Kristy McKendrick, ND, DOM, MAcOM, LAc, Dipl. OM
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- Kevin Grant
- 5 years ago
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1 Kristy McKendrick, ND, DOM, MAcOM, LAc, Dipl. OM 2499 S. Capital of TX Hwy, Suite A200 Austin, TX Natural Medicine for the Entire Family TM PH: PERSONAL INFORMATION NAME_ DATE AGE DATE OF BIRTH MARITAL STATUS ADDRESS CITY STATE ZIP_ HOME PHONE CELL PHONE WORK PHONE ADDRESS # OF CHILDREN HEIGHT WEIGHT PREGNANT NOW OCCUPATION_EMPLOYER WHO REFERRED YOU EMERGENCY NOTIFICATION NAME RELATIONSHIP TELEPHONE CURRENT HEALTH CONCERNS LIST HEALTH CONCERNS IN ORDER OF IMPORTANCE: 1. Rate Severity 1 = Mild 10 = Worst Imaginable Date started, for how long? If you had the condition before, when? What irritates the condition? Worse at certain times of day? WHAT HAVE YOU DONE FOR THESE CONDITIONS? WAS IT OF BENEFIT? IS THIS CONDITION INTERFERING WITH ANY OF THE FOLLOWING ACTIVITIES WORK SLEEP DAILY ROUTINE SPORTS/EXERCISE OTHER 1
2 WHAT ACTIVITIES AGGRAVATE YOUR CONDITION INDICATE PAINFUL OR DISTRESSED AREAS: Please clearly mark any areas of pain (with XXX s), scars (with ) and numbness (with OOO s). PLEASE LIST OTHER DOCTORS YOU HAVE SEEN FOR THIS CONDITION 1. NAME/CITY TYPE OF DOCTOR DIAGNOSIS RESULTS DATES SEEN TREATMENT 2. NAME/CITY TYPE OF DOCTOR DIAGNOSIS RESULTS DATES SEEN TREATMENT PLEASE LIST ANY SURGERIES YOU HAVE HAD 1. TYPE: DATE: DOCTOR: 2. TYPE: DATE: DOCTOR: 3. TYPE: DATE: DOCTOR: PLEASE LIST ANY ACCIDENTS AND/OR INJURIES: AUTO, WORK-RELATED, OR OTHER 1. TYPE: DATE: HOSPITALIZED: YES NO 2. TYPE: DATE: HOSPITALIZED: YES NO 3. TYPE: DATE: HOSPITALIZED: YES NO 2
3 PREVIOUS NATUROPATHIC/ACUPUNCTURE EXPERIENCE HAVE YOU EVER CONSULTED WITH AN ND or LAC? _ IF SO, WHO? _ WERE YOU HAPPY WITH THE RESULTS OF YOUR VISIT(S)? WHAT THERAPIES WERE USED? (ACUPUNCTURE, CUPPING, MOXIBUSTION, LASER, NUTRITION CONSULTATION, HERBS, HOMEOPATHY ) HABITS Alcohol: Type Amount Smoking: Packs daily How long Interested in stopping? Caffeine: Coffee, soda or tea, cups daily Other Sleep: Difficulty falling asleep Continuity disturbances Hours of sleep per night Daytime drowsiness Other Exercise routine: How often MEDICINE / SUPPLEMENTS PLEASE LIST ALL DRUGS YOU CURRENTLY TAKE OR HAVE TAKEN IN THE PAST 6 MONTHS NAME DOSAGE FOR WHAT NAME DOSAGE FOR WHAT NAME DOSAGE FOR WHAT NAME DOSAGE FOR WHAT PLEASE LIST ALL NUTRITIONAL SUPPLEMENTS, VITAMINS, AND HOMEOPATHIC REMEDIES YOU PRESENTLY TAKE NAME FOR WHAT NAME FOR WHAT NAME FOR WHAT NAME FOR WHAT NAME FOR WHAT DIET DO YOU EAT BREAKFAST EVERY DAY? IF SO, WHAT DO YOU EAT? _ HOW MANY MEALS PER DAY DO YOU EAT? HOW MANY FRUIT SERVINGS DO YOU CONSUME PER DAY? VEGETABLES? DO YOU HAVE A SPECIAL DIET? IF SO, WHAT IS IT? DO YOU HAVE ANY FOOD ALLERGIES? IF SO, WHAT ARE THEY? HOW IS YOUR PHYSICAL HEALTH? (CIRCLE ONE) EXCELLENT GOOD FAIR POOR GETTING WORSE 3
4 MEDICAL HISTORY 4
5 FAMILY HISTORY PLEASE GIVE THE FOLLOWING INFORMATION ABOUT YOUR IMMEDIATE FAMILY: HAVE ANY BLOOD RELATIVES HAD THE FOLLOWING ILLNESSES? IF SO, PLEASE INDICATE RELATIONSHIP: RELATIONSHIP FATHER AGE IF LIVING AGE AT DEATH STATE OF HEALTH OR CAUSE OF DEATH ILLNESS DIABETES FAMILY MEMBER MOTHER CANCER BROTHERS AND SISTERS BLOOD DISEASE GLAUCOMA EPILEPSY SPOUSE ARTHRITIS BACK PROBLEMS CHILDREN HEART DISEASE GOUT HIGH BLOOD PRESSURE WHAT DO YOU HOPE TO ACCOMPLISH FROM OUR TIME TOGETHER? HOW LONG DO YOU EXPECT IT TO TAKE TO ACCOMPLISH THAT GOAL? CONSENT FOR CONSULT AND TREATMENT I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the Health Practitioner s office of any changes in my medical status. I understand acupuncture treatment to involve the use of needles, acupressure, cupping, lasers and electrical stimulation, etc. Acupuncture may affect people on all levels: physical, emotional, mental and spiritual, because it works with the whole body to create balance. I fully understand that there is no stated or implied guarantee of success or effectiveness after a specific treatment or a series of treatments. Signature Date_ (Parent or Guardian, if under 18) 5
WELCOME to the Florence Chiropractic and Wellness Center.
WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,
Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212
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Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
Surgical History Please list all operations and dates:
1 General Information *Please complete in blue or black ink only* Name: Date: Address: City: State: Zip Code: Date of Birth: Email: Telephone: (Cell) (Home) (Work) Referred by: Occupation: Primary Doctor:
Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL:
Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F M ALLERGIES TO MEDICATIONS: ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL: MAY WE LEAVE A MESSAGE? YES
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Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
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Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
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Patient Information Form
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Name: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No
Medical History Form Name: Age: Sex: M F Family Physician: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you under a doctor s care at
EGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:
EGEA MEDICAL WEIGHT LOSS CENTER Medical History Form Name: Age: Sex: M F Primary Care Physician: Home Phone : Present Status: 1. Are you in good health at the present time to the best of your knowledge?
Please Check the appropriate box: Single Divorced Married Widowed Number of Children & Ages:
Date: Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Primary Number: Secondary Number: Mobile Number: Home Email: Work Email: Date of Birth: Age: Gender: M F
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Adult Intake Form. Please complete this form before your first visit
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stoneburner acupuncture
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Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
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Phone (h) (w) (c) Address. Referred by. Birthday Age Height Weight. Ethnicity Marital Status Children. Occupation Hours in regular work week
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PEDIATRIC INTAKE. Child s Name: Date: Name of Parent(s)/Legal Guardians: Relationship to child: Address: City: State: Zip Code:
PEDIATRIC INTAKE I appreciate your willingness to fill out this form as completely as possible. It is invaluable information for developing a treatment plan tailored to your child s individual needs. General
ADVANCED NUTRITIONAL CONSULTING
ADVANCED NUTRITIONAL CONSULTING Steven Salyers DC MS CNS DACBN Certified Nutrition Specialist, Diplomat American Clinical Board for Nutrition Last Name: First Name: Street Address: City: State: Zip: Phone:
Health History. Date. Address. City State Zip. Age Height Weight BMI. Date of birth Male Female. . Are you currently a patient at OHSU?
OHSU BARIATRIC SERVICES Health History Please fill out this form completely and email or fax to the contact information at the bottom of this form. We will contact you to set up an appointment. Date Name
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WELCOME. Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally.
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I choose not to specify
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Health Appraisal Please complete all information to the best of your ability
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NEW PATIENT INFORMATION *All information provided is kept in strict confidence
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Consultation Intake Form. Name: Age: Sex: M F T Address: Phone: (day) (evening) Birth date: Present physical complaints:
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ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE AND FINANCIAL POLICY
Patient Information: Name: Date of Birth: Social Security #: Gender: Marital Status: Primary Address: City: State: Zip Code: Please put a check mark next to any phone number that we may leave a message
Chiropractic Case History/Patient Information
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History of Present Condition
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Primary Medical Associates. Patient Information Sheet:" Patient Name Date of Birth " Mailing Address: " City State Zip " Phone# (H) SS# "
1 of 10 Patient Information Sheet: Patient Name Date of Birth Mailing Address: City State Zip Phone# (H) SS# Patient s Employer Phone# ==================================================================
Welcome to Medina Family Chiropractic and Acupuncture!
Welcome to Medina Family Chiropractic and Acupuncture! Please fill out this form and return it to the front desk. Let us know if you have any questions! Personal information Date: First name: Middle name:
PATIENT HEALTH HISTORY
Big Sky Wellness Center 265 Foys Canyon Rd. Kalispell, MT 59901 406-755-4119 (office) 406-755-0577 (fax) PATIENT HEALTH HISTORY Date: Name: Physical Address: Occupation: City: State: Zip: Employer: Mailing
HILLCREST CENTRE FOR HEALTH 832 St. Clair Ave W. Toronto, ON M6C 1C1 Tel: Fax:
Adult Intake Name Date of first visit Date of birth (M/D/Y) Gender M F Address: E-mail Address: May we add you to our mailing list? (Your email address will not be shared): Y N Telephone number: Home:
NEUROLOGICAL SURGERY, P.C.
NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated
NEW PATIENT INFORMATION RECORD PATIENT INFORMATION
Zumbro Vein Institute NEW PATIENT INFORMATION RECORD PATIENT INFORMATION 501 Blackburn Drive Martinez, GA 30907 706-854-8340 Fax: 706-854-8341 www.veinsaugusta.com First Name: Last Name: MI: Social Security
Do you exercise? Yes No If yes, what kind? How often?
HEALTH PROFILE Dietary consultation involves a health profile which purpose is not to establish a diagnosis, but rather to determine a client s health status in order to guide his or her weight-loss plan.
Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No
![Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No](/thumbs/89/99616722.jpg "Welcome. In case of emergency, contact: Is condition due to an accident? [ ] Yes [ ] No")
Patient Information Welcome Who is responsible for this account? SSN Relationship to Patient Patient Name Insurance Co. Name: Preferred First Name Group #: ID #: Sex [ ] M [ ] F Age: Birthdate SS# Birthdate