Posture Performance & Wellness

Menu

Home
About us
Patient Resources
Contact Us

Menu

Home
About us
Patient Resources
Contact Us

Menu

Home
About us
Patient Resources
Contact Us

Patient Information and Condition Form

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Date

Birth Date

Age

Gender

Driver's License Number

State

Patient's Email *

Father's Name

If you are under 18 years of age, then please enter your father's name.

Father's date of birth

Father's Phone number

Mother's Name

If you are under 18 years of age, then please enter your mother's name.

Mother's date of birth

Mother's Phone number

Guardian's Name

If you are under 18 years of age, AND NOT WISH TO ENTER YOU PARENT'S DETAILS, then please enter your Guardian's name.

Who do you normally live with?

Father and Mother
Father
Mother
Legal Guardian
None of these

Marital Status

How many children?

Selected Value: 0

Street

Enter your Current Address

City

Enter your Current Address

State

Enter your Current Address

ZIP

Enter your Current Address

Phone

Enter your Current Address

Street

Other addresses where you reside, if applicable (e.g., parent's home, any other address where you regularly reside)

City

Other addresses where you reside, if applicable (e.g., parent's home, any other address where you regularly reside)

State

Other addresses where you reside, if applicable (e.g., parent's home, any other address where you regularly reside)

ZIP

Other addresses where you reside, if applicable (e.g., parent's home, any other address where you regularly reside)

Phone

Other addresses where you reside, if applicable (e.g., parent's home, any other address where you regularly reside)

Your Occupation

Employer

Work Address

Student At

Status

Name of Spouse

Spouse's date of birth

Spouse's Occupation

Spouse's Employer

Spouse's Work Address

Work Phone

Spouse is a Student At

Status

Relationship of Emergency Contact to Patient

Who should we contact in the event of an emergency?

Phone

Who should we contact in the event of an emergency?

Address Of Contact Person

Who should we contact in the event of an emergency?

How did you learn about us?

Is your condition on injury due to an accident or work-related cause?

Yes
No

Date of Accident

Did the condition or injury result from automobile accident?

Yes
No

Did it result from a work-related accident or cause?

Yes
No

Describe Briefly

If accident was work-related

If the condition did not result from an automobile accident or relate to yur work, where did the accident occur?

Approximately when did your condition occur?

Describe your conditions, symptoms, or the purpose of this appointment.

Have you ever had the same or similar condition?

Yes
No

If Yes (above) when and describe

Healthcare Provider 1 Name

Please Indicate any other healthcare providers who you've seen for this injury or condition, and when you last saw them

Healthcare Provider 1 Type of Practice

Date of Last Visit to Healthcare Provider 1

Healthcare Provider 2 Name

Please Indicate any other healthcare providers who you've seen for this injury or condition, and when you last saw them

Healthcare Provider 2 Type of Practice

Date of Last Visit to Healthcare Provider 2

Healthcare Provider 3 Name

Please Indicate any other healthcare providers who you've seen for this injury or condition, and when you last saw them

Healthcare Provider 3 Type of Practice

Date of Last Visit to Healthcare Provider 3

Date of Last Physical Examination?

What surgery have you had?

When did you had the surgery?

Serious illnesses or conditions?

When did you had the illness or conditions?

Have you been treated for any health condition by a physician in the last year?

Yes
No

If above is Yes, please describe.

What are the medications or drugs are you taking?

Have you ever suffered from?

Dizziness
Backaches
Heart Trouble
Diabetes
Hemia
Arthiritis
Headaches
Numbness
Asthma
Neuritis
Digestive Disorders
Nervousness
Sinus Trouble
Anemia
Cancer

Women Only : Are you pregnant or is there any possibility you may be pregnant?

Yes
No
Uncertain

Do you have Health Insurance?

Yes
No
Not Sure

Name of Insurance Company

Full Name Of Policy Holder

Policy Holder's Date of Birth

Health Insurance ID

Health Insurance Group Number

Does the policy holders have the insurance through his/her employer?

Yes
No

If Yes, who is the employer?

Attorney Name

Contact Info

I understand and agree that health and accident insurance policies are an arrangement between my insurance company and myself -- not between my insurance company and this office. I agree to pay my estimated patient responsibility and further understand that the estimated responsibility is neither a guarantee of payment by my insurance company, nor necessarily an accurate reflection of my actual responsibility as determined by my insurance company upon processing of my claims. In the event that my insurance company does not pay on my charges at the estimated rate or within a reasonable period of time, upon request of this office I will immediately pay the balance owing on my account unless otherwise agreed to in writing. I understand that an interest charge may appear on all accounts over 90 days. I further understand and agree, that if this office must take any action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse this office for all costs of such collection efforts, including, but not limited to, all court costs and attorney fees.I authorize this office to release any medical information relating to my treatment to any insurance companies which may be responsible for paying benefits to me, and to any attorney s who may be representing me due to my condition, and to complete any usual and customary reports and forms at no charge to assist in collecting from my insurance companies, attorneys, or other payers. I have read, understood, and agree to the foregoing. The information which I have provided is true and complete to the best of my knowledge.

Patients Signature

Date

PLANO SPINE CENTER

555 Republic Dr. ste 109
Plano Tx 75074

CONTACT INFO

Email: MichaelRashiddc@gmail.com
Phone: (972)693.4787

MENU

Home
About us
Patient Resources
Contact
Privacy / Terms of Service

SERVICES

Sports Injury Care
Weight Loss Guidance
Trigger Point Therapy Mastery
Holistic Wellness Approach
Personal Injury
Decompression
Digital X Rays

PATIENT GUIDE

Choosing a Doctor
Health Journals
Insurance Coverage
Talking to your Doctor
Medical Error

OPENING HOURS

Mon-Fri: 10am to 6pm
Sat: By Appointment Only
Sunday: Closed

Facebook Linkedin

© 2024 PLANO SPINE CENTER