PATIENT INTAKE FORM. Age: Sex: Date of Birth: Address: City: Zip: Home Phone: Work Phone: Cell Phone:
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1 CA-Acu, Inc. 900 E. Katella Ave. Suite H, Orange,CA Shabnam Pourhassani, L.Ac 2901 Wilshire BLVD, Suite 233, Santa Monica, CA Newport Center Drive, Suite 145, Newport Beach,CA PATIENT INTAKE FORM Name: Date: Age: Sex: Date of Birth: Address: City: Zip: Home Phone: Work Phone: Cell Phone: Married Occupation: Divorced Widowed Employer: Single Separated Address: Reason for your appointment today: In Case of Emergency, Please Notify: Phone: Payment Information: Credit Card #: VISA MasterCard American Express Discover Expiration Date: Primary Care Provider: Address: Phone: Referral:
2 Name: Patient History Form Age: Present Health Concerns (in order of importance): Duration: MEDICAL/HEALTH HISTORY: Current Health Provider(s): Phone: Reason for seeing: ( ) ( ) ( ) Date last full physical exam: Results: normal other ( ) Date last labwork and urine test: Results: normal other ( ) Date last prostate exam (males): Results: normal other ( ) Date last PAP and pelvic exam (females): Results: normal other ( ) Date last mammogram (females): Results: Date last DEXA or bone imaging (females): Results: Surgeries and Hospitalizations with Dates: Illnesses and Injuries with Dates: Allergies (drugs, food, environmental). Please circle any, if life-threatening: Prescription Drugs (include dosage): Supplements: Previous Integrative Treatments: MEDICAL/FAMILY HISTORY: Condition Allergies Alcoholism Anemia Rheumatoid Arthritis Osteoarthritis Diabetes Cancer ( ) High Cholesterol Epilepsy Heart disease Self/Family Member Condition Kidney disease Mental disorder Obesity Stroke Thyroid (low/high) Osteoporosis Fractures (Mom/Grandma) Autoimmune Disease Bleeding Tendency High Blood Pressure Self/Family Member
3 SOCIAL HISTORY Personal Habits (Please List Current or Past Use, Frequency, and Quantity): Tobacco: Caffeine: Alcohol: Recreational Drugs: EXERCISE: List Type of Activities: Frequency per week: REVIEW OF SYSTEMS (please circle if you are experiencing any of the following symptoms): Hematologic: Gastrointestinal: Cardiovascular: Genitourinary: Gynecological: Anemia Bad breath Stroke Kidney Infection,/UTI Menopause Blood diseases Constipation Nosebleeds KD disease/stones/blood in urine Breast lump/discharge Fatigue, Dizziness Heartburn/ Ulcers Varicose veins Frequent/night time urination PMS Bleeding/bruising Hepatitis/Jaundice High/Low blood pressure Incontinence Age period started: Blood clots Diarrhea Chest pain Frequent, night time urination LMP Skin/Nails: Nausea, Vomiting Heart Disease Testicular pain/mass Periods last days Skin rash/hives Bitter taste in mouth Irregular heart beat Prostate problem Periods come every days Brittle Nails Rectal itching Swelling/edema Sexual dysfunction Pain with periods HEENT: Hemorrhoids Cold hands/feet STD Heavy menstrual bleeding Headaches Burping Varicose veins Systemic Review: No. of pregnancies Hearing loss Gas/Bloating Neuro-psychiatric: Hot flashes No. of children Ringing in the ears Cramping Tingling, numbness Excessive sweating No. of miscarriages Eye pain/itchy eyes Laxative use Weakness Excessive thirst No. of abortions Sore throat/allergies Blood in stools Eating disorder Fever/chills Vaginal discharge/itching Sneezing/runny nose Frequency of BM Seizures Respiratory: Currently pregnant? Yes/No Nosebleeds Consistency of stool Paralysis Tuberculosis Endocrine: Sinusitis/allergies Musculoskeletal: Poor balance Asthma/wheezing Hair loss/thinning Jaw pain(tmj) Difficulty walking Poor memory Difficulty breathing Dry skin Mouth/tongue sores Muscular pain/weakness Poor concentration Cough Hormone therapy Catches colds easily Joint pain/stiffiness Depression, anxiety Pneumonia Sleep: Hours/night: Bedtime: Waketime: Do you have problems with: Staying asleep Falling asleep Other sleep issues Do you wake up at night? If yes, how often and at what times does this happen? Energy level (average per week, circle one): (lowest energy) (highest energy) Stress level (average per week, circle one): (lowest stress) (highest stress) Sources of stress: How do you cope with stress? Pain Scale (circle areas and level of pain): (lowest pain) (highest pain) Please check all that apply: Pain is: Dull Sharp Diet History (include any liquids, tea, coffee, etc.): Breakfast yesterday: AM Snack foods: Lunch yesterday: PM Snack foods: Dinner yesterday: Late PM Snack foods: Bars/Shakes: Glasses or Ounces of plain water intake/day: Please List Any Dietary Restrictions: What level of change to your living habits are you willing to make to improve your overall well-being? Whatever It Takes Significant Change Some Change No Change X Patient / Guardian Signature Date
4 Please write down all the medications that you are currently taking at home. Please include any homeopathic/herbals or non prescription medications. Medication Dosage/Strength How Many Times/Day Pharmacy (name and number):
5 Consent I, consent and agree to the Treatment and Supplements recommended for me by the practitioners at the CA-Acu, Susan Inc. Samueli from the Center following for choices: Integrative Medicine from the following choices: d General Diagnostic Procedures including physical exams, neurological and musculoskeletal assessments, tongue and pulse assessment. Lifestyle Counseling and Exercise Prescriptions. Herbs/Natural Medicines prescription of various therapeutic substances including plants, minerals, and animal materials. Substances may be given in the form of tea, pills, powders, essences, essential oils, tinctures (may contain alcohol), plasters, and topical creams. Dietary Advice and Therapeutic Nutrition use of foods, diet plans, and nutritional supplements. Soft Tissue Therapy use of tui na and acupressure. Electric/Infrared/Ultraviolet Therapies includes the use of low volt electroacupuncture, transcutaneous stimulation, microcurrent stimulation, electromagnetic wave therapy, and infrared and ultraviolet therapies. Acupuncture insertion of specialized sterile needles through the skin into underlying tissues at specific points on the surface of the body. Cupping a technique used to relieve symptoms in which cups made of glass are placed on the skin with a vacuum created by heat or other device. Gua Sha rubbing on an area of the body with a blunt, round instrument. Potential benefits: Restoration of health and the body s maximal functional capacity, relief of pain and symptoms of disease, assistance in injury and disease recovery, and prevention of disease or its progress. Results cannot be guaranteed. Research has shown acupuncture to be effective in approximately 70% of the general population. Potential risks: fainting, dizziness, discomfort, pain, infection, discoloration, bruising or burns from needle insertions, cupping, topical procedures, heat therapies, drug/herb interaction side effects, allergic reactions, nausea, loose bowel movements, and abdominal cramping from prescribed herbs or supplements or dietary advice; and soft tissue or bone injury from soft tissue therapy; and aggravation of pre-existing symptoms. Adjunctive Care: Our practitioners solely provide adjunctive care and are not available after business hours. If you experience an adverse reaction to any recommended supplements or treatment, please immediately contact our practitioners during business hours. If our practitioners cannot be reached, please discontinue the supplements and leave a voic .
6 You will be contacted on the next working day. If you are experiencing an acute condition, severe, adverse reaction, or emergency situation, please either contact your primary care physician or call 911immediately. You are expected to have a primary care medical physician follow your care at all times. Our practitioners are not responsible for any hospital coverage, after hour, weekend, or general medical care you may seek. History: Completely fill the Wellness History Form. Alert our practitioners if you suspect or know that you are pregnant since some of the therapies could present a risk to pregnancy. Our practitioners do not use labor-stimulating acupuncture points or any labor-inducing substances unless the treatment is specifically for the induction of labor. A treatment intended to induce labor requires a letter from a primary care provider authorizing or recommending such a treatment. Alert our practitioners if you have a cardiac pacemaker since electro-therapies may be contraindicated in this case. Photographs may be taken before, after, and with each follow-up visit/treatment. I understand the Benefits, Risks, Limitations, and Precautions described herein. I will abide by all instructions and precautions in order to achieve optimal results. I take full responsibility for my health during treatments and hold the practitioners free from any legal actions. The maximum damages in case of any valid dispute will be the refund of my treatment fees. I voluntarily consent to the recommended treatment and/or supplements realizing that no guarantees have been given to me by the practitioners regarding the cure or improvement of my condition. I have read the above information and have had all my questions answered to my satisfaction. Name: Signature: Date: / / Witness Name: Signature: Date: / / SUSAN SAMUELI CENTER FOR INTEGRATIVE MEDICINE SW Birch Street, Suite 190 Newport Beach, Ca CA-Acu, Inc. 900 E. Katella Avenue,Suite H, Orange, CA Wilshire Blvd,Suite 233 Santa Monica, CA Newport Center Dr. 145, Newport Beach, CA 92660
7 CA-Acu, Inc. CANCELLATION POLICY FOR SERVICES As part of our effort to provide you with the best of care and accommodate all appointment requests, we have implemented a Cancellation Policy. We appreciate your business and know that your time is as valuable as ours. If you are unable to keep your appointment, please call us as soon as possible, so that we may help another patient in your place. If you are calling after hours, you may leave us a message on our voice mail system to cancel or reschedule your appointment. If you will be late for your appointment, please call us so that we may advise you if you can be accommodated, or if we will need to reschedule you. As all services are provided by appointment only, we ask you for a minimum of 24 hours notice. If you do not notify us, you will be billed for THE FULL AMOUNT of scheduled services. We do understand that emergency situations may arise, please share that with us when you call and they will be handled on an individual basis. We will attempt to confirm all appointments in advance, however, this is done as a courtesy and the responsibility of canceling an appointment remains with the patient. I have read the above cancellation policy and agree to its terms and conditions: Name: Date: Signature:
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Name: Date of Birth: Age: Address: City State Zip
Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?
New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
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HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
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NEW PATIENT HEALTH HISTORY
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
LAKES INTERNAL MEDICINE
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MGH Beacon Hill Primary Care New Patient Form
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Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology
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CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below.
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Scottsdale Family Health
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Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
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Today s date: Mr. Miss Mrs. Ms. Dr. Birth date: (mm/dd/yy) Social Security Number: First name: Last name: Age: Email: Marital status: Single Divorced Married Separated Partner Widowed Street address: Apt: