Symptoms and Ill Health (Present State)

Similar documents
HEALTH. CENTER Main St NE, Suite 101 PO Box 507 Duvall, WA ph fax Dr. Jeffrey P. Metcalf

Welcome to our Chiropractic Office! P l e a s e P r i n t C l e a r l y a n d f i l l I n c o m p l e t e l y.

Patient Health Information Consent Form

Patient History. Name: Date: / / 20. Street Address: City: State: ZIP:

9129 Dickey Drive Mechanicsville, VA 23116

Welcome to the beginning of optimal health!

Welcome to the beginning of optimal health!

Initial Child & Adolescent Questionnaire

Welcome to Hatlen Family Chiropractic

NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:

W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c

WELCOME TO OUR OFFICE!

PATIENT INFORMATION & CONDITION FORM

Cooley Chiropractic. Date of Birth. Married Single Spouse Name. Street City State Zip. . Name. Occupation. Current Symptoms. When Symptoms began

Welcome to Pinnacle Chiropractic Spine and Sports Center

Welcome to Pinnacle Chiropractic Spine and Sports Center

Adult History Form. Patient Name Today s Date Birth Date Sex Weight Height Name You Go By Please Check Married Single

Patient Intake Form. Address City State and Zip

Welcome to Optimum Chiropractic & Wellness Center To The NEW PATIENT Outline of Procedures for Care And Consent to Initiate Care

May Family Chiropractic Health Information and Health History Patient Name: Gender: Male Female

Personal Injury Intake Form

Welcome to Fosston Chiropractic Clinic, P.A.

*Family Chiropractic Care* New Patient Information Worksheet*

PEDIATRIC HISTORY FORM

Fulcrum Orthopaedics Patient Registration Packet

Child Health History Form Whole Body Health

APPLICATION FOR CARE AT CHIROSOUTH SPINE & SPORT

MOTOR VEHICLE COLLISION QUESTIONNAIRE

Neck & Spine Patient Demographic

Fulcrum Orthopaedics Patient Registration Packet

Workers Compensation Demographic

1. Severity? (0-10) Duration? 2. Severity? (0-10) Duration? 3. Severity? (0-10) Duration?

Application for Care PATIENT DEMOGRAPHICS HEALTHCARE. Whom may we thank for referring you to this office?

NEW PATIENT REGISTRATION FORM

New Patient Registration Form NJR_NP_F100

WHY THIS FORM IS IMPORTANT

NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT MAILING DOCTOR S NAME: PLEASE EXPLAIN: DOCTOR S NAME: RESULTS:

Entrance Case History (Please write or print clearly)

PATIENT INFORMATION. Last Name: First Name: MI: Date of Birth: SS #: Gender: Male Female. City: State: Zip Code:

Don't forget to bring the following items to your appointment (if available):

Patient Name Age Date of Birth. Patient Address. City State Zip Code. Home Phone Cell Phone Work Phone

Patient s Name Home Phone # Last First Middle Would you like reminders sent here? Y N Cell # Address City State Zip

Achieving Health Clinic New Patient Information

PS CHIROPRACTIC PATIENT CASE HISTORY

Informed Consent for Chiropractic Care

DOUGLAS JAY SPRUNG MD, FACG, FACP The Gastroenterology Group

Patient s Full Name DOB Age. Patient s SSN Sex: Male Female Preferred Language. Place of Birth: City State Country

PATIENT INFORMATION. Address: Sex: City: State: address: Cell Phone: Home Phone: Work Phone: address: Cell Phone:

Patient: Gender: Male Female. Mailing Address: Ethnicity: Not Hispanic or Latin Hispanic/Latin Home Phone #:

Welcome to Rebound Sports & Physical Therapy!

Middle Initial: Street Address: City: Date of Birth: Age: Marital Status: Occupation: Employer: Name of Spouse: Emergency Contact:

Patient Name First Middle Last Address Street City State Zip Home Phone Work Phone Cell Phone. Date of Birth SS#

PATIENT APPLICATION FOR TREATMENT

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

SMG OB/GYN Lake Lansing St. Johns Returning Patient Questionnaire (Please print clearly and Fill out Entirely)

Spine Solutions By Donald Mackenzie, MD Relieving the pain Healing the spine Rejuvenating the person

PATIENT REGISTRATION FORM Please Print

New Patient Paperwork

PLASTIC SURGERY ASSOCIATES OF LEHIGH VALLEY MEDICAL HISTORY QUESTIONNAIRE (MR: )

Dodge. County. Schools

CURRENT HEALTH CONDITIONS

Surgical Associates of Central FL, PA 1181 Orange Avenue Winter Park, FL

PATIENT INFORMATION SHEET:

WITHOUT YOUR WRITTEN CONSENT, WE CAN NOT SPEAK TO ANYONE REGARDING YOUR MEDICAL CARE due to privacy laws. You have the right to list anyone you

PETER BOWER, M.D Rolkin Court, Suite 301. Charlottesville VA (434) F(434) Today's date. Name:

Anne C. Roulo, DC 7501 Murdoch Ave, Shrewsbury, MO, Patient Data Sheet

Age: Birthdate: Date of Last Physical exam:

Body Basics Physical Therapy Medical History

PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED. THANK YOU!

PATIENT INFORMATION FORM

Bellevue Neurology PATIENT DEMOGRAPHIC FORM

James B. Duke, MD PA Orthopedic Surgery 2300 SE 17 th Street, Suite 500 Ocala, FL

Rockrimmon Integrated Medical

2201 Murphy Avenue, Suite 307 Nashville, TN Phone Fax Date. Patient s Full Name

Welcome to University Family Healthcare, PA.

New Patient Intake Questionnaire

HNS Chiropractic New Patient Intake Form

Columbia Gorge Heart Clinic 1108 June St. Appointment date/time Hood River, OR fax Physician

Medications List. Allergies. Drug Name Dosage Directions Reason Taking

Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:

Patient Demographic Sheet

Pediatric New Patient Form

POTS Treatment Center 7515 Greenville Avenue, Suite 1005 Dallas, TX

Burton M. Sundin, M.D. / Reps B. Sundin, M.D. Date: Name (Last, First, MI): Address: Zip, City, State: Home#: Work#: Cell#: address:

Print Patient Name. Patient Signature

PATIENT REGISTRATION

MORGAN ROAD CHIROPRACTIC AND PHYSICAL MEDICINE PATIENT INFORMATION INSURANCE. How Did You Hear About This Office?

MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE

THE COUNSELING PLACE ADULT INTAKE FORM Yearly Family Income:

APPOINTMENT INFORMATION SHEET

PATIENT REGISTRATION FORM

PATIENT INTAKE PACKET

GRAHAM CHIROPRACTIC CENTER, INC. BRYAN GRAHAM, DC, CCSP

Patient Health Questionnaire - PHQ ACN Group, Inc. - Form PHQ-202 ACN Group, Inc. Use Only rev 7/18/05

DEMOGHRAPHICS INSURANCE INFORMATION

History Form. PAST SURGICAL HISTORY Surgeries/Hospitalizations Year Complications/Problems with anesthesia

DAHIYA FACIAL PLASTIC SURGERY AND LASER CENTER CONSULTATION AND MEDICAL HISTORY. Name Date of Birth Today s Date Address: Street City State Zip

Last Name First Middle. Mailing Address. City State Zip Phone. Date of Birth Age Soc. Sec# Cell. Employer Work Phone

Patient Registration Form

We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.

Transcription:

Name Date Address City State Zip Home Phone ( ) Work Phone ( ) Cell ( ) Date of Birth Age ( ) Referred by Friend/Family Yelp Google Other Search Engine Facebook Instagram Groupon Event PhoneBook Occupation Employer Marital Status Single Married Divorced Widowed Spouse s Name Spouse s Occupation Number of Children & Ages Have you ever received Chiropractic Care? Yes No When & Where Date of last X-ray Social Security # E-Mail Address Symptoms and Ill Health (Present State) Major Complaint Pain or problem started Pains are Sharp Dull Constant Intermittent (frequency) Does the pain radiate? Yes No What activities aggravate your condition/pain? What activities lessen your condition/pain? Is the condition worse during certain times of the day? Is this condition interfering with work? Sleep? Routine? Other? Is the condition getting progressively worse? Other Doctors seen for this condition Any home remedies? Other symptoms: Headaches Jaw Problems Neck Pain/Tension Back Pain Dizziness/Fainting Eye Problems Thyroid Issues Numbness in Toes Nervousness Lights Bother Eyes Pins & Needles in Arms Pins & Needles in legs Fatigue Ears Ring Shortness of Breath Hands or Feet Cold Depression Hearing Problems Night Sweats Stomach Upset Sleeping Problems Loss of Memory High/Low Blood Pressure Constipation/Diarrhea Irritability Loss of Smell Chest Pain Loss of Balance Allergies Loss of Taste Sudden Weight Gain/Loss Fever Please indicate where your complaint is on the following diagram: Please rate the pain on the following scale: No Pain 0----------1----------2----------3----------4----------5----------6----------7----------8----------9----------10 The Worst Pain Ever Have you been under drug and medical care? What medications are you taking? How Long? Have you had surgery? What When

Loss of Whole Body Health (Birth Present) Name Date Yes No Birth Process Forceps, C-Section, Breach/cephalic? Patient Comment Growth & Development Major childhood illnesses? Chronic Ear Infections? Sore Throats? Bedwetting? Accidents? Child abuse How? Other traumas? What? When? Yes No Did/do you smoke? Did/do you drink any alcohol Diet (do you eat healthy foods?) Have you been in accidents? Drugs? (Prescriptive or non-prescriptive) Exercise regularly? Did/do you have occupational stress? Physical stress? Mental stress? Hobbies/Sports injuries? Sleeping posture Side Stomach Back Other traumas or problems Chiropractic provides three types of care. The first is Initial Intensive Care which corrects the most recent layer of Spinal and Neurological damage (Vertebral Subluxation Complex). This care usually reduces or eliminates the symptoms. Then Reconstructive Care begins which corrects the years of damage that occurred when there were few symptoms. And finally, Chiropractic offers a genuine approach to Wellness Care. All of these options will be explained at your Empowerment Session. Then you ll be able to begin a course of care that fits your health goals. Patient Signature Date For 100% Office Use Posture Findings Bilateral Weight Scales Left Right Positive Ortho/Neuros 3 T s: Thoughts (mental/emotional stressors): Traumas (physical stressors): Toxins (chemical/environmental stressors): Health Goals

Introduction to the Office Let us extend a warm and personal welcome to you on behalf of the 100% team! We want to provide you with the finest health care and we ll offer you many informative and entertaining educational opportunities. First, you ll want to make informed decisions regarding your health. During the course of your care you ll be presented with several choices that will affect your ability to reach your individual health objectives. Secondly, this information will be useful in making decisions about your health for the rest of your life. To begin this process, here are a few important terms and procedures as you begin care: On your first visit we will gather information about you through our Initial Discovery (examination and consultation). There will be someone here to assist you in each step along the way. If you re not sure about what we need, just ask. Nothing will be done without your consent and full understanding. We will be giving you information and clinical data in the form of literature, personal and media presentations. These are designed to help you understand your own case and the procedures you ll experience in this office. Everything is brief and to the point. It is recommended that you read the material and keep it together for reference during the course of your care. Just as we need to know about you, you should know about us. Chiropractic education currently consists of three years of pre-chiropractic college education in the biological sciences, followed by another five years of Chiropractic education and clinical internship. Then we are required to attend many hours of post-graduate education each year for license renewal. On top of this, our office is frequently involved in various seminars to keep abreast of the latest information. We have minimized paperwork in our office. However, there are clinical forms that must be filled out accurately for your health, legal and professional reasons. We ask that you read a form through before completing it so you understand its intent. If you have questions, please ask. Your attitude about your health is as important to us as the specific reason you ve consulted our office. Below are four prevalent health attitudes. Please mark the one that most closely reflects your personal values. Treatment Only. I only consult a doctor when I have an ache or a pain and discontinue care as soon as it has cleared up. Prevention. In addition to symptomatic treatment, I consult specialists occasionally to prevent problems from recurring. Maintaining Health. I m conscious about my health, diet, exercise, etc. and actively pursue these because I feel better, perform better and it maximizes my potential. Family Health. I take an active part in assisting, informing, and maintaining health, with my family. I m concerned with the long-term affects of good health. Name Date

Terms of Acceptance When a person seeks Chiropractic care and we accept a person for such care it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent confusion. Adjustment: A specific application of forces to facilitate the body s correction of the vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spine resulting in nerve dysfunction, resulting in the lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease. Our focus in this office is the vertebral subluxation. However, if we encounter non-chiropractic or unusual findings we will advise you. If you desire advice, diagnoses or treatment for those findings we recommend that you seek another healthcare provider. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our ONLY practice objective is to locate, analyze and correct vertebral subluxation by specific adjustments. I, have read and fully understand the above statements. (print name) All questions regarding the chiropractors objectives to my care in this office have been answered to my complete satisfaction. I therefore accept care on this basis. Signature Date CONSENT TO EVALUATE AND ADJUST A MINOR I, being the parent or legal guardian of have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive Chiropractic care. Signature Date PREGNANCY RELEASE This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his staff have my permission to perform X-ray. Date of last menstrual period: Signature Date

Patient Privacy Acknowledgement 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 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 PHI to the minimum needed for what the insurance companies require for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time.. 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 affect 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 or office. 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 refused to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic practice has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Name of Patient: Date: Patient Signature: I acknowledge that I will receive a copy of my records on my second visit. Patient Should you agree to share your information with anyone, please list their names below.

2024 © careersdocbox.com Privacy Policy | Terms of Service | Feedback