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1 Adult Health Summary East Gate Health Dore Vanden Heuvel CTCMPAO # Bagot St., #108, Kingston ON K7K 3B Personal Information First Name Last Name Telephone Home/Mobile Work Home/Street Address Apt # Sex M F Other City Province Postal Code Date of Birth (DD/MM/YY) Marital Status Occupation Emergency Contact Information First Name Last Name Relationship to Patient Phone Family Doctor Name Clinic Phone Clinic Address Clinic 1
2 Ongoing Health Conditions List any ongoing conditions. Ongoing health conditions Allergies to any drugs, foods, or chemicals Drug reactions Treatments that you have tried or are currently trying Prescription medications Over-the-counter medicines, vitamins, minerals, or homeopathic remedies Past Medical History List any relevant past medical history. Hospitalizations Surgeries Prior injuries Past medical conditions 2
3 Review of Body Systems Circle C if you currently have the problem and P if you had it in the past. General Cancer Excessive hair loss Fevers/chills Sweat easily/excessively Emotional/Mental Mood swings Attempted suicide Tension Memory problems Increased irritability Easily angry Endocrine Hypothyroid Hypoglycemia Excessive thirst Immune Reactions to vaccinations Chronic swollen glands Slow wound healing Skin Rashes Acne/boils Hives Itching Head Headaches Head injury Dandruff Sensitivity to cold Sudden tiredness/weakness Time of day Rapid weight gain/loss Depression Anxiety/nervousness Poor concentration Fears/phobias Mental mistakes Hallucinations, hearing voices Sensitivity to cold Diabetes Excessive hunger Chronic infections Chronic fatigue Psoriasis Dry skin Eczema New moles/changes in moles Migraines Jaw/TMJ problems Sensitive scalp Ears Hearing loss Earaches Discharge Excess wax Ringing Chronic ear infections Itching Loss of balance/vertigo 3
4 Eyes Glasses/contacts Impaired vision Double vision Spots in eyes Redness Sensitive to light Itching Blind spot(s) Since Near sighted Far sighted Eye pain/strain Cataracts Tearing/dryness Glaucoma Discharge Blurring Colour blind Nose and Sinuses Nose bleeds Hay fever Stuffiness Sinus problems Injury Loss of smell Allergies Obstructions Mouth and Throat Frequent sore throat Grinding teeth Jaw clicks Fever blisters Gum problems Dental cavities Silver fillings Gold crowns Hoarseness Bad breath Metallic taste in mouth Canker sores Sensitive teeth Loss of teeth _ Neck Lumps Goitre Swollen glands Pain/stiffness Neurological Concussion/head injury Muscle weakness Fainting Loss of memory Vertigo/dizziness Poor concentration Paralysis Numbness/tingling Loss of coordination Seizures/convulsions Loss of balance Speech problems 4
5 Respiratory Chronic or frequent cough Spitting up mucous Wheezing Pain on breathing Shortness of breath Bronchitis Pneumonia Frequent colds Spitting up blood Chest pain Difficulty breathing Asthma Emphysema Pleurisy Cardiovascular Palpitations/irregular heart beat Stroke Rheumatic fever Phlebitis Murmur Heart disease Ankle/leg swelling Chest pain High/low blood pressure Easy bruising/bleeding Gastrointestinal Difficulty swallowing Bloating Indigestion Passing gas Change in appetite Ulcer Diarrhea Colitis Hemorrhoids Hernia Rectal pain/itching Gall bladder issues Food cravings Heartburn Belching Nausea/vomiting Change in thirst Stomach pain Spitting up blood Constipation Bloody stool Black stool Hepatitis Change in bowel movement Bowel movements per day Foods that disagree Urinary Painful urination Strong smelling urine Inability to urinate Abnormal thirst Bladder/kidney disease/infections Frequent infections Decrease in flow Frequent urination during day/night Inability to hold urine Swelling of hands/feet/ankles Kidney stones Blood/sugar/pus in urine Colour of urine Pale Yellow Dark Frothy 5
6 Reproductive Herpes Gonorrhea Genital infection HIV+ Yes No Sexually active now Yes No Pain during intercourse Yes No Chlamydia Syphilis Warts on genitals Male Hernias Testicular pain Painful erection Infertility Discharge or sores Frequent masturbation Difficult or loss of erection Lump/swelling/mass in testicles Prostate disease Female Menopause Yes No If yes, age of last menses Symptoms of menopause _ Age of first menses Regular cycle Yes No Length of cycle days Bleeding between cycles Yes No Duration of flow days Pain or cramps Yes No Clots Light Medium Heavy Before flow After flow starts Abnormal PAP Vaginal dryness Swelling/lumps in breasts Ovarian cysts Endometriosis Vaginal infections/discharge Vaginal itchiness Nipple discharges Cervical dysplasia Uterine fibroids Type of birth control Difficulty conceiving Yes No Number of pregnancies Number of live births Number of miscarriages Number of abortions Check all PMS symptoms that apply. Depression Bloating Increased appetite Weight gain Breast tenderness 6
7 Musculoskeletal Joint pain or stiffness Broken bones Muscle spasms/cramps Back pain Arthritis/rheumatism Numbness/tingling Weakness Shoulder pain Pain Use the diagrams to show where you have pain. Describe the pain. How intense is the pain?. How often do you have the pain? What helps to reduce the pain? What makes the pain worse? Signature of Patient or Decision Maker Date Relationship to patient 7
Medical History Form
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Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
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Patient Health History
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New Patient Intake Form
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Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Signature: Today s date: (Parent or Guardian if a minor)
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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
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
Patient Information Form
Tara Annesley B.Sc., N.D., C.Ht. Patient Information Form Today s day/month/year Name: (first) (middle) (last) Address: City: Postal Code: Telephone Home: Work: Cell: Date of birth: day/month/year Age:
PATIENT INTAKE AND HISTORY FORM
PATIENT INTAKE AND HISTORY FORM (Please print) Name Date of Birth Race: American Indian or Native Alaskan Asian Black/African-American Native Hawaiian or Other Pacific Islander White Refused to report/unreported
ND DSOM LAc CNS PREFERRD NAME: LEGAL NAME: PRONOUNS: GENDER: GENDER DESIGNATED AT BIRTH: DATE OF BIRTH:
PREFERRD NAME: LEGAL NAME: PRONOUNS: GENDER: GENDER DESIGNATED AT BIRTH: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: PHONE NUMBER: PERMISSION TO LEAVE MESSAGE ON VOICEMAIL: Y N EMAIL: PERMISSION TO COMMUNICATE
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
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
PATIENT INTAKE FORM. Employer Name and Address:
PATIENT INTAKE FORM Name: Date: Address: City: State: Zip: Telephone (home): ( ) (work): ( ) (cell): ( ) Email address: Age: Date of Birth: Gender: Female / Male Education: Occupation: Hours per week:
Emotional Relationships Social Life Sexually Recreation
Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we