Be Well Natural Health Clinics
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- Clarissa McCoy
- 5 years ago
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1 Be Well Natural Health Clinics Cabot Road, Suite 114 Robert Abell N.D., L.Ac. Laguna Hills, California Lisa Abell L.Ac Phone (949) Fax (949) Introduction Letter Thank you for choosing our clinic to help you with your medical needs. We are here to help in any way possible. If you have any questions, please feel free to ask. We are enclosing a new patient information packet which contains 1) History and Intake forms, 2) Patient Payment Responsibility, 3) Acknowledgment of Receipt of Notice of Privacy Practices and 4) Consent for Complementary and Alternative Services. All of these forms need to be filled out completely. If the forms are not filled out completely we will ask you to finish them before you see your doctor. This may take up some of the appointment time reserved for you. Our clinic requires a minimum 24 hour notice to cancel your appointment. There is a $ missed appointment fee for new patients and a $ missed appointment fee for follow ups. We require a credit card to secure your appointment date and time, your credit card will be automatically charged for a missed appointment. If you have any questions please feel free to contact the office during our office hours. Monday through Thursday 10am to 5pm and Fridays 10am to 1pm. We also ask that you please not wear any perfume or strong smelling lotions. Thank you. Sincerely, Be Well Natural Health Clinics
2 1 Be Well Natural Health Clinics Cabot Road, Suite 114 Laguna Hills, California Phone (949) Fax (949) Name Date Address City State Zip Code Telephone Number (home) (Work) (Cell) Address Date of Birth Age Identification/ Social Security # Gender: Male Female Single Married Partnership Separated Divorced Occupation Hours Per week Retired Employer Work address Work Phone Number How did you hear about our office? Has any other family member already been a patient at the clinic? Emergency contact Relationship Phone # Address
3 2 Health History Questionnaire SUCCESSFUL HEALTH AND PREVENTIVE MEDICINE ARE ONLY POSSIBLE WHEN THE DOCTOR HAS A COMPLETE UNDERSTANDING OF THE PATIENT PHYSICALLY, MENTALLY AND EMOTIONALLY. PLEASE COMPLETE THIS QUESTIONNAIRE AS THROUGHLY AS POSSIBLE. PRINT ALL INFORMATION AND MARK ANYTHING YOU DON T UNDERSTAND WITH A QUESTION MARK. Are you currently receiving healthcare? If yes, where and from whom? If no, when and where did you last receive medical or health treatment? What was the reason? What are your most important health problems? List in order of importance: 1) 2) 3) 4) 5) Do you have any known contagious diseases at this time? If yes, what?
4 3 Family History Age (if living) Health (G=good/P=poor) Age at death Check those applicable Cancer Diabetes Heart Disease High Blood Pressure Stroke Epilepsy Mental Illness Asthma/Hay fever/hives Anemia Kidney Disease Glaucoma Tuberculosis Cause of death Father Mother Brother Sister Spouse Child For all the following sections please write Y, P or N on the line: Y= a condition you have now P= a condition you have had N= never had Childhood Illness Scarlet fever? Diphtheria? Rheumatic fever? Mumps? Measles? German measles? Hospitalizations and Surgery What hospitalizations or surgeries have you had?
5 4 X-Rays and Special Studies X-rays, CAT scans, or other studies you have had: Electrocardiogram? Electroencephalogram? Immunizations Polio? Pertussis? Tetanus Shot? Diphtheria? Measles? Other? Allergies Are you hypersensitive or allergic to: Any drugs? Any foods? Any environmental? Current Medications Do you take or use? Laxatives? Pain Relievers? Antacids? Cortisone? Appetite Suppressant? Antibiotics? Tranquilizers? Thyroid Medication? Sleeping Pills? Prednisone? Hormone Replacement Therapy? Birth Control? Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking. 1) 2) 3) 4) 5) 6)
6 5 Breakfast: Lunch: Dinner: Snacks: Drinks: Foods you crave: Foods you dislike: Foods you are allergic/sensitive to: Typical Food Intake General Height: Weight: Weight 1 yr ago: Max Weight: When: When during the day is your energy the best? The worst? Mental /Emotional Treated for emotional problems? Mood Swings? Considered/Attempted Suicide? Poor concentration? Depression? Anxiety? Tension? Memory Problems? Endocrine Hypothyroid? Hypoglycemia? Excessive thirst? Fatigue? Heat or cold intolerance? Diabetes? Excessive Hunger? Seasonal Depression? Immune Vaccinations? Chronic fatigue Syndrome? Chronically swollen glands? Reactions to vaccinations? Chronic Infections? Slow wound healing?
7 6 Seizures? Muscle weakness? Loss of memory? Vertigo or dizziness? Neurological Paralysis? Numbness or tingling? Easily stressed? Loss of balance? Joint pain or stiffness? Broken bones? Muscle spasms or cramps? Muscoskeletal Arthritis? Weakness? Sciatica? Easy bleeding or bruising? Deep leg pain? Varicose Veins? Blood/Peripheral vascular Anemia? Cold hands/feet? Thrombophlebitis? Skin Rashes? Eczema/Hives? Acne/Boils? Color change? Perpetual hair loss? Lumps? Night sweats? Head Headaches? Head injury? Migraines? Jaw/TMJ problems? Spots in eyes? Impaired vision? Blurriness? Color blindness? Double vision? Eyes Cataracts? Glasses or contacts? Eye pain/strain? Tearing/dryness? Glaucoma?
8 7 Nose and Sinus Frequent colds? Stuffiness? Sinus Problems? Nose bleeds? Hay fever? Loss of smell? Mouth and Throat Frequent sore throat? Teeth grinding? Gum problems? Dental cavities? Copious saliva? Sore tongue/lips? Hoarseness? Jaw clicks? Neck Lumps? Goiter? Swollen glands? Pain/Stiffness? Respiratory Cough? Spitting up blood? Asthma? Pneumonia? Emphysema? Pain on breathing? Shortness of breathing at night? Sputum? Wheezing? Bronchitis? Pleurisy? Difficulty breathing? Shortness of breath? Shortness of breath lying down? Cardiovascular Heart disease? High blood pressure? Murmurs? Fainting? Rheumatic fever? Swelling in ankles? Angina? Low blood pressure? Blood clots? Phlebitis? Palpations/Fluttering? Chest pains?
9 Gastrointestinal 8 Trouble swallowing? Change in thirst? Nausea? Vomiting blood? # of Bowel Movements per week? Is this a change? Constipation? Diarrhea? Gall bladder disease? Ulcer? Hemorrhoids? Heartburn? Change in appetite? Vomiting? Blood in stool? Pain/Cramps? Belching/Gas? Black stools? Jaundice? Liver disease? Urinary Pain on urination? Frequency at night? Frequent infections? Increased frequency? Inability to hold urine? Kidney stones? Male Reproduction Hernias? Testicular pain? Venereal disease? Are you sexually active? Sexual orientation? Impotence? Premature ejaculation? Syphilis? Testicular masses? Prostate disease? Discharge/sores? Chlamydia? Gonorrhea? Condyloma? Herpes? Birth control? What type?
10 9 Female Reproduction Age of 1 st menses? Are cycles regular? Bleeding between cycles? Painful menses? Heavy/Excessive flow? PMS? PMS Symptoms? Birth Control? Number of pregnancies? Number of miscarriages? Endometriosis? Date of last menses? Length of cycle? Duration of menses? Clotting? Discharge? Sexually active? What type? Number of live births? Number of abortions? Ovarian cysts? Difficulty conceiving? Menopausal Symptoms? Pain during intercourse? Chlamydia? Herpes? Syphilis? Sexual orientation? Cervical Dysplasia? Abnormal PAP? Sexual difficulties? Gonorrhea? CondylomA? Do you do breast exams? Breast tenderness/lumps? Nipple discharge?
11 10 Habits Main interest and hobbies? Do you have a religious or spiritual practice? Do you exercise? What kind of exercise? How often? What? Hours of sleep? Sleep well? Awaken rested? Have a supportive relationship? Have a history of abuse? Any major traumas? Used recreational drugs? Been treated for drug dependence? Do you eat three meals a day? Do you go on diets often? Do you drink coffee? Do you drink black/green tea? Do you drink cola/soda? packs per day? Do you eat refined sugar/artificial sweeteners? Do you add salt? How does your condition affect you? Enjoy your work? Take vacations? Spend time outside? Watch television? How many hours? Read? How many hours? Use alcoholic beverages? Treated for alcoholism? Do you use tobacco? Smoked previously? How many years? How many
12 11 What do you think is happening? Why? What do you feel needs to happen for you to get better? What do you enjoy most about your life? How much effort are you willing to make at this time to improve your health? [ ] Minimal [ ] Some [ ] Complete
13 12 Please write any additional information below: Welcome! Please bring in any and all medications, vitamins or supplements you are currently taking. If you have any questions, please ask!
