To your radiant health and wellbeing. Yours, Ulli Allmendinger MSc Ayurveda
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- Dana Briggs
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1 Welcome! Thank you for considering me for your holistic and natural health care needs. In preparation for your consultation, find enclosed a Client Health Profile for you to review, complete and bring with you to your first appointment. Ulli Ayurveda is a synergistic integration of the one of the oldest, continuously practiced traditions of medicine on the planet Ayurveda and modern nutritional and herbal medicine. Ayurveda respects that the human body, mind, spirit and soul are an inseparable whole, and essentially comprised of energy and consciousness. It also believes that humans are both deeply connected to and interdependent with nature. Disease is understood in terms of disharmony among the different levels of our existence (body, mind, spirit and soul), or between ourselves and nature. Respecting the truly holistic nature of our being, I utilize several integrated approaches not only to address specific health issues but also to achieve optimal metabolism and weight, strong immunity, balanced energy, and a clear, calm and positive state of mind:! Through Ayurvedic Lifestyle & Diet Consultations, I will guide you in developing daily routines and eating habits best suited to your metabolic type and the daily and seasonal biorhythms.! Through Holistic Herbal Consultations, I will develop personalized herbal strategies and formulas that will meet the specific needs of your body and mind, using only the highest-quality organic and/or wild-crafted herbs.! Through educating you in AyurPrana, AyurYoga, Holistic Nutrition, and Eastern Philosophies, I will empower you to take better control of your health and achieve personal fulfillment. To your radiant health and wellbeing. Yours, Ulli Allmendinger MSc Ayurveda
2 Name Date Home Address City, Area, Neighborhood Post Code Home Phone GSM: Would you like to join our mailing list? Date of Birth Time of Birth Place of Birth Age Occupation Marital Status Children & Ages Main Physician Phone 1. What are your main health concerns and when did they begin? 2. What would you like to achieve in terms of your health and wellness? 3. Are you currently receiving care from any other natural health professionals? Please provide names. 4. Are you taking any medications and/or supplements (vitamins, herbs)? NAME PURPOSE DOSE FREQUENCY 5. Do you use any of the following? Cigarettes? Years Amount Have you smoked in the past? When did you quit? Recreational drugs? What types? How frequently? Alcohol? What types? How frequently? 2
3 Coffee? How many cups per day Black tea? How many cups per day? 6. Health History: Have you or a family member been diagnosed with any of the following conditions (check boxes that apply and write when the diagnoses was made): CONDITION MYSELF FAMILY MEMBER PATERNAL Allergies " " " Anemia " " " Asthma " " " Emphysema " " " Chronic Obstructive Pulmonary " " " Disease (COPD) Tuberculosis (TB) " " " Hypertension " " " High Cholesterol " " " Heart Disease " " " Hepatitis A " " " Hepatitis B " " " Hepatitis C " " " Diabetes " " " Thyroid Disease " " " Mononucleosis " " " Any Venereal Diseases (STDs) " " " Kidney Disease " " " Osteo-Arthritis " " " Rheumatoid Arthritis " " " Cancer " " " Multiple Sclerosis " " " HIV / AIDS " " " Psychiatric Disorders " " " Eating Disorder (Anorexia or Bolemia) " " " Stomach Ulcers " " " Crohn s Disease " " " Ulcerative Colitis " " " Celiac Disease " " " Irritable Bowel Syndrome " " " FAMILY MEMBER MATERNAL Please list any other major diseases that you or a family member have been diagnosed with in the past: 7. List major accidents, injuries, surgeries and/or other hospitalizations and their dates? 3
4 8. Health Profile (Please check anything apply to you and fill in related information) GENERAL Height Weight What is your desired weight? Significant weight changes in the past Do you exercise regularly? Types? How frequently? How would you describe your overall energy level? " Very good " Good " Low " Very low When in the day is your energy usually highest? When in the day is your energy usually lowest? Body temperature: " I usually feel cold " I usually feel hot " Usually only my hands / feet feel cold / hot " Usually comfortable; neither too hot or too cold " I prefer warm/hot weather " I prefer cool/cold weather : Sweating: " I sweat easily & profusely " I sweat very little or none " I sweat at nights " I sweat normally : Food & drink: Do you feel like you have a healthy diet? " Yes " No " I am not sure Do you feel like you drink enough water? " Yes " No " I am not sure : EYES " Far-sighted " Near-sighted " Astigmatism " Blurred vision " Poor night vision " Floaters " Cataracts " Glaucoma " Pain/ soreness " Itching " Tearing " Broken vessels EARS, NOSE, THROAT (MAJJA & ASTHI DHATU, PRANAVAHA SROTAS) " Frequent Earaches " Poor hearing " Tinnitus " Nasal Congestion " Sinus Congestion " Nasal dryness " Nasal drainage " Nosebleeds TEETH " Cavities " Root Canal " Implants " Gum infection " Grinding teeth " Clicking jaw " Jaw pain NEURO-PSYCHOLOGICAL (MAJJA DHATU, MANOVAHA SROTAS) " Poor sleep " Poor memory " Difficulty concentrating " Depression " Irritability " Anxiety " High stress levels " Foggy or spacey feeling " Dizziness " Migraine " Headaches " Loss of balance " Lack of coordination " Muscle spasm/twitching " Seizures " Numbness, if yes, where? RESPIRATORY (PRANAVAHA SROTAS) " Hayfever " Bronchitis " Asthma " Pneumonia " Pain on breathing " Shortness of breath " Cough " Difficulty breathing when lying down " Mucous in throat " Production of phlegm, what color? IMMUNOLOGICAL (RASA DHATU) " Frequent colds, how often? times / year " Sore throat, how often? times/ month " Canker sores, how often? times/ year " Cold sores, how often? times/ year " Swollen glands 4
5 ULLI AYURVEDA CLIENT HEALTH PROFILE CARDIOVASCULAR (PRANAVAHA SROTAS, RASA/RAKTA DHATU) " High BP " Low BP " High cholesterol " Irregular heart beat " Palpitations " Chest pain or pressure " Fainting " Breathing difficulties " Cold hands / feet " Ankle swelling " Easy bruising " Varicose veins APPETITE & DIGESTION (ANNAVAHA & PURISHAVAHA SROTAS) " Very strong appetite " Poor appetite " Food cravings -What kind? " Bad breath " Indigestion " Abdominal pain " Heartburn / Reflux " Gas " Bloating " Nausea " Vomiting " Pain / discomfort below ribs " Difficulty digesting fatty meals " Gallstones When? ELIMINATION " Diarrhea " Loose stools " Constipation " Blood in stools " Mucous in stools " Black stools " Rectal pain " Hemorrhoids How frequently do you usually have a bowel movement? " More than 2 times per day " 2 times per day " Once per day " Once every 2 days " Once every 3 days " Less than every 3 days MUSCOSKELETAL (MAMSA, ASTHI DHATUS) " Neck pain " Back pain " Hip pain " Knee pain " Shoulder pain " Pain of arms / legs " Pain of hands / feet " Muscle pain " Muscle Stiffness " Muscle weakness " Reduced range of movement " Cracking, popping joints " Joint pain / stiffness " Broken bones " Osteopenia In the diagrams below, please shade all areas where you currently or regularly feel discomfort:!! 5
6 SKIN, HAIR, NAILS (RASA, RAKTA, ASTHI DHATU) " Dry Skin " Oily Skin " Pimples " Pustules " Itching " Rashes " Hives " Eczema " Psoriasis " Recent moles " Liver spots " Poor healing sores " Easily bleeding " Poorly healing wounds " Dry hair "Oily hair " Thinning / weak hair " Dandruff " Hair loss " Scalp itching " Brittle nails " Ridges on nails " White spots on nails " Clubbing of nails URINARY (MUTRAVAHA SROTAS, SHUKRA DHATU) " Painful or burning urination " Frequent urination " Urgency of urination " Dribbling at the end of urination " Urinary incontinance " Blood in urine " Cloudy urine " Frequent Urinary Tract Infections " Kidney / bladder stones " Water retention / Edema; if yes, where? MALE-REPRODUCTIVE " Prostate enlargement " Testicular pain, discomfort, swelling " inguinal pain or discomfort " Erectile dysfunction " Premature ejaculation " Low libido FEMALE-REPRODUCTIVE " Vaginal discharge, if yes what is the color and consistency? " Vaginal itching " Ovarian cysts " Uterine fibroids " Fibrocystic breasts " Anemia " Pain with intercourse Do you menstruate? Length of your cycle (period to period)? Light, normal, or heavy? What age did you have your first period (menarche)? Duration of bleeding? Do you have premenstrual symptoms (PMS)? Check if applicable: " Anxiety " Mood Swings " Depression " Craving Sweets " Dizziness " Headaches " Insomnia " Increased Appetite " Decreased Appetite " Abdominal Bloating " Diarrhea " Constipation " Fatigue " Breast Tenderness " Water Retention " Lower Back Pain How many pregnancies have you had? Births? Miscarriages? Abortions? Do you use contraceptives? Are you post-menopausal? If so, which ones? If yes, when was the approximate date of your last period? If you have menopausal symptoms, please describe your major symptoms. gynecological issues? Thank You For Taking The Time 6
7 Legal Disclaimer: Services offered at Ulli Ayurveda are not intended to diagnose or treat any disease, nor are they an alternative to the treatment prescribed by your doctor. If you have a medical diagnosis or you suspect you may have a serious medical condition, you should see a specialist for the appropriate medical intervention. The nutritional, lifestyle and herbal consultations offered at my center are intended for providing information and recommendation only. They are not a prescription, or otherwise obligatory. I, the undersigned, hereby confirm that I have read, understood and agreed to the above statement, and that I am consulting with practitioners at Ulli Ayurveda of my own free will. Signature Date Print name 7
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Headache Follow-up Visit Form
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City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:
Pamela A. Pappas MD, MD(H) Classical Homeopathy for Mind, Body, and Soul 8114 E. Cactus Rd., Suite #240 Scottsdale, Arizona 85260 Phone: 480.656.9218 Fax: 602.626.3695 E-mail drpam@drpampappas.com New
N E W C L I E N T Q U E S T I O N N A I R E
V A N E S S A Y O U S S E F, BSc (Kine), ND Madison Clinic 4950 Yonge St, Concourse Level, Unit 2 Toronto, Ontario M2N 6K1 Phone: 416-222-8235 Email: vanessayoussefnd@gmail.com N E W C L I E N T Q U E
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
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:
Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star **
Date: Name: Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Email: Date of Birth: Place of Birth: Age: Employer
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
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
Ayurvedic Intake Form
Ayurvedic Intake Form Name: Today s Date Date of birth: Time of birth: Place of birth: Place of childhood: Other Places lived: Current address: Home phone: Work phone: Email address: Occupation: Age: Sex:
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Health Intake Form. List your top five concerns or reasons for requesting your appointment with Dr. Weiss
List your top five concerns or reasons for requesting your appointment with Dr. Weiss 1. 2. 3. 4. 5. Please give any information you think is important regarding these top concerns: Health Intake Form
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
HIPAA Acknowledgement and Appointment Reminder Form
HIPAA Acknowledgement and Appointment Reminder Form I acknowledge that I have been provided access to Salado Acupuncture s Notice of Privacy Policies. I understand that I have the right to review Salado
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Acupuncture & Herbal Therapies
Acupuncture & Herbal Therapies 2520 Central Ave. St. Petersburg, FL 33712 (Phone) 727-551-0857 (fax) 727-202-6896 Last Name: First Name: Male/Female: Date of Birth: Address: City: State: Zip: Home Phone#:
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
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
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: