PATIENT INFORMATION HEALTH INFORMATION
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- Bertha Lloyd
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1 NATUROPATHIC INTAKE FORM PATIENT INFORMATION Name: Date of Birth (m/d/y): Complete Address Date: Sex: M F Age: Telephone Cell: Home: Work: Emergency contact Name: Phone: Relation: Medical Doctor: Name: Phone : Address: Fax (if avail): Your Occupation and Company: Do you have health insurance with Naturopathic Medical Coverage?! Yes!No How did you hear about our clinic? Do you give us permission to add you to our mailing list to receive occasional newsletters containing recipes and health articles with the option of unsubscribing?! Y! N HEALTH INFORMATION Please list your specific health concerns in order of importance to you: Date of Onset: Age: Age: Age: 1. _ 2. _ 3. _ 4. _ Please list your most stressful life experiences (physical or psychological): ADDRESS 275 LANCASTER ST W KITCHENER, ON N2H 4V2 PHONE (519) FAX (519) INFO@HEALTHMOMENTUM.CA
2 CONTEXT OF CARE REVIEW What three (3) expectations do you have from this visit? Please rate your level of motivation to affect positive change in your health? (10=motivated) 0% % How important is your present faith/spiritual practices for you (10 = very important): 0% % Rate your stress level (10 = high) 0% % What factors most contribute to your stress?! Health! Work! Money! Family! Marriage! Other: Please describe the emotional climate of your home: What is your blood type?! A+! B+! O+! AB+! A-! B -! O-! AB- MEDICAL HISTORY Please indicate if you have had any of the following diagnostic tests performed: Notable finding: Notable finding: Thyroid Panel!Y!N Cholesterol!Y!N Liver Panel!Y!N Hormone level!y!n Complete Blood Count!Y!N EKG!Y!N Blood Sugar test!y!n Chest x- ray!y!n Colonoscopy!Y!N Mammography!Y!N Please list any past surgeries or hospitalizations, dental work and past injuries (ie. Broken bones, joint sprains, burns, falls, car accidents etc.) with the approximate dates: ADDRESS 275 LANCASTER ST W KITCHENER, ON N2H 4V2 PHONE (519) FAX (519) INFO@HEALTHMOMENTUM.CA
3 NATURAL SUPPLEMENTS & DRUG MEDICATIONS Please list all current vitamins/minerals, herbs, or homeopathic remedies that you take on a regular basis. Natural Supplements Dose/day For how long? Reason for Use Please list all your current pharmaceutical medications (prescription and over- the- counter). Drug Medications Dose/day For how long? Reason for Use Are the medications well tolerated?!y!n If no, please list the adverse reaction or side effect and from what medication: Did you have any adverse reaction to any of the childhood vaccinations?!y!n If yes, please explain. In the last 10 years, approximately how many courses of antibiotics have you taken? FAMILY HISTORY Please indicate whether any family members have had any of the following illnesses:! Alcohol/Drug abuse! Alzheimer s! Arthritis! Asthma! Cancer! Depression! Other mental illness Relation! Diabetes! Heart disease! Hypertension! Kidney disease! Osteoporosis! Stroke! Thyroid condition Relation ADDRESS 275 LANCASTER ST W KITCHENER, ON N2H 4V2 PHONE (519) FAX (519) INFO@HEALTHMOMENTUM.CA
4 LIFESTYLE Quantity/day Drink water!y!n (distilled! reverse osmosis! spring! tap!) Drink coffee!y!n (regular! decaf!) Drink wine!y!n ` Drink beer!y!n Drink pop!y!n (diet! regular!) Use artificial sweetener (splenda, aspartame etc.)!y!n Do you smoke!y!n Exposed to animals!y!n nd Exposed to tobacco smoke? (2 hand smoke)!y!n Exposed to toxins (heavy metals, mold etc.)!y!n Eat salmon!y!n, tuna!y!n Recreational drug use!y!n Dietary restrictions!y!n Vegan? Vegetarian? Other? Please list all allergies (food, medication, environmental): Do you exercise?!y!n If yes, how often and what exercise do you enjoy? Please describe a typical day s diet: Breakfast: Lunch: Dinner: Snacks: Do you eat quickly, standing up, or on the run?!y!n Anything else I should know about you: ADDRESS 275 LANCASTER ST W KITCHENER, ON N2H 4V2 PHONE (519) FAX (519) INFO@HEALTHMOMENTUM.CA
5 DECLARATION AND CONSENT TO TREATMENT Even natural therapies have the potential to cause adverse reactions. To help reduce this possibility, it is very important that you inform your naturopathic doctor of; any disease process that you are suffering from, if you are on any medication or over the counter drugs, if you are pregnant, attempting to become pregnant or you are breast-feeding. Despite intensive training and precautionary measures, there is always the possibility of health risks from natural therapies. These include but are not limited to: Aggravation of pre-existing symptoms or minor to severe allergic reactions to supplements, herbs or homeopathics. Pain, bruising, injury, fainting or tissue damage from venipuncture, bodywork, acupuncture, biopuncture or B12 injections; Fainting or puncturing of an organ with acupuncture needles; Muscle strains and sprains, disc injures from spinal manipulation. I understand that my naturopathic doctor will answer any questions that I have to the best of his/her ability. I understand that the results are not guaranteed. I do not expect the naturopathic doctor to be able to anticipate and explain all risks and complications. I will rely on the naturopathic doctor to exercise judgement during the course of the procedure which they feel at that time is in my best interests, based on the facts then known. With this knowledge, I voluntarily consent to diagnostic and therapeutic procedures mentioned above, except for: (please list exceptions below): I intend this consent form to cover the entire course of treatment for my present condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. If I am unable to make my appointment I must provide advance notification within 2 business days in which case no charge will be applied. (initial) Appointments missed without notification will be subjected to the full visit cost. THIS IS TO ACKNOWLEDGE that I have been informed and I understand that: I. Any treatment or advice provided to me as a patient is not mutually exclusive from any treatment or advice that I may receive from another licensed health care provider. II. I am at liberty and encouraged to seek or continue medical care from other Health Care providers, such a General Medical Practitioner s or Specialists. III. No employee, consultant or anyone else under the Clinic's direction is suggesting or advising me to refrain from seeking or following the directions of another licensed health care provider. IV. The treatment and therapies rendered or recommended by Dr. Sarah Millar, ND or Dr. Cecilia de Martino, ND may be different than those usually offered by a medical doctor or other licensed health care provider. Parents/Guardians I AGREE that I am solely responsible for the safety of my child/children while on the premise of Health Momentum. Children are to be supervised at all times and never left un-attended by the parent. I DECLARE that I have received a full and complete explanation of the treatment or services that I may receive by Dr. Sarah Millar, ND or Dr. Cecilia de Martino, ND and hereby authorize and consent to treatment. Client Full Name (please print) Date of Consent Client Signature Naturopathic doctor Signature ADDRESS 275 LANCASTER ST W KITCHENER, ON N2H 4V2 PHONE (519) FAX (519) INFO@HEALTHMOMENTUM.CA
6 CLINIC PRIVACY POLICY FOR COLLECTION, USE, AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our clinic, while providing you with quality naturopathic care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We will try to be as open and transparent as possible about the way we handle your personal information. All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are trained in the appropriate use and protection of your information. Our privacy policy outlines what our clinic is doing to ensure that: Only necessary information is collected about you; We only share your information with your consent; Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols; Our privacy protocols comply with privacy legislation and standards of our regulatory body, the Board of Directors of Drugless Therapy Naturopathy HOW OUR CLINIC COLLECTS, USES, AND DISCLOSES PATIENTS PERSONAL INFORMATION This clinic will collect, use and disclose information about you for the following purposes: To assess your health concerns, to provide excellent and comprehensive health care, to advise you of treatment options, to remind you of upcoming appointments, to communicate with other treating health-care providers, to comply with legal and regulatory requirements or our regulatory body, the Board of Directors of Drugless Therapy Naturopathy, to invoice for goods and services. By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of you personal information as outlined above. I have reviewed the above information that explains how your clinic will use my personal information, and the steps your clinic is taking to protect my information. I agree that Health Momentum can collect, use and disclose personal information about me as set out above in the information about the clinic s privacy policies. Client Full Name (please print) Date of Consent Client Signature Naturopathic doctor Signature ADDRESS 275 LANCASTER ST W KITCHENER, ON N2H 4V2 PHONE (519) FAX (519) INFO@HEALTHMOMENTUM.CA
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Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
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AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
PERSONAL INFORMATION. Date of Birth Age (Last) (First) (M.I.) Address City/State Zip. Phone # Home Work Cell
*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
DR. MARK HOOPER DR. MARK THURSTON DR. NICK HERBERT
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Women s Fertility Intake Date:
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ADULT CLIENT INFORMATION SHEET Date of Initial Appointment:
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Office Location: Media Glen Mills Havertown Date of Evaluation. Last Name, First, Address. City State Zip. Home Phone: ( ) -- Work Phone:( ) -- SS#
Pain Relief and Physical Therapy 203 E Baltimore Pike, Suite 2 101 W. Eagle Road, Suite 1 Media, PA 19063 Havertown, PA 19083 Phone: 610-565-0670 Phone: 610-789-9887 Fax: 610-565-7706 Fax: 610-789-9883
(FIRST) (MIDDLE) (LAST) STREET: CITY: STATE: ZIP CODE:
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Dr Chu Acupuncture Clinic 1615 Maxwell Dr. Suite D. Hudson, WI Patient Notes
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Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
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Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY (859) General Information
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Please Read First. Thank you for your time in advance, and I look forward to working with you to achieve your optimum health.
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Arden Yingling, L.Ac., MAcOM (TX #AC01588) 9300 US 290, Austin TX 78736 512.640.9778 arden@songbirdacupuncture.com songbirdacupuncture.com New Pediatric Patient Information Child's Name Today s Date Birth
I choose not to specify
Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone