INTAKE FORM. Last Name First Name. Address. City State Zip. Home Phone ( ) Work ( ) Occupation. D.O.B. Height Weight Gender
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1 INTAKE FORM Initial Appointment Date Last Name First Name Address City State Zip Home Phone ( ) Work ( ) Cell ( ) (office use only) Occupation D.O.B. Height Weight Gender Marital Status: Single Married Partnered Divorced Separated Widow(er) Emergency Contact (name/number) Who referred you? Where exactly is the problem? Outline your discomfort in red Coach Izzy s Healing and Strength is a division of Integrated Healing and Strength Systems, Inc.
2 Rate the recent level of pain by shading in the thermometer below. Has it been getting BETTER or WORSE? (Circle one) Describe how it feels: (aching, cramping, dull, sore, deep, sharp, shooting, stabbing, stinging, tingling, burning, numbness, radiating - if so where?) How did it start the first time and this time, if this is not the first? (Sudden or gradual onset and mechanism of injury) How often does it bother you? All the time x per week x per month How long does it last once it is there? Always there minutes/hours No pattern What makes it feel worse? What makes it feel better? Do you have a diagnosis from a Doctor? If, yes please list it. 2
3 What other therapies/remedies have you tried? What were the results? Have you ever had any surgeries and were they beneficial at the time? List any other health problems for which you are being treated: Do you have any preexisting conditions that relate to this present injury? Yes No If yes, please explain: Current Medications: What do you believe caused or is causing this condition? Do you believe it is possible to heal 100%? If not, what %? And why? How long do you feel it will take? How would your life improve when you resolve this issue(s)? 3
4 On a scale of 0-10, how much effort are you willing to put in to achieve maximum healing? Circle the level of stress you are experiencing on a regular basis on a scale of 1 to 10 (1 being the lowest): (please continue on next page) 4
5 General Medical History Arthritis Allergies Asthma Alcoholism Alzheimer s disease Autoimmune Disease Blood pressure problems Bronchitis Cancer Chronic fatigue syndrome Carpal Tunnel syndrome Cholesterol, elevated Circulatory problems Colitis Dental Problems Depression Diabetes Diverticular Disease Drug addiction Eating Disorder Epilepsy Emphysema Eyes, ears, nose, throat problems Environmental sensitivities Fibromyalgia Food intolerance GERD Genetic Disease Glaucoma Gout Heart Disease Infection, chronic Inflammatory Bowel Disease Irritable Bowel Syndrome Kidney or Bladder Disease Learning Disabilities Liver or gallbladder disease (stones) Mental Illness Migraine Headaches Neurological problems (paralysis, Parkinson s) Sinus Problems Stroke Thyroid trouble Obesity Osteoporosis Pneumonia Sexually Transmitted Disease Seasonal Affective disorder Skin Problems Tuberculosis Ulcer Urinary Tract Infection Varicose Veins Other Medical (Women) Menstrual Irregularities Endometriosis Infertility Fibrocystic breasts Fibroids/ovarian cysts PMS Breast Cancer Pelvic Inflammatory Disease Vaginal Infections Decreased Sex Drive STD Other Age of first period: Date of last gynecological exam Mammogram + PAP + Form of Birth Control # of Children # of Pregnancies C-Section Surgical Menopause Menopause Date of last menstrual cycle Length of Cycle: Days Interval of time between cycles Days: Any recent changes in normal menstrual flow (e.g. heavier, large clots) Family Health History (Parents and Siblings) Arthritis, rheumatoid Asthma Alcoholism Alzheimer s disease Cancer Depression Diabetes Coach Izzy s Healing and Strength is a division of Integrated Healing and Strength Systems, Inc.
6 Drug Addiction Easting Disorder Genetic Disorder Glaucoma Heart Disease Infertility Learning Disabilities Mental Illness Mental Retardation Migraine Headaches Neurological Disorders (Parkinson s, paralysis) Obesity Osteoporosis Stroke Suicide 0ther: Health Habits Tobacco Cigarettes # /day Cigars #/day Alcohol Wine: # glasses/ d or wk Beer: # glasses/ d or wk Liquor: # ounces/ d or wk Coffee: # 6 oz cups/ d Tea: # 6 oz cups/ d Soda w. Caffeine: # cans/ d Other Sources Water: # glasses/ d Current Supplements Multivitamins Vitamin C Vitamin E EPA/DHA Evening Primrose/ GIA Calcium, source Magnesium Zinc Minerals, describe Friendly Flora (acidophilus) Digestive Enzymes Amino Acids CoQ10 Antioxidants (e.g. lutein, resveratrol, etc.) Herbs (teas) Herbs-extracts Chinese Herbs Ayurvedic herbs Homeopathy Bach Flowers Protein Shakes Super-foods (e.g. bee pollen, Phylonutrient blends Liquid Meals (e.g. Ensure) Other: Would you like to: Have more energy Be stronger Have more endurance Increase your sex drive Be thinner Be more muscular Improve you complexion Have stronger nails Have healthier nails Be less moody Be less depressed Be less indecisive Feel more motivated Be more organized Think more clearly and be more focused Improve memory Do better on tests in school Not be dependent on over-the-counter medications like aspirin, Tylenol Benadryl, Sleeping Aids Stop using laxatives or stool softeners Be free of pain Sleep better Have agreeable breath Have agreeable body odor Have stronger teeth Get less colds/flus Get rid of your allergies Reduce your risk of inherited disease tendencies (e.g. cancer, heart disease, diabetes, etc.) 6
7 Read This! I ll need your help with the following, so we can have the best session possible: Your intake form Have it filled out and ready to save us lengthy history intake. My policies Go over them. They cover rate structure, scheduling, cancellation, and other important topics. Location My address and a map link are included in your confirmation. I have also included directions in the last page of this form. Strenuous Exercise Avoid it at least 3 hours prior to your session (to prevent false diagnosis) and up to 48 hours after (to prevent flare-ups or relapses). These restrictions might change depending on your case. Your Outfit and Hygiene Wear clean, light workout clothes and socks. Avoid lycra, bras with wires, fragrances, hair grooming products, heavy moisturizing lotions, and OTC topical balms. Refer to section 6 of policies. Have Your Payment Ready Credit cards only. Be Properly Hydrated And avoid heavy meals, alcohol, and tobacco. Finally Bring an open mind and a good attitude Thank you and let s make this a remarkable first step in your healing journey. I look forward to working with you. 7
8 Policies (Please Keep) The following procedures minimize your costs, protect your privacy, and ensure a pristine and comfortable environment for your therapy. 1) Cancellations/Rescheduling 48 Hours (two business days) for all appointments. No-Shows or Late-Cancellations incur full billing rate. 2) Rates One Hour (4 Units) $130 if paid same day, $170 if billed (full billing rate). Forty Minutes (3 Units) $95 if paid same day, $125 if billed (full billing rate). 3) Payment Methods Credit cards only. Visa, Master Card, Discover, and American Express, including cards linked to HSA/Flexible Spending Accounts. 4) Unpaid Bills Unpaid bills (including No-Shows and Late Cancellations) go to collections after two months (or sixty days) of initial billing date. All collections conducted by Parson-Bishop Services, Inc. 5) Itemized Bills Provided at the end of your sessions if requested. Your itemized bill contains the dates and length of your sessions, the amount you paid, as well as the CPT (Procedure Code) (Manual Therapy) or (Massage Therapy). 6) Extra Clean Up Fee The following incurs a $35 extra clean-up fee: exercise sweat, hair grooming products, grease, dirt, mud, and topical balms (Bengay, Tiger Balm, Icy patch, etc.). You will be informed. For sanitary reasons, no animals are allowed. 7) Manual Cancellation/Rescheduling Fee The full details are in this link: 8) Better safe than sorry If you are symptomatic, cancel your appointment within the allotted time. Many of my patients are in frail health and I cannot risk exposing them. 9) s, phone calls Conducted during business hours only. Please check website for current business hours. 10) Companions Only patients are allowed in the treatment room. Exceptions granted for minors and medically approved cases (must provide proof). All other companions must remain in the common waiting area. 11) Recordings Absolutely no recordings of the session in any form or media. Exceptions granted only through mutual legal representation at your expense. Thank you respecting not only my practice, but also your fellow patients. 8
9 Directions to my Office Address is 9431 Coppertop Loop NE, Suite 102 A3, Bainbridge Island, WA Take Route 305 onto Sportsman Club Road NE. Turn onto NE Business Park Ln and make the first left onto Coppertop Park Business Complex. Make the second right. I m located in the very first building on the ground floor (9431). Look for my signs. Please announce your arrival by flipping the switch in the directory panel in the common waiting area. I ll come out to greet you. Call Ext. 101 if you need assistance. I ll see you soon! 9
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Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH p: f:
New Patient Intake Form 4 Market Place, PO Box 1585, Hollis, NH 03049 p: 603.465.2235 f: 603.465.2236 About You Last Name: First Name: Middle Initial: Nickname: Date of Birth: Age: Gender: [ ] M [ ] F
Medical Health Questionnaire
Medical Health Questionnaire New Patient Name Change Address Change Insurance Change ALL SECTIONS MUST BE COMPLETED FOR ALL PATIENTS: Today s Date / / Patient Name: Last First Middle Initial Date of Birth:
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Personal Information Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
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:
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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 HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
IN CASE OF AN EMERGENCY NOT LIVING WITH YOU
GENERAL INFORMATION Name (as it appears on insur card) Address City State Zip Home phone Cell Email Marital status DOB SS# Employer Work # Parent name (if minor) IN CASE OF AN EMERGENCY NOT LIVING WITH
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX
TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES 13414 Medical Complex Drive, Suite 6 Tomball, TX 77375 281-516-0212 Welcome! We are glad that you have chosen Tomball Regional Internal Medicine Associates
North Georgia Urology Center, P.C. Urology Patient Questionnaire
Today s Date North Georgia Urology Center, P.C. Urology Patient Questionnaire Dear Patients: to help the urologist give you better care, please take a moment of valuable time to answer the following questions.
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal