Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet
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1 Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet Date Name: Address: City: State: Zip: Social Security Number: Home Phone: ( ) Cell Ph.: ( ) Work Ph.: ( ) Gender: M F Date of Birth: Age: Marital Status: S M D W Work Status: Full time Part time Retired # of Children Employer: Occupation: Employer Address: City: State: Zip: Name of Spouse or Partner. For Minors, Name of Parent or Guardian: Age: Employer: Occupation: Employer Address: City: State: Zip: Work Phone:( ) In case of emergency contact: Relationship: Do you have Medicare insurance? Y N Plan/Group #: List chiropractors you have seen previously How did you find us, and may we thank someone for referring you? 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 health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 1
2 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand how my PHI will be used and I agree to these policies and procedures: Consent to Services: I authorize Dr. Anne C. Roulo to perform examinations, diagnoses, x-rays (when necessary), chiropractic adjustments, physiotherapy, and other appropriate health care procedures. I will have the opportunity to ask questions about the nature and purpose of such procedures, and any possible risks and alternative procedures. I have the right to refuse any procedure. Cancellation Policy We expect that you will give 24 hours notice when cancelling or rescheduling an appointment. - Late cancellations will incur a $25 fee. The fee will be waived if the appointment is rescheduled and kept within one week. Emergency situations or extenuating circumstances will be dealt with on a case by case basis. - Missed appointments will be charged the full price of an adjustment. I understand that payment is due in full at time of service unless prior arrangements have been made. Fees are based on upon individual services and may vary from visit to visit. I agree to pay in full at the time of service and will file my own insurance. Reimbursement is determined by my contract with my insurance company. 2
3 Health History: Habits: Drinks/day Alcohol Tobacco: Packs/day Soda/diet soda Stress level: High Mod Low Coffee/tea Sleep: 8+ hrs 6-8 hrs 4-6 hrs < 4 hrs Sweetener Exercise: 5-7x/wk 3-5x/wk 1-3x/wk Water intake 64+ oz oz none Type (per day) oz 8-16 oz Meals/day: < 8 oz Veggies and fruits/day: glass = 8-12 oz Diet -Do you feel your diet is adequate? Y N -Are you on a special diet or particular diet? Y N If yes explain -How long has it been since you felt really good? Days Weeks Months Years >10 years -What is your general state of health? Excellent Good Fair Poor -Please rate how serious you are about getting well (scale of 1-10) -Please rate how serious you are about staying well (scale of 1-10) -Are you willing to follow a treatment plan designed to help you return to health? Y N -Are you willing to take supplements and make dietary changes? Y N Medications: Please check and list all medications that you are currently taking with the date you began taking them. Medication Name Date Started Antacids Antibiotics Anti-depressants Anti-diabetics Anti-inflammatory Blood pressure lowering meds Cholesterol lowering meds Hormone Replacement (HRT) Oral contraceptives Over-the-Counter Other Other Do you take vitamins/supplements or herbs? Y N Please list: Allergies: Please list all allergies. Food: Medications: Seasonal/Other: 3
4 Please list any surgical procedures, hospitalizations, and automobile accidents or other traumas. Please mark with an X any illnesses that you have now or have had in the past. Also, identify any conditions your family members have now or have had in the past. G = Grandparents, M = Mother, F = Father, S = Siblings Arthritis Blood pressure problems Heart disease Anemia or other blood disorder Diabetes or hypoglycemia Kidney disease Bladder problems Gall bladder problems Hepatitis Colon disease Ulcers Headaches Emphysema Gout Asthma Pneumonia Tuberculosis Muscle disorders Neurological Problems Immune system problems Tumors: non-cancerous Cancer HIV/AIDS Anxiety Cold sores Alcoholism Drug Abuse Deep vein thrombosis Epilepsy Stroke Osteoporosis 4
5 Symptoms: Please mark P (past) or C (current), and circle any that are of particular concern to you. General Convulsions Confusion Dizziness Fatigue Loss of sleep Loss of weight Nervousness Numbness Sweats Weakness in limbs Fever Pain Over Stomach Constipation Diarrhea Colon Trouble Hemorrhoids Liver Trouble Jaundice Gall Bladder Trouble Asthma Frequent Colds Enlarged Thyroid Tonsillitis Sinus Trouble Muscles and Joints Twitching Stiff Neck Backache Swollen Joints Tremors Foot Trouble Painful Tailbone Pain between Shoulders Hernia Spinal Curvature Gastro-intestinal Poor Appetite Poor Digestion Excessive Hunger Belching Foul Gas Nausea Vomiting Vomiting or Blood Women Only Painful Periods Excessive Flow Irregular cycle Hot Flashes Cramps or Backache Miscarriage Vaginal Discharge Fertility Problems Pregnant? Yes No Nursing? Yes No Cardiovascular Rapid Heart Slow Heart High Blood Pressure Low Blood Pressure Pain over Heart Stroke Poor Circulation Ankle Swelling Hardening of Arteries EENT Poor Vision Crossed Eyes Pain in Eyes Deafness Earache Ear Noises Ear Discharge Nasal Obstruction Nose Bleeds Sore Throats Horseness Hay Fever Skin Skin Eruptions Itching Bruise Easily Dryness Boils Sensitive Skin Eczema Varicose Veins Respiratory: Chronic Cough Spitting Blood Spitting Phlegm Chest Pain Difficulty Breathing Genito-urinary Frequent Urination Painful Urination Blood in Urine Kidney Infection Bed Wetting Inability to control urine Prostate trouble Decreased Libido Health Concerns: Please list your top health concerns in order of priority
6 What type of treatment are you looking for? Please check all that apply. I am looking for the most minimal amount of care to patch up the symptoms of my condition. I am looking to resolve my symptoms, and then go on to address the cause of my condition. I am looking to resolve my symptoms, achieve optimal health, wellness, and disease prevention. Please check all that apply: I have a health condition, I am concerned and I don t know what it is. I have a medical condition and am receiving medical treatment and am unhappy with my results. I have a medical condition and wish to enhance my medical treatment. I have been to other doctors and/or chiropractors and continue to have health problems and wish to see if Dr. Roulo s approach will help me. I am currently on medications/drugs and wish to get off them. If yes, have you suggested this to the prescribing physician? I am currently on medications/drugs and wish to stay on them. I wish to discontinue medical treatment and am seeking an alternative method. Primary Concern: Location and severity of pain: Indicate the location and type of pain on the drawing using the following symbols: Dull xxxxx Cramping ///// Sharp/stabbing Burning Tingling ///// Numbness On a scale of 1 to 10, with 1 representing minimal pain, and 10 representing unbearable pain, how would you rate your pain? -Is your concern a result from: an auto accident? an injury at work? another accident? -Has another doctor treated you for this condition? Y N When? -Type of treatment -Is this condition interfering with your: Work Sleep Daily Routine Recreation Other: -What do you believe is wrong with you? 6
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Welcome to Our Office! The following information is needed for our files so we can better serve you as a patient. Please fill in all portions of the term. If you need any help, please ask the receptionist.
Workers Compensation Demographic
Workers Compensation Demographic Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave Msg. Email Do
New Patient Intake Questionnaire
New Patient Intake Questionnaire NAME: DATE: / / BIRTHDATE: / / REFERRED BY: AGE: REASON FOR VISIT: LOCATION OF PAIN: BACK HIP BUTTOCK LEG FOOT RIGHT LEFT NECK ARM SHOULDER HAND RIGHT LEFT OTHER (DESCRIBE)
PATIENT REGISTRATION
PATIENT REGISTRATION Date: Patient Name Last First Middle Initial (Nickname) Home Address Street Apt# City State Zip ( ) Male ( ) Female Body part being evaluated Marital Status: ( ) Single ( ) Married
Patient Information: Last Name First Name MI. Address Apt/Room # City Zip. Community name (if not at home) Martial Status: S M W D
HouseCalls-MD 2998 W. Montague Ave. Suite 117 N. Charleston, SC 29418 Info@housecalls-md.com Office 843-501-2031 www.housecalls-md.com Fax 888-453-0810 Patient Information: Last Name First Name MI Gender
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single
WELCOME TO OUR OFFICE!
WELCOME TO OUR OFFICE! Name Date: / / Address City State Zip Home Phone Cell Phone E-Mail Birthdate Age SS# Race: Marital Status: M W D S Employer Work Phone Occupation Name & Birthdate of Primary Insured
Would you like to follow us on: Twitter Facebook Physician's Signature
PATIENT REGISTRATION INFORMATION TODAY S DATE: / / Last Name First Name MI Soc. Sec. # Date of Birth Sex Male Female Patient Address Apt. City, State, Zip Single Married Divorced Widow Home Phone Work
Patient Demographic Sheet
Patient Demographic Form Please PRINT Patient Demographic Sheet Last name First Name Middle Initial Date of Birth Social Security Number Gender Male Female Marital Status Married Single Divorced Life Partner
TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP DATE OF BIRTH
TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE MALE FEMALE DATE OF BIRTH EMAIL SOCIAL SECURITY # DRIVERS LICENSE # DRIVERS
SPOUSE/GUARDIAN (If patient is married, give spouse information. If patient is a child, give parent information.)
Please Fill Out Completely: Infectious Disease Specialists of Athens 1500 Oglethorpe Ave, Suite 300B Athens, GA 30606 Phone: (706) 559-4405 Fax: (706) 559-4773 Patient s Last Name First Name MI Social
PATIENT INFORMATION. Patient s Name: Birthdate: ( ) F ( ) M LAST FIRST MI. ( ) Married ( ) Single ( ) Divorced ( ) Separated ( ) Widowed Occupation:
UPON COMPLETION OF PATIENT REGISTRATION PACKET, PLEASE BRING ALL FORMS TO YOUR APPOINTMENT. YOU MAY ALSO FAX COMPLETED FORMS TO THE OFFICE AT 910-575- 9103. THANK YOU. PATIENT INFORMATION Patient s Name:
Workers' Compensation Demographic Form. Patient Information
Workers Comp Patient Demographic Workers' Compensation Demographic Form Please Print Clearly Patient Information Date of Visit Account Number Workers' Compensation Coordinator Patient Name (Last, First,
Patient s Name Home Phone # Last First Middle Would you like reminders sent here? Y N Cell # Address City State Zip
PLEASE PRINT PATIENT REGISTRATION DATE: Patient s Name Home Phone # Last First Middle E-mail: @ Would you like reminders sent here? Y N Cell # Address City State Zip Social Security # Birthdate Sex Marital
Achieving Health Clinic New Patient Information
Achieving Health Clinic New Patient Information Patient Cell# Home# Address City ST Zip E-Mail (please print) For massage appointment reminders do you prefer a: Text or Phone Call? Date of Birth Age Married
Retina Center of Oklahoma Demographic Information Sam S. Dahr,MD
Retina Center of Oklahoma Demographic Information Sam S. Dahr,MD PATIENT LAST NAME: FIRST NAME: MI: MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE: WORK PHONE: CELL PHONE: MARITAL STATUS: DATE OF BIRTH:
Flossmoor: (708) Harvey: (708) Tinley Park: (708) ICOR: (708) Crestwood: (708) Patient Signature:
Patient Information Guidelines Department of Outpatient Therapy Services Physical, Speech and Occupational Therapy The staff at Ingalls Outpatient Therapy Services Department is dedicated to providing
2200 Northern Boulevard, Suite 133 East Hills, NY Fax (516) Transitional Care
2200 Northern Boulevard, Suite 133 East Hills, NY 11548 855-670-6077 Fax (516) 918-9039 Transitional Care Dear New Patient: We welcome you to our practice as a transitional patient. We will be managing
Fullerton Physical Therapy and Sports Care, Inc.
Fullerton Physical Therapy and Sports Care, Inc. Patient Information: Title Address Patient Name (Last, First, Middle initial) City/State/Zip Home Phone Work Phone Cell Phone Social Security DOB Gender
Welcome and thank you for choosing Jerman Family Dentistry
Welcome and thank you for choosing Jerman Family Dentistry We provide dental services for the entire family. The following is helpful information to serve you better as a patient. If there are questions
PATIENT INFORMATION:
NEW PATIENT INFORMATION DATE: / / HOME PHONE: NAME: (First) (MI) (Last) ADDRESS: CITY: STATE: ZIP CODE: BIRTHDATE: / / Sex: Male Female Marital Status: S M D W Occupation: Work Phone: Employer: City &
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell