By Karen E Johnson, RN, MPH, Naturopath

Save this PDF as:
Size: px
Start display at page:

Download "By Karen E Johnson, RN, MPH, Naturopath"

Transcription

1 By Karen E Johnson, RN, MPH, Naturopath

2 DISCLAIMER AcuColors does not provide medical advice, diagnosis or treatment. Content from AcuColors is not intended to be used for medical diagnosis or treatment. The information provided in this book is intended for general consumer understanding and self-improvement only. The information provided is not intended to be a substitute for professional medical advice. As health and nutrition research continuously evolves, we do not guarantee the accuracy, completeness, or timeliness of any information presented in this book.

3 AcuColors Objectives: 1. Discover an alternative way of healing with Acucolors. 2. Discover basic TCM Diagnostic methods to pinpoint meridian imbalances. 3. Learn how to apply colored light on the acupoints to heal the Body- Soul-Spirit levels. 4. Work through at least one health issue using the 3 Acucolors treatment techniques for whole holistic healing.

4 WHAT IS ACUCOLORS? AcuColors is a healing therapy that incorporates many of TCM concepts, such as Acupuncture & Iridology, to address the whole person in Body, Soul and Spirit. Colored light heals, restores function deep into the cells of the body, & releases hidden negative emotions.

5 ACUCOLORS works with: the WHOLE Person in Body-Soul-Spirit Physical Body: the Body is the physical vector which carries the Soul and the Spirit in this world. It needs nutrition and exercise to remain healthy and functional. It is subject to harm from accident or illness. Emotional Soul: The Soul is the psychological reflector of emotion. It can be portrayed as an aura around the outside of the body. Mind Spirit: The Spirit is our rational, intellectual director, or the mind. It is our beliefs and our standards by which we interpret situations and our connection with higher sources of information, or God.

6 The Meridians The Spirit, the information director, is located at the center of the meridian network of the body. Meridians are energy pathways that carry information from the Spirit to the Soul and to the Body. This communication is essential to good health. Any miscommunication leads to illness and is usually caused by conflict between the soul (emotion) & spirit (thought) and hidden negative emotions which cause energy flow blockages in the meridians.

7 FIVE PAIRED MERIDIAN PATHWAYS SPIRITUAL MERIDIAN NETWORK Liver/Gall Bladder Lv/GB Stomach/Spleen St/Sp Kidney/Bladder Ki/Bl MAIN SOUL EMOTION Anger Worry Fear PHYSICAL DISEASE TENDENCIES OF THE BODY Allergies, Anxiety, Aphasia, Chronic Fatigue, Convulsions, Dizziness, Eye & Ear issues, Fever, Gallstones, Hip pain, Hypertension, Leg arthritis, Meningitis, Migraines, Mood disorders, Muscle Atrophy, Nausea, Numbness, PMS, Rib pain, Sciatica, Shoulder pain, Stroke, Tinnitus, Weakness Anemia, Anorexia, Diabetes, Food Poisoning, GERD, Glaucoma, Hives, IBS. Dyspepsia, Indigestion, Joint & Bone pain, Knee pain, Menstrual cramps, Muscle Spasms, Nausea, PMS, Smell or Taste issues, Sty, Toothache, Ulcers, Urinary Tract infections Anorexia, Arthritis, Bladder infections, Edema, Epilepsy, Fatigue, Foot pain, Hearing & Speech issues. Hiccups, IBS, Impotence, Joint pain, Knee, Leg, Low Back Pain, Low Libido, Muscle spasms, Osteoporosis, Premature Graying, Prostatitis, Rapid Pulse, Reproductive issues. Hereditary weaknesses, Respiratory ailments, Sciatica, Sexual dysfunction, Systemic diseases, Tinnitus. Urinary disorders, Vertigo Lung/Large Intestine Lu/LI Heart/Small Intestine Ht/SI Sadness Love Acne, Allergies. Asthma. Bell s Palsy, Bronchitis, Cold symptoms, Congestion, Cough, Cough. IBS, Crohn s, Depression, Diarrhea, Dry Skin, Eczema, Elbow pain, Fatigue, Flu, Immune deficiencies, Itching, Learning disorders, Nasal Obstruction, Sinus infection, Sneezing, Sore throat, Stress, Toothache, Ulcerative Colitis, Upper Back pain, Anemia, Blood Pressure/Heart rate & rhythm, Celiac disease, Chronic Cough; Shoulder & Neck pain. Sore Throat, Fatigue, Insomnia, Mouth sores, Mumps, Neuralgia, Nightmares. Fever, Numbness in fingers, Poor Circulation in arms & legs, Poor Memory, Sweating, Swollen Glands, TMJ syndrome.

8 What happens if we repress a negative emotion? The repressed emotion blocks energy flow through the meridian channels of the body causing physical damage at the cellular level of the body. The negative emotion is trapped like being inside a fog. ACUCOLORS releases trapped emotions and opens up the blocked meridians allowing positive light energy to heal the cells of the body.

9 Part I Diagnostic Techniques Areas of Inspection: Fingertips Nailbeds Tongue Ears Eyes Face Meridian Measurement

10 Fingertip Testing 1. Press firmly in the middle of the last digit of each finger, just under the round fingertip pad. Sharp pain that makes you want to yell OUCH! is a positive response. 2. Follow the testing in this order: Left Hand (LH) ; Right Hand (RH) Check for Imbalance side to side. If sore fingers are not the same on LH or RH, then there is a Laterality imbalance and need Corpus Callosum treatment. 4. When there is a T o F difference top to bottom, such as hot hands and cold feet, then there is a Polarity issue and a Vertical treatment is needed. BODY SYSTEM SENSITIVE FINGER(S) REGULATING FUNCTION FINGER CHART BY BODY SYSTEM Lymphatic Lv GB RH & LH Thumb(1 st ) Immune support & eliminate toxins thru lymphatic system. Nervous Sp St RH & LH Index (2 nd ) Transfer info between nerves & muscles for movement Musc Skel Ki Bl RH & LH Middle (3 rd ) Transfer info between nerves & muscles for movement Endocrine Lu LI RH & LH Ring (4 th ) Gland & Hormone Regulation Blood Ht SI RH & LH Little (5 th ) Circulation of oxygenated blood to the vital cells & organs PROBLEM Congestion Degeneration Degeneration Dysregulation Stagnation

11 LATERALITY & POLARITY Horizontal (Side to Side) Treatment LOCATION: Corpus Callosum point, mid nose & upper lip. 20 sec on point INDICATION: Balances Side to Side. COLOR: Yellow Vertical (Top to Bottom) Treatment LOCATION: Hypothalamus points in line with the pupils midway between hairline & eyebrows. Also GV2 at top of buttocks fold. 20 sec each point INDICATION: Balances Top to Bottom. COLOR: L=Orange; R=Blue: GV2=Orange

12 NAILBED INSPECTION COLOR Yellow shows LvGB from impaired Lymph Drainage. Yellow, Green or Black can also mean a bacterial infection. Yellow with Pink base = Diabetes (SpSt) Blue indicates a weak heart. Blue-green shows a fungal infection. (HtSI) Red excess RBCs. If in nailbed, it confirms a heart problem. (HtSI) White could mean liver disease. ½ White ½ Pink = Kidney disease. Pale nailbed = Anemia (KiBl) ABNORMALITIES a. Longitudinal Ridges = FA deficiency, poor absorption of food, aging, kidney disorder, infection, arthritis (KiBl) b. Clubbing = depletion of O2 in blood, COPD, Celiac disease, IBS (LuLI) c. White spots = weak immune system d. Onychomycosis = systemic fungal e. Spoon nails = blood iron disorders

13 TONGUE INSPECTION COLOR NORMAL: pink, flexible with a think clear coat & moisture VIOLET: (LvGB:Anger) venous stagnation, slow blood circulation, poor oxygenation RED: (KiBl:Fear) fever, vitamin deficiency, dehydration; the more red the more inflammation or acidity. This causes Stomach and Kidney damage. PALE (LuLI:Sadness) = Blood deficiency, Low BP, hypothyroid, metabolic deficiency leading to cold hands & feet, dehydration. REGION Dehydration GERD

14 EARS For organ function & buried emotions, probe the organ points for pain. If painful, use the complementary color to release the buried emotion and heal the organ. ORGAN Bladder (Bl) Kidney (Ki) Gallbladder (GB) Liver (Lv) Large Intestine (LgI) Lung (Lu) Spleen (Sp) Stomach (St) Heart (Ht) Small Intestine (SmI) COLOR Green Red Violet Yellow Orange Blue Orange Blue Pink Turquoise Heart prob

15 EYES Hematogenic (Brown eye)-- Glandular, Lymphatic congestion (LvGB) 1.Chronic Stress Rings -fibers buckle 2.Radii Solaris -toxic waste dump 3.Cholesterol Ring= too much cholesterol in blood. Lymphatic (Blue eye)-- Allergies, Overactive immune system; Colds, Sinus, Respiratory infections, GI disorders; Arthritis, Adrenal, Kidney & Thyroid problems (LuLI) 1.Neurogenic fibers- CNS weak 2.Lymphatic Congestion mucous 3.Hematochromia-- LvGB Pancreas issues 4.Scurf Rim-dark ring around outside of iris=skin circulation issues. Use dry skin brushing to increase circulation. Biliary ( Green Mixed Blue with Brown eye)-- GI, GB issues; Pancreatic Blood Sugar issues; Diarrhea, Constipation, Flatulence (SpSt) 1.Polyglandular endocrine 2.Lymphatic Rosary-congestion 3.Uric acid-=gout 4.Ballooning in Nerve Wreath- excess gas, hiatal hernia

16 IRIS MAPPING

17 I RIDOLOGY P HOTOS R

18 Look for unusual: Eye Color Collarette size, shape, color Spots and where they fall drug toxicity? Scurf Rims Cholesterol Ring Radii Solaris Open Lesions White part of eye-dbl troicha sx of Ca Congestions (white)

19 Notice Size, shape of pupil High inflammatory areas in abdomen Amount of mucous

20 Green Eyes? High catarrh Double Troicha in sclera Irregular collarette

21 FACE INSPECTION OBSERVE FOR CHANGES IN: Color darkened areas, pigment changes Shape --asymmetry Skin wrinkles, swelling Meridian Zones any changes over meridian areas 1. CHEEKBONE Swollen Blue-White color=diaphragm & CNS). 2. EYE -inner corners Adenoids swollen, brown=chronic constipation, breast issues. Ki 3. NOSE - Red or swellings =Lu ; Red Nose tip=thyroid 4. UPPER LIP -(heart fold) =Lighter & retractions are cardiac signs. 5. R LOWER LIP - swellings =Lv. 6. CENTER CHIN = pancreas. Pc includes genitals 7. L LOWER LIP =Sp. 8. LIPS = Narrow tight lips =mesenchymal issues. SI LI 9. CENTER UPPER LIP Acid folds of gas, bloating, metabolism- St 10. CENTER BROW Conflict Acid folds from stress & conflict. LvGB

22 MERIDIAN MEASUREMENT

23 Part II TREATMENTS Traditional Chinese Medicine (TCM) does not treat individual health conditions since they are only symptoms of greater energy imbalances in the body. 1. The Regulatory Treatments resynchronize the overall 5 paired meridian systems. (Section 1) 2. Treating specific health issues (A-Z) releases negative emotions in targeted organs. (Section 2) 3. Rebalancing the meridian systems cures the disease. (Section 3)

24 SECTION 3: MERIDIAN BALANCING REBALANCING THE MERIDIAN SYSTEMS CURES THE DISEASE. Meridians are energy pathways that link the outside physical body to the inside spirit body. The meridians are closely linked to the nervous system and the nerve pathways that feed every organ and part of the body, yet they also control the flow of chi throughout the whole body-soul-spirit. When a meridian is out of balance, symptoms will show up. From 5 Paired Meridian Pathway table, MigHA are from LvGB imbalance. HOW TO BRING MERIDIANS INTO BALANCE: Meridian Tracing: A good way to balance the meridians is tracing the meridian pathways. Trace the pathway either by using a bingo magnet pointing the negative pole toward the skin to sedate, or by using the cool color. Each meridian has 2 sides--right and Left. Stroke both sides of each meridian in the cool color blue to sedate over-activity such as diarrhea, starting at RED and ending at GREEN. Stimulate an underactive bowel, or constipation, using the warm color orange tracing the Large Intestine meridian, beginning at GREEN and ending at RED. Sedate Strong Points-- Sedate strong points with a cool color or using magnet with (-) end toward skin. Stimulate Weak Points Tonify weak points with a warm color or using magnet with (+) end toward skin. Side to Side Balancing: this is done using complementary colors. For example, the Liver meridian has been detoxified. Now to balance the meridians, Violet is used to trace the Left side of the Liver meridian and Yellow on the Right.

25 LIVER-GALL BLADDER Anger is a powerful emotion that may produce migraine HAs, eye problems, myopathy or tendinitis. Meridian Underactive Warm Color Overactive Cool Color Liver Yellow Violet Gall Bladder Yellow Violet

26 STOMACH-SPLEEN Ever heard of the Worry-Wart that ends up with stomach ulcers? Meridian Underactive Warm Color Overactive Cool Color Stomach Orange Blue Spleen Orange Blue

27 KIDNEY-BLADDER Fear and anxiety are common in young children and can even be transferred from the parents to the unborn child while in the womb. Meridian Underactive Warm Color Overactive Cool Color Kidney Red Green Bladder Red Green An additional step, stroking 5 times on the Kidney/Bladder lines on the feet can clear unwanted antepartum emotions. 1. Kidney Line 5x 3 rd toe to heel on bottom of L&R foot Orange 2. Bladder Line 5x 5 th toe bunion to heel on side of L&R foot Yellow

28 LUNG-LARGE INTESTINE Grief or sorrow will settle in the lungs. Meridian Underactive Warm Color Lung Orange Blue Large Intestine Orange Overactive Cool Color Blue

29 HEART-SMALL INTESTINE The Heart should be full of Unconditional Love. This meridian should never be out of balance. If it is, then the others are as well, since the other meridians protect the Ht/SI at all costs. Meridian Underactive Warm Color Overactive Cool Color Heart Rose Turquoise Small Rose Turquoise Intestine

30 When there is light in the soul there will be beauty in the person. When there is beauty in the person, there will be harmony in the house. When there is harmony in the house, there will be order in the nation. When there is order in the nation, there will be peace in the world. --Old Chinese Proverb I-Ching Hexagram

31 For Further Information: The website has a copy of this presentation and a link to my Amazon e-books.

Introduction to. AcuColors. Karen Johnson, RN, MPH, Naturopath, CCP

Introduction to. AcuColors. Karen Johnson, RN, MPH, Naturopath, CCP Introduction to AcuColors Karen Johnson, RN, MPH, Naturopath, CCP DISCLAIMER AcuColors does not provide medical advice, diagnosis or treatment. Content from AcuColors is not intended to be used for medical

More information

Introduction THE PHYSICAL BODY

Introduction THE PHYSICAL BODY Introduction THE PHYSICAL BODY Traditional Chinese Medicine (TCM) teaches us that the whole person includes 3 entities the Body, the Soul and the Spirit. When disease strikes, it affects all 3, not just

More information

On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below:

On a scale of 1 10 (10 being optimal health) please rate where you feel your health is in the the areas below: Healthcare History djp Pure-Health wellness centre www.pure-health.com Wellness Profile General Health On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the

More information

What do you believe is causing your most important health concern?

What do you believe is causing your most important health concern? Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to

More information

AN INTRODUCTION TO. KAREN E JOHNSON, RN, MPH, CCP, NATUROPATH

AN INTRODUCTION TO. KAREN E JOHNSON, RN, MPH, CCP, NATUROPATH AN INTRODUCTION TO AcuColors KAREN E JOHNSON, RN, MPH, CCP, NATUROPATH WWW.ACUCOLORS.COM karen@acucolors.com Text copyright @ 2016 Karen E Johnson All rights reserved. Without limiting the rights under

More information

Emotional Relationships Social Life Sexually Recreation

Emotional Relationships Social Life Sexually Recreation Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we

More information

Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM

Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of

More information

Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP

Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP Shiatsu Intake Form DATE PURCHASED PRODUCT/SERVICE FIRST NAME LAST NAME Date of Birth Age Height Weight Home Address City State ZIP Home Phone Cell Phone Email Name of Emergency Contact Would you like

More information

Johanna M. Hoeller, DC PS

Johanna M. Hoeller, DC PS ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:

More information

Medical History Form

Medical History Form General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:

More information

Inner Balance Acupuncture

Inner Balance Acupuncture Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:

More information

Acupuncture Health History Page 1 of 5

Acupuncture Health History Page 1 of 5 General Contact Information Acupuncture Health History Page 1 of 5 Name: Date of Birth: Address: City: Postal Code: Contact Numbers#: Home #: Email: (By checking you give David E. Chung Permission to email

More information

Symptom Review (page 1) Name Date

Symptom Review (page 1) Name Date v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each

More information

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex

More information

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166 Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By

More information

The Rehabilitation Institute Cancer Rehabilitation

The Rehabilitation Institute Cancer Rehabilitation DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors

More information

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email

More information

Questionnaire for Lipedema Patients

Questionnaire for Lipedema Patients Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees

More information

Facial Assessment. Color. Lines in the Skin.

Facial Assessment. Color. Lines in the Skin. Facial Assessment Color. Red. Heat, inflammation, upward movement. White. Closure of capillaries, cold, shock, downward/inward movement. Blue. Lack of oxygen. Purple. Stagnation, bruises. Yellow. Liver,

More information

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency

More information

Oriental Medicine Questionnaire

Oriental Medicine Questionnaire Oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Occupation: Height: Weight: Who referred you to this office? 1.What brought you

More information

CONTENTS. Preface. Introduction. The Gem Sticks. Working with the Hand Rod or Pendulum. Types of Therapy. Gemstone Reflexology By Nora Kircher

CONTENTS. Preface. Introduction. The Gem Sticks. Working with the Hand Rod or Pendulum. Types of Therapy. Gemstone Reflexology By Nora Kircher Gemstone Reflexology By Nora Kircher CONTENTS Preface Introduction The Gem Sticks Amethyst Aventurine Fluorite Heliotrope Rock Crystal Rose Quartz Rutile Quartz Sodalite Working with the Hand Rod or Pendulum

More information

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist *All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:

More information

06/09/2005 Medical history and intake form

06/09/2005 Medical history and intake form Medical history and intake form Please complete this form as accurately as possible - it helps to provide you with the best possible treatment. Address including postcode Contact numbers Home/work/mobile

More information

The Rehabilitation Institute Cancer Rehabilitation

The Rehabilitation Institute Cancer Rehabilitation DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors

More information

PATIENT INFORMATION FORM (WOMEN ONLY)

PATIENT INFORMATION FORM (WOMEN ONLY) PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for

More information

The TMJ Therapy Effects of Joint Manipulation

The TMJ Therapy Effects of Joint Manipulation The overall postural structure associated with TMJ disorders is part of the The TMJ Therapy concern. Chiropractic manipulation has helped realign the joints in your TMJ, neck, and low back and along with

More information

Tongue Evaluation. Body Color. Including colors at different locations. Indications. Body temperature regulation.

Tongue Evaluation. Body Color. Including colors at different locations. Indications. Body temperature regulation. Tongue Evaluation Christopher Rodgers, Student Body. Refers to the overall appearance including muscles, arteries, and veins. Associations. Conditions of the cardiovascular, nervous, reproductive, urinary

More information

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F: BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints

More information

Patient Intake Form for Allegany Ear, Nose, & Throat

Patient Intake Form for Allegany Ear, Nose, & Throat Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:

More information

PATIENT MEDICAL HISTORY INTAKE FORM

PATIENT MEDICAL HISTORY INTAKE FORM Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information:

More information

BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY

BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural health care. The ability to draw effective conclusions

More information

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital

More information

Balanced Healing Acupuncture, LLC

Balanced Healing Acupuncture, LLC Balanced Healing Acupuncture, LLC Intake Form NAME: Last First: GENDER: Date of Birth / / Age Email Address Address City State Zip Code Preferred Phone Number Cell Home Work Preferred Method of Communication:

More information

Patient History Form

Patient History Form Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age

More information

NEW PATIENT HEALTH HISTORY

NEW PATIENT HEALTH HISTORY NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there

More information

MERIDIAN SYMPTOMOLOGY

MERIDIAN SYMPTOMOLOGY MERIDIAN SYMPTOMOLOGY According to Fukushima Kodo and Shudo Denmai a Summation by Jake Paul Fratkin, OMD Originally published in North American Journal of Oriental Medicine, Vol. 5, No. 12, March, 1998.

More information

American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ (520)

American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ (520) American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ 85741 (520) 544-6603 Notes for new Patients: Your first session * Can you imagine not having to wait at a doctor's

More information

Symptom Questionnaire

Symptom Questionnaire Symptom Questionnaire The following questionnaire is a general assessment of your health developed by Dr Royal Lee D.D.S. Each grouping represents a particular area of your body that may be causing you

More information

Medical History Form

Medical History Form Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart

More information

Metabolic Assessment Form

Metabolic Assessment Form Metabolic Assessment Form Approach Wellness and Aesthetics 200 Forsythe Street Fayetteville, NC 28303 Office: (910) 322-7368 Fax: (910) 483-5796 www.tawellness.net Name: Age: Sex: Date: Part 1: Please

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology

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

More information

205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date:

205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date: 205 W Giaconda Way, Suite 135 Tucson, AZ, 85704 (520) 219-2400 www.forever-able.com info@forever-able.com Name: Birth date: Age: Today s Date: Address: Email: Home phone: Mobile phone: May we add you to

More information

New Patient Medical History Intake Form

New Patient Medical History Intake Form New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd

More information

Nutrition Consultation Intake Form Please write or print clearly

Nutrition Consultation Intake Form Please write or print clearly Artemis in the City, LLC Danielle Heard, MS, MS, HHC Clinical & Functional Nutritionist ph: 866-330-5421 fx: 212-535-3234 www.artemisinthecity.com Nutrition Consultation Intake Form Please write or print

More information

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4 Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: 905-793- 8868 Fax: 905-793- 8957 630 Peter Robertson Blvd, Brampton ON L6R 1T4 ADULT INTAKE FORM Name: (Last) (First) (Preferred Name) Address:

More information

WELLNESS HISTORY. Patient s Name: Date

WELLNESS HISTORY. Patient s Name: Date u:\share\sr dr\wellness history1 08-08-13 1 WELLNESS HISTORY Patient s Name: Date 1) Have you ever been to Acupuncturist? Yes No If Yes: Currently In the past, When: Did it help? What treatment did you

More information

Laser Vein Center Thomas Wright MD Page 1 of 4

Laser Vein Center Thomas Wright MD Page 1 of 4 Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber

More information

MEDICAL QUESTIONNAIRE (female)

MEDICAL QUESTIONNAIRE (female) MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.

More information

ACUPUNCTURE INTAKE FORM

ACUPUNCTURE INTAKE FORM , ND ACUPUNCTURE INTAKE FORM Thank you for taking the time to complete the following new patient forms. Given this form is extensive, it plays an integral role in achieving our mutual goal of your optimal

More information

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact

More information

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES abdominal pain acne aging process accelerated allergies, including asthma, hives, rashes, sinus congestion anemia (blood hemoglobin low) anorexia anovulatory (no ovulation) anxiety anxious depression appetite

More information

MEDICAL QUESTIONNAIRE (male)

MEDICAL QUESTIONNAIRE (male) MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent

More information

MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History

MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information

More information

Eastern Body Therapy

Eastern Body Therapy 2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security

More information

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone. CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)

More information

Luo Vessels, Cutaneous and Muscle Regions

Luo Vessels, Cutaneous and Muscle Regions Chapter 3 Luo Vessels, Cutaneous and Muscle Regions 1 Characteristics of Luo Vessels Connect external/internal pairs Distribute qi throughout the body Harmonize circulation 2 In all, there are fifteen

More information

Amarillo Surgical Group Doctor: Date:

Amarillo Surgical Group Doctor: Date: Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:

More information

Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland

Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland Patient Information Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland 21014 410-913-8322 Patient Name: Date of Birth: Age: Male: Female: Single: Married: Separated:

More information

Bodily Conditions Rooted in Hormone Imbalance

Bodily Conditions Rooted in Hormone Imbalance Check this list for all conditions that apply to you. The total possible score is 209. Count the number of symptoms you check. The higher your score, the more likely you need to address hormone imbalances.

More information

Introduction of Korean Acupuncture focusing on Saam Five Element Acupuncture and Facial Acupuncture

Introduction of Korean Acupuncture focusing on Saam Five Element Acupuncture and Facial Acupuncture Introduction of Korean Acupuncture focusing on Saam Five Element Acupuncture and Facial Acupuncture Sanghoon Lee MD(Korean Medicine), MPH, PhD, DiplAc, LAc.(USA) Professor of Acupuncture & Moxibustion

More information

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more

More information

RHEUMATOLOGY PATIENT HISTORY FORM

RHEUMATOLOGY PATIENT HISTORY FORM !! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant

More information

Medical History Form

Medical History Form Medical History Form Full Name Title: Mr/Mrs/Ms/Miss Address Date of Birth Date Telephone: Mobile: Email: How did you hear about the Garden of health? G.P s Name and Address Are you currently seeing your

More information

Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:

Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship

More information

Headache Follow-up Visit Form

Headache Follow-up Visit Form !1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:

More information

New Client Health & Wellness Paper Work

New Client Health & Wellness Paper Work Nutritionally Yours Health Solutions 604 Macy Drive, Roswell GA 30076 678-372-2913 / alanepnd@gmail.com New Client Health & Wellness Paper Work Today's Date Patient Name: _ Parents Name (if patient is

More information

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - - ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:

More information

28-DAY CLEANSE GUT C.A.R.E. by Dr. Vincent Pedre. Pre-Program Medical Symptoms Questionnaire

28-DAY CLEANSE GUT C.A.R.E. by Dr. Vincent Pedre. Pre-Program Medical Symptoms Questionnaire 28-DAY CLEANSE HAPPY GUT GUT C.A.R.E. by Dr. Vincent Pedre Pre-Program Medical Symptoms Questionnaire NAME ADDRESS EMAIL PHONE RATE EACH OF THE FOLLOWING SYMPTOMS BASED UPON HOW YOU HAVE FELT OVER THE

More information

Hippocratus Ayurvedic Acupressure Part II Index

Hippocratus Ayurvedic Acupressure Part II Index Hippocratus Ayurvedic Acupressure Part II Index Treatment of Hyperacidity & Gastritis / Ulcers Prevention of Loss of Energy Part I 1. Acute Gastritis 1 2. Heart and throat burning 2 3. Abdomen distention

More information

LECOM Health Ophthalmology

LECOM Health Ophthalmology Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable

More information

Horse Meridians & Ting Points

Horse Meridians & Ting Points Horse Meridians & Ting Points Just like the Chakras are the main energy centers, the Meridians are the major pathways. They help to determine where the energy travels through the body. If these pathways

More information

Medical Questionnaire

Medical Questionnaire MEDICIS Health Testing Center Avenue de Tervueren 236 115 Bruxelles Tel : 2/762.5.44 Medical Questionnaire Name :. Maiden name : First name :. Sex :. Address :...... Phone (private) : Office :. Date of

More information

Patient History Form

Patient History Form Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:

More information

Digestion: Small and Large Intestines Pathology

Digestion: Small and Large Intestines Pathology Digestion: Small and Large Intestines Pathology Dr. Ritamarie Loscalzo Medical Disclaimer: The information in this presentation is not intended to replace a one onone relationship with a qualified health

More information

DIAGNOSIS YES NO. KIDNEY YIN DEFICIENTY (Ki Yi- -) Do you have lower back weakness, soreness, or pain, or knee problems?

DIAGNOSIS YES NO. KIDNEY YIN DEFICIENTY (Ki Yi- -) Do you have lower back weakness, soreness, or pain, or knee problems? Answer yes or no to each of the following questions. Don t worry about what the symptoms mean; just note whether you experience them. If you have more than one--fourth to one--third yes re- sponses in

More information

Nutrient Assessment Chart

Nutrient Assessment Chart Vitamin A Assessment Chart Chicken skin on backs of arms Chronic acne Dry eyes Food allergies Poor night vision Recurrent infections and colds Reduced hair growth in children Ulcers B Vitamins Afternoon

More information

DHATU ASSESSMENT. Total the number of symptoms for each tissue category. 1. BLOOD PLASMA (RASA). The clear, serum portion of the blood.

DHATU ASSESSMENT. Total the number of symptoms for each tissue category. 1. BLOOD PLASMA (RASA). The clear, serum portion of the blood. DHATU ASSESSMENT Total the number of symptoms for each tissue category. 1. BLOOD PLASMA (RASA). The clear, serum portion of the blood. Excessively dry skin Dehydration Premature graying of the hair Cold

More information

Zone 1 & 2 Pupilary Zone and Nutritive Zone. Zone 3 Humoral or Inner Ciliary Zone 5/10/ Stomach Digestion 2. Intestine - Absorption

Zone 1 & 2 Pupilary Zone and Nutritive Zone. Zone 3 Humoral or Inner Ciliary Zone 5/10/ Stomach Digestion 2. Intestine - Absorption IIPA Ready Iridology Class 1 ~ Introduction, Terms and Basics Class 2 ~ Anatomy of the Eye Class 3 ~ Collarette Class 4 ~ Zones and Constitutional Types Class 5 ~ Pigmentation Class 6 ~ Lacunea Class 7

More information

Patient Health History for Fertility

Patient Health History for Fertility Patient Health History for Fertility Name: Date: Address: City, State, Zip code Phones: Home Work: Cell: Email address: Date of Birth: Age: Occupation: Emergency contact: Ob/Gyn: Current Medications: What

More information

NEW PATIENT QUESTIONNAIRE

NEW PATIENT QUESTIONNAIRE Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program

More information

The Food Intolerance Institute of Australia

The Food Intolerance Institute of Australia The Intolerance Institute of Australia The Symptoms Matrix The Symptoms Matrix allows you to narrow the possibilities of your food rather than diagnose it. To get an accurate identification of your food

More information

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?: NAME _ Please take the time to fill this form out completely. The more information we have, the better we can assist you, and will make better use of your initial visit. What is the main problem you would

More information

ATORIS 10, 20, 40 mg film-coated tablets

ATORIS 10, 20, 40 mg film-coated tablets PACKAGE LEAFLET: INFORMATION FOR THE USER ATORIS 10, 20, 40 mg film-coated tablets ATORVASTATIN This leaflet is a copy of the Summary of Product Characteristics and Patient Information Leaflet for a medicine,

More information

PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS?

PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS? 2 PHYSIOTHERAPIST Date of last visit MASSAGE THERAPIST Date of last visit SPECIALISTS Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS? WHAT IS THE PRIMARY REASON YOU ARE SEEKING CONSULTATION/TREATMENT?

More information

What is the most important information I should know about bortezomib? What should I discuss with my healthcare provider before receiving bortezomib?

What is the most important information I should know about bortezomib? What should I discuss with my healthcare provider before receiving bortezomib? 1 of 5 6/10/2016 3:46 PM Generic Name: bortezomib (bor TEZ oh mib) Brand Name: Velcade What is bortezomib? Bortezomib interferes with the growth of some cancer cells and keeps them from spreading in your

More information

Have a healthy discussion. Use this guide to start a. conversation. with your. healthcare provider

Have a healthy discussion. Use this guide to start a. conversation. with your. healthcare provider Have a healthy discussion Use this guide to start a conversation with your healthcare provider MAKE THE CONVERSATION COUNT Here are some things you may want to reflect on and discuss with your healthcare

More information

The Enzyme Deficiency Checklist

The Enzyme Deficiency Checklist The Power of Enzymes Without enzymes you could not exist. Enzymes trigger thousands of call to actions in the body that are necessary for you to survive. The Role of Enzymes If your body was a factory,

More information

HASPI Medical Biology Lab 01a

HASPI Medical Biology Lab 01a ! What Does It Test For? Very Low Low Glucose Electrolytes Ferritin Blood ph The glucose test measures the amount of sugar, or glucose, in the blood or urine. A very high or very low glucose test can indicate

More information

LAKES INTERNAL MEDICINE

LAKES INTERNAL MEDICINE LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education

More information

Acupuncture. The Art of Healing with Needles

Acupuncture. The Art of Healing with Needles Acupuncture The Art of Healing with Needles What is Acupuncture? Strategic placement of needles to stimulate acupoints on meridians to restore proper flow of Qi and Blood and balance of Yin and Yang to

More information

Premium Specialty: Pediatrics

Premium Specialty: Pediatrics Premium Specialty: Pediatrics Credentialed Specialties include: Adolescent Medicine, Pediatric Adolescent, and Pediatrics This document is designed to be used in conjunction with the UnitedHealth Premium

More information

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information. Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell

More information

Glucose Electrolytes Ferritin Blood ph. Possible Results White Bright pink Clear White. Bright pink; fades to light pink. Light Pink fades to clear

Glucose Electrolytes Ferritin Blood ph. Possible Results White Bright pink Clear White. Bright pink; fades to light pink. Light Pink fades to clear What Does It Test For? Very Low Low Glucose Electrolytes Ferritin Blood ph The glucose test An electrolyte Ferritin is a protein The blood ph test The liver is an White blood cells measures the test measures

More information

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer

More information

Patient Information & Health History

Patient Information & Health History Patient Information & Health History Name Date Date of Birth (mm/dd/yy) Age Male Female Address City Postal Code Occupation Phone (H) E-mail Phone (C) Married Single Divorced Widowed Phone (W) Spouse s

More information

Facial Accupressure Massage. Taha Haque, D.O. CAM Workshop

Facial Accupressure Massage. Taha Haque, D.O. CAM Workshop Facial Accupressure Massage Taha Haque, D.O. CAM Workshop 1 10July2015 Benefits of facial accupressure Enhance local blood flow Firm and tone face and neck Mild to moderate symptomatic relief of headaches,

More information

WELCOME TO OUR OFFICE

WELCOME TO OUR OFFICE WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment

More information

Initial Consultation

Initial Consultation Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention

More information