. We are committed to providing you and your family with the best chiropractic care. In our ongoing process to make sure that all your needs are met, our billing department will be available to discuss fees and this policy with you. Payments for all services will be due at the time services are rendered. In order to serve you better, we accept cash, check, Visa, MasterCard and Discover. As a courtesy to you, it is our policy to bill your insurance carrier, although you are ultimately responsible for the entire bill. As the responsible party, please understand: (Please initial the following) 1. Your insurance policy is a contract between you and the insurance company. We are not a party to that contract. Our relationship is with you, not your insurance company. We will not become involved disputes between you and your insurance carrier regarding deductibles, co-payments, covered charges, secondary insurance and usual and customary charges. As your medical provider, we will only supply factual information to facilitate claim processing. 2. Fees for services, which include unpaid balances, deductibles and co-payments, are due at the time service. Returned checks and unpaid balances may be subject to collection placement and collections fees. 3. All charges are your responsibility whether your insurance carrier pays or does not pay. If your insurance does not remit payment within sixty days, the balance will be due in full from you. If any payment is made directly to you for services billed by Stelmack Pinpoint Health Care, you recognize the obligation to promptly remit payment to this office. 4. You understand and agree that if you fail to make any of the payments for which you are responsible in a timely manner, after such default and upon referral to a collection agency or attorney, you will be responsible for all the costs of collecting monies owed, including court costs, collection fees and attorney fees. 5. The above does not apply for those patients that are considered Workers Compensation or Auto Accident claims. However, be advised that as a compensation or MVA patient, you may be held responsible for charges in the event that your claim is controverted. 6. We ask that you provide us with 24 hour notice of cancelled appointments, failure to do so will result in a $25 fee. You acknowledge this $25 fee will be incurred if you miss an appointment and do not provide 24 hour notice. We understand that financial problems may affect timely payment, so we encourage you to communicate any such problems to us, so that we may assist you in keeping your account in good standing. I have read and understand the above information and will be responsible for the patient listed below. Print Name of Patient: Date of Birth: / / Signature of Patient or Responsible Party / / Date
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PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very
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
Family History: Cancer Diabetes High Blood Pressure Heart Problems/Stroke Rheumatoid Arthritis
INITIAL HEALTH STATUS Sex M/F Patient Name: Birthdate: Age: Address: City: State: Zip: Phone ( ) Email: Occupation: Employer: Work Phone( ) Address: City: State: Zip: Subscriber Name: Health Plan: Subscriber
PRIMARY CARE PHYSICIAN
PATIENT INFORMATION OFFICE USE ONLY HIPAA No-Show form Patient Financial form Referral LRYGB / LVSG / LAGB / DOS: SELF LAST NAME FIRST ADDRESS CITY DATE OF BIRTH PLEASE LIST PREFERRED NUMBER OF CONTACT
CHIROPRACTIC PATIENT REGISTRATION AND HISTORY
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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):
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 INFORMATION PATIENT EMPLOYER INFORMATION GUARANTOR / POLICY HOLDER INFORMATION INSURANCE INFORMATION
Physician Name: David R. Lionberger, M.D. PATIENT DEMOGRAPHIC INFORMATION SHEET Last Name First Name Middle Social Security No. Date of Birth Age Male or Female (Please circle one) Marital Status: M S
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Today s Date: Height Weight Shoe size (CIRCLE) Allergies None Penicillin Sulfa Drugs Codeine Aspirin Tape Latex Iodine-Shellfish Other allergies: Medications SOCIAL HISTORY (CIRCLE) Do you smoke? No Yes
PATIENT INFORMATION. Street address: Social Security no.: Home phone no.: ( ) City: State: ZIP Code:
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Address: How did you hear about us? Name: Date of Birth: / / Address: City: State: Zip code: Phone Number: HOME - - WORK - - CELL - - EMPLOYER:
Date of Appointment: / / Email Address: How did you hear about us? Have you been seen here before? YES NO If YES, WHEN?: PATIENT INFORMATION Name: Date of Birth: / / AGE: SSN: - - GENDER: Male Female Marital
Name Social Sec. # Date of Birth Male/Female First MI Last. Address City State Zip. Home Phone Cell Phone . Employer Occupation Work Phone
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Acknowledgement of Receipt of Notice of Privacy Practices
Acknowledgement of Receipt of Notice of Privacy Practices **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. Signature For Office Use
PATIENT REGISTRATION FORM
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PHARMACY INFORMATION
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Registration Form. City: State: Zip: Birthdate: Marital Status: M S W D. Patient Employer: Occupation: Employer Address: Emp.
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Patient Full Name: E-Mail Address: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Emergency Contact Name/number: Occupation: Status: Employed Full Time Student Part Time Student
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
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
Dear Patient: Please complete this questionnaire. You answers will help us determine if chiropractic care can help you. Thank you.
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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
PATIENT INFORMATION SHEET
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Please list all current medications and supplements that you are taking:
PATIENT HEALTH AND MEDICAL HISTORY Today s Date: Chief Complaint for Today s Visit: Was this injury gradual or sudden onset? Date of sudden onset: Please explain: Do you have a history of present symptoms?
PATIENT INFORMATION. Patient s Full Name: (First) (Middle) (Last)
PATIENT INFORMATION Patient s Full Name: (First) (Middle) (Last) Birth date: Age: Race: Sex: [ ] Female [ ] Male Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed SS# Address: City: State:
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
TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A.
TEXAS PULMONARY & CRITICAL CARE CONSULTANTS, P.A. James T. Siminski, M.D., FCCP Donald L. Washington Jr, M.D. 1604 Hospital Parkway, Suite 403 Bedford, TX 76022-6932 (817) 354-9545 (817) 354-8157 Fax Thank
IMAGING CENTERS. Mammography Breast Ultrasound Bone Densitometry. MAMMOGRAPHY QUESTIONNAIRE (Please Print)
MAMMOGRAPHY QUESTIONNAIRE (Please Print) Date Physician Name SS #: Complete Address Birth Date Age Home #: Work #: For MAWC-IC Use : Acct# X-Ray# YES NO HAVE YOU EVER HAD A MAMMOGRAM? WHERE? YES NO ANY
Lasting Impressions Dentistry Sabrina Habib Heppe DDS, PS (206)
Personal Information Last Name First Name Pref. Name MI Mailing Address Apt # City State Zip Home# ( ) Cell# ( ) Sex: M F E-Mail: Confirmation of Apts by Email? Yes No Date of Birth / / SSN#: Marital Status:
INSURANCE INFORMATION
PATIENT INFORMATION Last Name First Name M.I. Marital Status: Married Single Divorced Widowed Social Security No.: - - Birth Date: / / Sex: M F Place of Birth: Driver s License Number: Preferred Language:
DEMOGRAPHICS. PATIENT INFORMATION Date Last Name First Name Middle Initial. Physical Address City State Zip. Mailing Address City State Zip
DEMOGRAPHICS PATIENT INFORMATION Date Last Name First Name Middle Initial Physical Address City State Zip Mailing Address City State Zip Sex Date of Birth Social Security # Home Phone Cell Phone Email
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
Welcome to Rosenman & Leventhal, P.C.
Welcome to Rosenman & Leventhal, P.C. Thank you for choosing our practice for all of your dermatological needs. Please have ALL of the attached paperwork filled out completely before arriving to our office.
Whom May We Thank for Referring You? Primary Care Physician. Insured/Responsible Party. Patient Information. Patient s Spouse/Guardian
Whom May We Thank for Referring You? Name: Other: Newspaper Radio TV Seminar Staff Yellow Pages Other Primary Care Physician Name: Address: Phone: Insured/Responsible Party Patient Information Name: Address;
Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -
New Patient Forms Today s Date: Name (Last, First, MI): Date of Birth: Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): _ Home Phone: _ ( ) Cell Phone: _ ( ) Work Phone:
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
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
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#:
Agape Physical Therapy and Sports Rehabilitation. Patient Name: Birthdate Social Sec.
INSURANCE INFORMATION As a courtesy to our patients, we will verify and file your insurance claim; HOWEVER, we cannot guarantee payment by your insurance company. We strongly suggest that you read your
Prefix Last First Middle Suffix. Maiden Gender SSN Marital Status Date of Birth
Prefix Last First Middle Suffix Maiden Gender SSN Marital Status Date of Birth Race Ethnicity Primary Language Address Line 1 Address Line 2 United States Zip City State Country Home Phone Cell Phone Work
CHIROPRACTIC 1 ST NEW PATIENT INFORMATION PATIENT INFORMATION
PATIENT INFORMATION INSURANCE INFORMATION Patient Name: : Address: Birthdate: Responsible for this account: Relationship to Patient: Insurance Co.: Group #: ID #: SS Number: Sex: M F Age: Employer/School: