Client Name: Date: Birthdate: Age: Gender: F M Address: City State Zipcode phone # home: cell: work:
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1 Client Name: : Birthdate: Age: Gender: F M Address: City State Zipcode phone # home: cell: work: Thermogram Hx: type: initial ROI scan follow-up ROI scan initial fullbody scan follow-up fullbody last thermogram date: total # previous scans: (prior to appointment today) I am requesting that my thermography results be sent to my healthcare provider: Yes No My provider s name, address, and phone number is: Client Signature: Male History: Please answer questions below by placing a check mark in the yes or no column yes no 1. Have you had an annual physical examination by a doctor? 2. Have you had a prostate exam? last exam: normal: yes no 3. Have you had your PSA tested? lab value: normal: yes no 4. How many children do you have? How old were you when your first child was born? 5. other: Have your had any past surgeries: any kind of surgery What year? any kind of surgery: What year? any kind of surgery: What year? any kind of surgery: What year? Other client history: Please answer questions below by placing a check mark in the hes or no column yes no 1. Do you currently smoke never current smoker How many years total did you smoke? How long since you stopped smoking? <12 months > 5 yrs >10 yrs > 20 yrs 2. Allergies: food environmental meds (describe): 3. other: Comments:
2 Name date: Current medications/supplements: Current Prescribed Medications (include # of months or years on medication): #yrs: -#mo -#yrs: -#mo #yrs: -#mo -#yrs: -#mo #yrs: -#mo -#yrs: -#mo Current Supplements (include # of months or years on supplementation): #yrs: -#mo #yrs: #mo #yrs: -#mo #yrs: #mo #yrs: #mo #yrs: #mo Current Symptoms: please check all that apply: General Symptoms tires easily, fatigue weight increase weight loss (unintentional) night sweats sensitivity to heat sensitivity to cold excessive thirst other CardioRespiratory: persistent cough sputum production (phlegm) wheezing chest pain shortness of breath trouble-breathing lying down palpitations other Musculoskeletal: muscle cramps muscle weakness joint pain joint stiffness swollen joints sprained/broken bones describe body part/s affected: Ears, Nose, Throat, Mouth ringing in ears R L loss of hearing R L loss of smell postnasal drip sinus congestion chronic cough dry, sore throat sore gums other Digestive Symptoms: nausea constipation diarrhea excessive gas, bloating heartburn (acid stomach) difficulty swallowing change in appetite other Nervous System: insomnia headaches dizziness memory loss loss of coordination other Genital/Urinary Tract: \ excessive Family urination, History frequency pain with urination decreased force of urine stream irregular menstrual periods excessive menstrual bleeding other Psychoemotional: depression irritiability lack of sex drive/desire change in personality mood swings other Comments:
3 Name_date: IHS client Hx page 2 Diagnoses/clinical concerns: Please answer questions below by placing a check mark in the yes or no column yes no 1. Have you ever been diagnosed with prostate cancer? month/year diagnosed? How was the cancer detected? self exam clinical exam thermogram ultrasound 2. Do you have any of the following (briefly describe)? how long? # mo # yrs yes no other cancer (type): thyroid problems: blood sugar problems: hormone imbalance: gallbladder disturbances: migraines/frequent headaches: sleep disturbance/insomnia: chronic fatigue/fibromyalgia: chronic pain/injury: arthritis: osteopenia.osteoporosis: adrenal fatigue/chronic stress: kidney concerns dental problems (left upper left lower right upper right lower ) chronic sinusitis: gastrointestinal disturbance: heart concerns: hypertension: lung disease (type): liver dysfunction: other:
4 Name: Today s date IHS client Hx Family History Family Health Status: deceased breast prostate other cancer heart high stroke obesity diabetes thyroid cancer cancer cancer type disease BP problem *(check all that apply) (yes) (yes) (yes) (yes) (describe) (yes) (yes) (yes) (yes) (yes) (yes) Mother Father Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Maternal Aunt Maternal Aunt Maternal Uncle Maternal Uncle Maternal Cousin Maternal Cousin Paternal Aunt Paternal Aunt Paternal Uncle Paternal Uncle Paternal Cousin Paternal Cousin
5 7606 N. Union Blvd, Suite A Colorado Springs, CO (719) * (719) fax Medical Disclaimer Agreement Integrated Health Solutions was created to provide personalized approaches to health and optimal wellness by bridging conventional medical healthcare with holistic programs. The intent is that IHS providers will partner with our clients to design a comprehensive package of assessment and healing for those seeking wholeness and health. If you wish to treat a specific disease or condition you should consult with a licensed medical physician. Integrated Health Solutions will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising there from. Print Name Signature Witness
6 7606 N. Union Blvd. Suite A Colorado Springs, CO (719) * (719) fax Shared Information Agreement Integrated Health Solutions was created to provide personalized approaches to health and optimal wellness by bridging conventional medical healthcare with holistic programs. The intent is that IHS providers will partner with our clients to design a comprehensive package of assessment and healing for those seeking wholeness and health. To ensure the maximum knowledge and creative potential of the IHS practitioners, it is essential to share all of their insights from their assessment and healing approaches with the client. This means that there will be one file that all practitioners can access and put information into and it also means dialogue will take place. IHS is committed to working with the clients doctor and sharing all information. This means the doctor will share his/her findings and lab and x-ray reports with IHS and vice versa. I, agree that IHS may share all clinical findings with each other and with my physician, Dr. _. I also agree that my physician may share all his/her clinical findings with IHS practitioners. I would like IHS to exchange and share all clinical information with the following practitioners, who are also involved in my care planning Print Name Signature Witness
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Client Name: Date: Birthdate: Age: Gender: F M Address: Phone # home: cell: work:
7606 N. Union Blvd. Ste. A Colorado Springs, Colorado 80920 phone: 719-573-2254 New Client Female History Client Name: Date: Birthdate: Age: Gender: F M Address: Email: Phone # home: cell: work: Thermogram
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Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
History Form for Exceptional Home-Based Care
Patient Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best care possible
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
SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE
Patient Name MRN DATE: SURGICAL BREAST PRACTICE NEW PATIENT QUESTIONNAIRE Date of birth Age REASON FOR VISIT Abnormal Mammogram R L please specify Lump/Thickening R L upper lower inner outer Pain R L upper
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
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
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