Employer. Why did you choose to come to our clinic? Whom may we thank for referring you? Reason for visit
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1 Wholistic Medicine Specialists of Atlanta Bradley Bongiovanni, ND 1055 Powers Place, Suite A Alpharetta, GA (fax) drb@wmsoa.com Name DOB Address Phone Work Phone Employer Occupation Why did you choose to come to our clinic? Whom may we thank for referring you? Reason for visit How long have you had this concern/condition? I think my health problems are caused by I have seen these other practitioners for my health: Review of Systems (check all apply) Have Now Had in Past Have Now Had in Past Anxiety Depression Fatigue Auto-Immune Disease Digestive problems Thyroid disease Infertility Heart disease Skin problems Asthma Insomnia Cancer Diabetes Osteoporosis Headaches Arthritis PMS Irregular cycles _ High Blood Press Chronic Infection Stress Other
2 I am allergic to Previous surgeries (with dates) Recent medical tests (type/dates) Other medical conditions I should know about I take the following medications/supplements: Antibiotics Heart medicine Minerals Vitamins Anti-depressants Herbs Pain relievers Other Blood thinners Insulin Sedatives Other Chemotherapy Laxatives Sleeping pills Other The following are part of my life (to the degree indicated): None Small Medium Large None Small Medium Large Alcohol Sugar Caffeine Exercise Nicotine Fun Stress Meditation Are you familiar with Naturopathic Medicine? Very Much A Moderate Amount Some Little None Is it okay to leave messages regarding your care on your answering machine? Further information you wish to provide: What are your goals/expectations for the appointment(s)? What do you know about our approach? In what SPECIFIC ways are your health problems impacting what you LOVE to do?
3 Typical Food Intake Breakfast: Lunch: Dinner: Snacks: Drinks through the day: Sweets: Dairy products: Alcohol: Exercise Do you exercise? How often? What kind/type? Lifestyle/Habits Do you smoke? Do you use recreational drugs? Do you enjoy your work? Do you have a religious or spiritual practice? About You and Your Expectations Why did you decide to pursue naturopathic healthcare with Dr. Bongiovanni? Wouldn t it be GREAT if my doctor What is your present level of commitment to address any underlying causes of your signs and symptoms which relate to your lifestyle? (Be honest with yourself here.) Rate from What behaviors/lifestyle choices/habits do you currently engage in that support your health? What behaviors/lifestyle choices/habits do you currently engage in that are detrimental to your health? What potential obstacles do you foresee in addressing the lifestyle factors which are undermining your health and in adhering to the therapeutic protocols which we will be sharing with you? Who can support you with the lifestyle changes you will be making?
4 Mental/Emotional Inventory Choose one statement from among the group of four statements in each question that best describes how you have been feeling during the past couple weeks. Circle the number beside your choice. Total your score at the end and inform your health care provider. 1 0 I do not feel sad. 1 I feel sad. 2 I am sad all the time and I can't snap out of it. 3 I am so sad or unhappy that I can't stand it. 2 0 I am not particularly discouraged about the future. 1 I feel discouraged about the future. 2 I feel I have nothing to look forward to. 3 I feel that the future is hopeless and that things cannot improve. 3 0 I do not feel like a failure. 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failure. 3 I feel I am a complete failure as a person. 4 0 I get as much satisfaction out of things as I used to. 1 I don't enjoy things the way I used to. 2 I don't get any real satisfaction out of anything anymore. 3 I am dissatisfied or bored with everything. 5 0 I don't feel particularly guilty. 1 I feel guilty a good part of the time. 2 I feel quite guilty most of the time. 3 I feel guilty all of the time. 6 0 I don't feel I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished. 7 0 I don't feel disappointed in myself. 1 I am disappointed in myself. 2 I am disgusted with myself. 3 I hate myself. 8 0 I don't feel I am any worse than anybody else. 1 I am critical of myself for my weaknesses or mistakes. 2 I blame myself all the time for my faults. 3 I blame myself for everything bad that happens. 9 0 I don't have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance I don't cry any more than usual. 1 I cry more now than I used to. 2 I cry all the time now. 3 I used to be able to cry, but now I can't cry even though I want to I am no more irritated by things than I ever am. 1 I am slightly more irritated now than usual. 2 I am quite annoyed or irritated a good deal of the time. 3 I feel irritated all the time now I have not lost interest in other people. 1 I am less interested in other people than I used to be. 2 I have lost most of my interest in other people. 3 I have lost all of my interest in other people I make decisions about as well as I ever could. 1 I put off making decisions more than I used to. 2 I have greater difficulty in making decisions than before. 3 I can't make decisions at all anymore I don't feel that I look any worse than I used to. 1 I am worried that I am looking old or unattractive. 2 I feel that there are permanent changes in my appearance that make me look unattractive. 3 I believe that I look ugly.
5 15 0 I can work about as well as before. 1 It takes an extra effort to get started at doing something. 2 I have to push myself very hard to do anything. 3 I can't do any work at all I can sleep as well as usual. 1 I don't sleep as well as I used to. 2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 3 I wake up several hours earlier than I used to and cannot get back to sleep I don't get more tired than usual. 1 I get tired more easily than I used to. 2 I get tired from doing almost anything. 3 I am too tired to do anything My appetite is no worse than usual. 1 My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 I have no appetite at all anymore I haven't lost much weight, if any, lately. 1 I have lost more than five pounds. 2 I have lost more than ten pounds. 3 I have lost more than fifteen pounds. (Score 0 if you have been purposely trying to lose weight.) 20 0 I am no more worried about my health than usual. 1 I am worried about physical problems such as aches and pains, or upset stomach, or constipation. 2 I am very worried about physical problems, and it's hard to think of much else. 3 I am so worried about my physical problems that I cannot think about anything else I have not noticed any recent change in my interest in sex. 1 I am less interested in sex than I used to be. 2 I am much less interested in sex now. 3 I have lost interested in sex completely. Please add the total score here: Total Score =
6 Informed Consent Referral Source: Nature and Purpose of Assessment: The goal of a naturopathic assessment is to determine the underlying cause(s) of your health concerns and to treat them effectively with safe, natural and non-toxic therapies. In addition to an interview where we will be asking you questions about your background and current medical symptoms, we may be using laboratory tests including but not limited to conventional blood testing (CBC and chemistry testing) and functional testing (nutritional, hormonal, and food allergy). Communication: Speaking with Dr. Bongiovanni should be primarily reserved for office visits. ing quick questions or comments is perfectly acceptable. Phone conversations less than 5 min are also acceptable. Phone conversations greater than 5-10 min will be billable for time. Laboratory testing: Lab results typically require 2-3 weeks from the time the lab receives your specimen. Lab results will be reviewed and explained at your follow up visit Fees: Payment does NOT include laboratory testing or supplements Please pay consultation fee using cash, check, or credit card at time of service Effective January 1, 2013: Initial-Comprehensive Visit = $245 (60 min) Follow up visit = $95 (30 min) Limits of Confidentiality: Information obtained during assessments is confidential and can ordinarily be released only with your written permission. There are some special circumstances that can limit confidentiality including: a) a statement of intent to harm self or others, b) statements indicating harm or abuse of children or vulnerable adults; and c) issuance of a subpoena from a court of law. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment, nor will it affect my eligibility for benefits. I also understand that I may revoke this authorization at any time by notifying the practitioner in writing. I have read and agree with the nature and purpose of this assessment and to each of the points listed above. I have had an opportunity to clarify any questions and discuss any points of concern before signing. Patient Signature Date Parent/Guardian or Authorized Surrogate (if applicable) Date
7 Medical Records Release Form Patient Name: Address: City: State: Country: Zip/Postal Code: Telephone: Fax: Date of Birth: Social Security Number: Doctor/Practice: Phone: Address: Fax: City: State: Zip: I authorize the release of my medical records or other health care information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information concerning my health and treatment during the period of to ; to be sent to the following person or company: Wholistic Medicine Specialists of Atlanta 1055 Powers Place, Suite A Alpharetta, GA (fax) * Please send the following health records: Patient Signature: Date:
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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
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Address
First Name Middle Last Today s Date / / Age Male/Female Date of Birth / / SS# - - Address City State ZIP Phone: Home Cell Phone Provider Email Address Do you have Medicaid? Y / N (present your card to
Niroga Ayurveda Restore & Balance Body, Mind, & Spirit (949)
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DENTAL QUESTIONNAIRE
Name: (First) (Last) (Preferred) Birthdate: (Month) (Day) (Year) Gender: Male Female Address: City: Prov: Postal Code: Cell Phone: (Number will be used for confirmation of appointments) Email Address:
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
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PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY
PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:
PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:
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UW MEDICINE PATIENT EDUCATION. Baby Blues and More. Postpartum mood disorders DRAFT. Emotional Changes After Giving Birth
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ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
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Do not write below this line DSM IV Code: Primary Secondary. Clinical Information
New Client Registration Today s date Name Age Sex Address Social security # Date of birth Home phone May I call you at this number? y / n Leave a message? y / n Other numbers at which I can call you Can
Christina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
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