14 13 Patient Payment Responsibility Agreement Dear Patient, This letter is to keep you informed of the policies regarding your payment responsibilities. AS a patient of Be Well Natural Health Clinics you are responsible for the total charges incurred from each visit to your practitioner. Charges are to be paid at the time of each visit. We recognize and appreciate that health care can involve major financial commitment. We aim to provide you with effective and affordable health care. Visa, MasterCard, Discover, American Express, Checks and Cash are all acceptable forms of payment. For insurance companies that cover alternative and complementary services we will assist you in billing your insurance company. Please remember that you have the primary relationship with your insurance company and you are responsible for the total amount owed at the time of your visit. We will provide you with the appropriate super-bill with the appropriate codes needed for you to be reimbursed by your insurance company. You will need to mail the super-bill provided to your insurance company and your insurance company will reimburse you for all the amounts covered. Before your first visit contact your insurance company or refer to your insurance contract agreement regarding coverage for Alternative and Complementary medical services. Items to note are: 1)the service is covered, 2)for which diagnosis is covered, 3) how many visits are allowed per calendar year, 4) the amount of your deductible, 5) are there any limitations. Answers to these questions will help clarify treatment and financial responsibility. Patients will be billed a missed appointment fee for any missed appointment or cancellation with less than a 24 hour notice. This charge will not be submitted to your insurance. Payment for all pharmacy items is due at the time of the visit. Most insurance companies do not cover Naturopathic pharmacy items. Please sign this form acknowledging you have read and agreed to the above notice. Please feel free to contact us regarding any questions. Signature: I have read the above stated policies of Be Well Natural Health Clinics and will comply with them henceforth.
Adult Health History
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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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.
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Medical History Form
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Adult Intake Form. Full name: Address: Province: City: Postal Code: Telephone number: Home: ( ) -
Adult Intake Form Personal Information: Full name: Date of Birth / / Gender: Today s Date: / / Occupation: Address: Province: City: Postal Code: Telephone number: Home: ( ) - Work: ( ) - Mobile: ( ) -
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
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Adult Health Summary East Gate Health Dore Vanden Heuvel CTCMPAO #1063 348 Bagot St., #108, Kingston ON K7K 3B7 613.545.3598 Personal Information First Name Last Name Telephone Home/Mobile Work Home/Street
MEDICAL HISTORY RECORD
MEDICAL HISTORY RECORD Please print and complete all information. Case. Male Female Medicare. Medicaid. Today s Date Birthdate Last Name First Middle Daytime Phone Home Phone Address City Marital Status
Revolutionizing Treatment * Restoring Hope * Improving Lives
Revolutionizing Treatment * Restoring Hope * Improving Lives 6802 S. Olympia Ave., Suite G100 Tulsa, Oklahoma 74132 Phone: 918-949-6676 Fax: 918-949-6670 Please fill out the all paperwork and bring it
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Naturopathic New Patient Form
611 Main St., Suite A Edmonds, WA 98020 Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Email: Marital Status: Emergency Contact:!!!!
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:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
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:
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-
I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION
PERSONAL INFORMATION NAME: TODAY'S DATE: ADDRESS HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: PHONE: HOME MOBILE WORK EMAIL ADDRESS: EMERGENCY CONTACT: STATUS: SINGLE MARRIED DIVORCED WIDOWED OTHER: NUMBER
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
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
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
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
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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
Fertility HEALTH HISTORY
Fertility HEALTH HISTORY Female Name: First Middle Initial Last Preferred name Male Name: First Middle Initial Last Preferred name Address: City: State: Zip code: Contact numbers: home work/cell: Please
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
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:
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
Health History Questionnaire Date: / /.
Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:
Adult Demographics Form
Adult Demographics Form Patient s Name: Preferred Name: Age: Patient s Social Security Number: Date of Birth: Sex: M / F Home Address: Apt: City: State: Zip: Cell phone #: Home Phone #: Work phone #: Email: