Dana Michaels, ND. Telephone conversations more than 5 minutes will be billed at session fees.
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- Roland Day
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1 aturopathic Wellness Center At Integrative Medical Clinic of Santa Rosa Dana Michaels, D Office Policies and Consent to aturopathic Health Counseling: These office policies have been created to better serve you. Please read the following and sign the bottom Please Bring to Appointment: Prescription medications, vitamins, supplements, or herbs in original labeled bottle. Recent laboratory results, imaging reports, or referring physician consultation notes. This completed packet. Appointment Fees: Adults: Initial visit is generally minutes at cost of $ Follow up visits will average 45 minutes at cost of $ $ Children (12 and under): Initial visit is $245; follow up visits are $ Telephone conversations more than 5 minutes will be billed at session fees. Payment is due at the time of services by cash, check, Visa or Mastercard. ou will be charged an additional $30 for any returned check. If you have insurance, we can generate a bill for you to submit to your carrier for possible reimbursement. Please inquire at the front desk upon arrival to appointment. Cancellation: ou may be charged for a missed appointment or late cancellation, if you do not provide 48-hours notice. Please be respectful that your appointment is time reserved for you. Dr. Dana Michaels is an independent practitioner at IMC. As a patient of Dr. Michaels, you agree to indemnify and hold IMC harmless of any liability you feel arises during your visit or by subsequent counseling. I have read, understand and agree to the above office policies. Print ame: Date: Signature: Dr. Dana Michaels aturopathic Wellness Integrative Medical Clinic of Santa Rosa
2 The aturopathic Wellness Center At Integrative Medical Clinic Of Santa Rosa Dana Michaels, D Patient ame: DOB: Would you like to receive The aturopathic Wellness Center eewsletter? In Order of importance, list your health issues: 1) 2) 3) 4) 5) Last time you had blood work done and with what physician? Family History: Age if living Age when died: Reason for death: Cancer: Specify type: High Blood Pressure: Heart Attack/Stroke: Heart Disease: Asthma/Allergies: Mental Illness: Tuberculosis (TB) Auto-Immune Disease: Diabetes Mellitus: Osteoporosis: Mother Father Siblings Grandparents Children List All Surgeries & Hospitalizations, including date occurred: Please note when you have had each of the following: X - Rays: HCV: MRI / Cat Scans: HIV Test: Ultrasounds: Last Eye Exam: Accidents: TB Test: Colonoscopy: Last Dental Visit Dr. Dana Michaels aturopathic Wellness Integrative Medical Clinic of Santa Rosa
3 Have you had the Disease (D), Vaccination (V) or either ()? Circle: Measles: D V Chicken Pox: D I Mumps: D I German Measles: D V Whooping Cough: D V Rubella: D V Tetanus: D V Hemophilus/Hib: D V Hepatitis B: D V Any vaccination reactions: List es (), o () or in the Past (P) regarding use of the following: Circle: Antacids: P Steroids: P Pain Relievers: P Laxatives: P Coffee: P If /P How many cups per day? Soda: P How much per day? Drink diet sodas? Smoking: P Packs per day? For how many years? Alcohol: P How often & how much if es/past? Alcohol Addiction: P Any Alcohol Treatment: P Family history of addiction? Recreational Drugs: P Which ones? Any Drug Addictions: P Any Drug Treatment: P List all Prescription Medicines, include dosages: (Remember to bring the bottles with you) utrient Supplements and Herbs, include dosages: (Remember to bring the bottles with you) Review of Systems: List es (), Past (P), or leave blank if never had the issue. SKI Rash: P Color Change: P Hives: P Lump: P Psoriasis/eczema: P Itchy: P Dry: P Warts/moles: P Cancer: P Perspiration: P HEAD Headache: P Migraine: P Dandruff: P Head Injury: P Oil/dry hair: P Hair loss: P OSE Frequent Colds: P osebleeds: P Congestion: P Post asal Drip: P Polyps: P Seasonal Allergies: P Dr. Dana Michaels aturopathic Wellness Integrative Medical Clinic of Santa Rosa
4 EES Dry/Watery: P Blurry Vision: P Double Vision P Cataracts: P Glaucoma: P Styes: P Strain: P Discharge: P Itchy: P Dark under Eyelid: P MOUTH/THROAT Canker sores: P Cold sores: P Sore Throat: P Gum disease: P Dentures: P Cavities: P Loss of taste: P Hoarseness: P ECK Stiffness: P Swollen Glands: P Full movement: P Tension: P RESPIRATOR Cough: P TB: P Shortness of breath w/ exertion: P Bronchitis: P Shortness of breath sitting: P Pneumonia: P Shortness of breath lying down: P Asthma: P Wheezing: P Painful breathing: P CARDIOVASCULAR High Blood Pressure: P Rheumatic Fever: P Low Blood Pressure P Murmurs: P Arrhythmias: P Palpitations: P Edema: P Chest Pain: P URIAR TRACT Incontinence: P Pain w/ Urination P Frequent Infections: P Kidney Stones P Urgency: P Discharge/Blood: P GASTROITESTIAL Heartburn: P Bowel Movement Frequency Indigestion: P Recent BM Change: P Bloating: P Diarrhea/Constipation: P ausea: P Blood in Stool P Vomiting: P Often Passing Gas P Change in Appetite: P Gall Bladder Disease P Pancreatitis: P Ulcer P Liver Disease: P Hemorrhoids: P MALE GEITALIA Testicular pain/swelling: P Sexually Active: P Hernia: P S.T.D.: P Impotency: P Sexual Orientation: Hetero Homo Bi Discharge: P Prostate Disease/Symptoms: P Dr. Moses Goldberg Dr. Dana Michaels The aturopathic Wellness Center Integrative Medical Clinic of Santa Rosa
5 FEMALE GEITALIA Age Period Began: How many days is your cycle? How many days does period last: Heavy menstrual bleeding: P Menstrual cramping: P Menstrual P PMS: P Food cravings P umber of Pregnancies: Miscarriages: Live Births: Abortions: Last Pap Smear: Sexual Orientation: Hetero Homo Bi Any abnormal Paps: P When was it abnormal: Menopausal since what age: Use of Hormones: P Low Libido P Which hormones used? Sexually Active: P Dry vagina: P Vaginitis: P Pain w/ Intercourse: P S.T.D.: P Mammography: P Dexa Scan: P If es, what were results: Please list any birth control used and at what ages: Do you perform monthly self-breast exams? Do you want instructions on the correct procedures of self-breast exams? MUSCULOSKELETAL Weakness: P Arthritis: P Stiffness: P Leg Cramps: P Tremors: P Pain: P ERVOUS Paralysis: P Sciatica: P Tingling/numbness: P Carpal tunnel syndrome: P Seizures: P Fainting: P Mental/Emotional Depression: P Anger/irritability: P Suicidal: P High-strung/tense: P Anxiety: P Fear/Panic P Eating disorder: P Psych Hospitalization: P ou are doing great, you are almost done! Weight: lbs_ Weight one year ago: Ideal Weight: Height: Energy Level: / 10 (0 = no energy, 10 = lots of energy) Fatigue: If yes, does it interfere with your daily activity? Exercise: How often do you exercise? What types of exercise? Sleep: How many hours? Do you wake up frequently? ightmares: P Wake Refreshed: P Sleep walk: P Grind teeth: P Snore: P Sleep aids: P Which ones: Dr. Moses Goldberg Dr. Dana Michaels The aturopathic Wellness Center Integrative Medical Clinic of Santa Rosa
6 Toxin Exposure: Did you grow up near any refinery polluted: If so, what kind? Have you had any jobs where you were exposed to solvents, heavy metals, fumes or other toxic materials? Have you ever had health problems when you put in new carpeting, painted your home, had new cabinets or did other refurbishing? Are you particularly sensitive to perfumes, nail salons, laundry rooms, gasoline or other vapors? Do you use pesticides, herbicides or other chemicals around your home? Social Life: Would you consider yourself a happy person? Do you enjoy your job: Hours worked per week: Highest Level of Education: Main interests and hobbies: Active spiritual practice: P Quality of significant relationship: History of sexual, mental/emotional, physical abuse: If so, at what age and by whom? What are your health goals? How committed are you towards making valuable changes? Little Moderately Very Activity Have you ever used: Would like to try: Acupuncture / Chinese Medicine Homeopathy Massage Chiropractic Energy work Feldenkrais Tai Chi / Chi Gung Herbal Medicine Biofeedback Counseling Therapy Hydrotherapy Dr. Moses Goldberg Dr. Dana Michaels The aturopathic Wellness Center Integrative Medical Clinic of Santa Rosa
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Inflammatory Bowel Disease Medical Exam Questionnaire
Patient Name: MR: Date: Name DOB / / Age Marital Status Race Gender M / F Height Present Weight Usual Weight Insurance Managed Care Self referral Yes No Yes No Yes No Primary Care Physician Referring Physician
CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form
SELF-REPORTING HEALTH HISTORY
SELF-REPORTING HEALTH HISTORY DATE: DEMOGRAPHIC INFORMATION : Age: Address: City: State: Zip Code: Work Phone: Home Phone: Fax Number: E-mail: Significant Other : Phone: CHIEF COMPLAINT - HISTORY OF PRESENT
Consent for Treatment Form
Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
55 S. Main Street, Driggs, ID (208)
Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F
Dr. Michelle Mackay Patel, ND
NATUROPATHIC ADULT INTAKE PERSONAL INFORMATION: First Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: What is your current gender identity? Male Female Transgender Male/Transman/FTM Transgender
Women s and Men s Health Intake Form Comprehensive Physical Therapy Center
Name: (Last, First) DOB: Date: Age: Referring Physician: Next Physician Appointment: Today s visit: What is the main reason you came to the office today? When did it start? What treatments have you had
Good News Naturopathic Clinic 83 East Ave STE 209, Norwalk CT (Tel) (Fax) New Patient Intake Form
Date: New Patient Intake Form Last Name: First Name: DOB: Age: Sex: M F SSN: Street Address: City: State: Zip: Insured? Y N Insurance Provider: Occupation: Employer: Home Phone: Cell Phone: Work Phone:
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:
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
stoneburner acupuncture
STONEBURNER ACUPUNCTURE, LLC Erin K. Stoneburner, LAc, MAcOM 1135 SE Salmon St, Suite 211 503.784.1660 stoneburner@gmail.com Date: Name: (First) (Middle) (Last) DOB: _ Age: Sex: Address: City/State: ZIP:
DATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
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
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
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
NEW CHILD PATIENT INTAKE FORM
Today's Date: Carmen Hering D.O. NEW CHILD PATIENT INTAKE FORM Patient Name: Please print Date of Birth - - Age: Please list primary caregiver(s) and relationship to child: Number of households: Address(s):