* * For Prevention & correction of Health Disorders. For details: MALLUR FLORA AND HOSPITALITY PVT. LTD

Size: px
Start display at page:

Download "* * For Prevention & correction of Health Disorders. For details: MALLUR FLORA AND HOSPITALITY PVT. LTD"

Transcription

1 For Prevention & correction of Health Disorders * * For Prevention & correction of Health Disorders For details: MALLUR FLORA AND HOSPITALITY PVT. LTD No 11 RBI Colony, Near Punjab National Bank, Anand Nagar Bengaluru Mobile: Design : LUMOS.in Good Manufacturing Practice

2 Ayurveda: The Knowledge Of Life Introducing Elixir for Life Vedas (sacred-knowledge) are ancient doctrines of great knowledge, acknowledged to be of relevance in the modern world. Ayurveda (life-knowledge) is considered as Upaveda of Atharvanaveda. Health is a prerequisite for achieving the supreme ends of life - material success, mental peace and spiritual freedom. Ayurveda is one of the oldest systems of health care, dealing with both the preventive and curative aspects of life in a most comprehensive way. Modern lifestyle has made us susceptible to a host of ailments. As we are stepping away from nature, many of nature s supplements are slowly vanishing. The stress and race of this lifestyle leaves the individual physically and mentally vulnerable. Although the modern man claims to have developed an advanced medical care with sophisticated medical equipments and powerful medicines, he is still struggling to conquer a number of ailments like acute renal failure, chronic kidney diseases, rheumatoid arthritis, osteoarthritis, gastric problems, liver cirrhosis, eradication of kidney stone, cancer, gangrene, diabetics, asthma, etc. It s here where the time-tested and globally appreciated realm of Ayurveda steps in. Seldom are we aware how an incident can lead to a surprising turn of events, as much as, to a great invention. A senior IAS officer had his father suffering from kidney failure in 2008, and his second son suffering from blood cancer in Since, he had heard about Vedas being rich source of methods and measures for health care and treatment, he started reading them. He discovered the role of plant parts in healing the body. Being an Agriculture Science graduate with the background of medicinal plants course study, he researched further to develop medicines that can heal our body without having any side effects. He, first, successfully tested his discovery to treat his own age-old rheumatoid arthritis, later clinically using it to treat the ailments of his son and father. Now, all of them are leading a healthy life. Encouraged with the results, he started researching further. He addressed a lot of common but serious ailments and found herbs extracts based on healing solutions. The results were so drastic that people who were relieved termed these potions as miracle. And hence, the inventor named them as Miracle Drinks.

3 Good Manufacturing Practice Thereafter, a number of eminent personalities, who had various incurable health disorders across India and beyond, volunteered to use the medicines on themselves. The results were amazing. That s when the idea of helping people at large struck the inventor and he decided to produce these potions to address different ailments. In 2015, the inventor, Mr S M Raju gave the formulae to Mallur Flora, a Bangalore based company, for commercial production on a condition that 50% of the profit from its sale has to be spent on education of rural, poor children in Gurukulashram concept from 6th standard to 12th standard in CBSE English medium. A personal tragedy, thus, became a blessing for the entire humanity. S1- Anti Ageing Support * * S2- Ortho Support S3- Cardiovascular Support S4- Liver Health Support S5- Renal Support S6- Gastro Support S7- Immune Care Support S8- Gouty Care Support S9- Psoria Care Support S10- Sugar Care Support S11- Gynic Care Support S12- Urinary Care Support S13- Digest Care Support S14- Migra Care Support 100% Herbal 100% Organic No side-effects Can be taken with any kind of Allopathic medicine It is an over-the-counter drug as per U.S. Food & Drugs administration. This drug can be purchased without a prescription. INVENTIONS: The invention has taken place due to inevitable reasons, i.e., to find a cure for rheumatoid arthritis for the inventor, to cure Acute Renal Failure problem of inventor s father and then to cure blood cancer of inventor s son. He successfully cured the patients with his medicine and thereafter, he set out on a pursuit of inventing medicines for various incurable predominant diseases keeping Vedic literature as a base and with the guidance of Dr. Arun Kumar Thakur, retired professor and head of the department of Pediatrics, Nalanda Medical College, Patna. HERBAL COMPOUNDS: It is a 100% herbal compound. No metals have been used. All the raw materials are handpicked by tribal folks in different states, and it has been tested under NABL/ISO accredited laboratories. All these herbs are mentioned in the schedule -1 of the Drugs and C o s m e t i c C o n t r o l A c t c o n s u m e d i n e m p t y stomach in the morning between5 AM to 7 AM by giving a gap between 5 to 10 minutes Indications Medicine Mono/ Combinations (herbal Compounds) For Various Incurable Diseases, On The Basis Of Vedic Literature Introduction With Alopathic Principles.

4 1940. Elixir contains simple herbal aqueous decoction having zero aflatoxin, pesticides and metals. It is manufactured in acres of Industrial Green Campus, spread across more than 90,000 square feet green concept, a 100% mechanized GMP unit. Licensed under drugs & cosmetics control act, License number AUS HOW DO THE HERBAL COMPOUNDS WORK ON THESE INCURABLE HEALTH DISORDERS / DISEASES? INVENTOR S OPINION: Probably phyto-chemicals of the herbal compounds knock the dormant cells of the particular organs for fresh cell growth, thereby, dysfunctional organs start functioning. SAFETY TESTS: All kinds of safety tests have been conducted as per the FDA parameters. COMPATIBILITY OF THE MEDICINE. It can be taken with any allopathic medicine and no side effects. Side effects: Till now, no side effects have been reported except its bitter taste. This bitter taste can be diminished by adding lemon juice and honey. However, if at all any uneasiness to take 30 ml of medicine in one go, then start with 7.5ml (one tea spoon), thereafter increase the dose to 15 ml (one table spoon) to 30 ml. It is an over-the-counter drug as per U.S. Food & Drugs administration. This drug can be purchased without a prescription. For General Health For Party-goers: 60 ml of liver care (S-4) with 60 ml of hot water before or after food will give great relief. It works as a great detox. For youth s general health: It can be used as an energy drink & also to control hair fall, to cure pre-mature whitening, to remove pimples and its scars, regaining glow on the face. Dosage: Anti Ageing () 30 ml in 60 ml hot water on empty stomach in the morning only. For old age problems: For weakness, fatigue and exhaustion. Dosage: Anti Ageing () 30 ml of medicine with 60 ml of hot water in the morning on empty stomach between 5 AM to 7 AM, and in the evening between 5 PM to 7 PM or before dinner. Results can be seen within a week. High cholesterol and Thyroid problem: Dosage: Anti Ageing () 60 ml of medicine with 60 ml of hot water in the morning on empty stomach between 5 AM to 7 AM, and in the evening between 5 PM to 7 PM or before dinner. Results may be seen in fifteen days to one month. Diabetes: For Uncontrolled Sugar levels and Diabetic Neuropathy: Dosage: Diabetic Care (0) and Cardiovascular Care (). Medicine should be consumed on empty stomach in the morning between 5 AM to 7 AM by giving a gap between 5 to 10 minutes from one medicine to another. Similarly, both the medicines should be taken in the evening between 5 PM to 7 PM or before dinner. Result can be seen within two weeks to four weeks. Dosage And Adminstration

5 Management and control of effective blood sugar level (Fasting, 110 to 200): Dosage: Diabetic Care (0) and Gastro Care (S-6) medicine should be consumed at particular hours. In the morning between 5 AM to 7 AM, 30 ml of Diabetic Care (S- 10) medicine should be taken in 60 ml of hot water on an empty stomach. In the evening between, 5 PM to 7 PM, 30 ml of Gastro Care (S-6) medicine should be taken in 60 ml of hot water. Results can be seen in two weeks to four weeks. Skin Psoriasis: Dosage: Both Psoria Care (S-9) and Immune Care (S- 7) should be taken separately in the morning, 30 ml of medicine with 60 ml of hot water, by giving 5 to 10 minutes gap. Repeat the same in the evening. Results can be seen in one week to four weeks. Uric acid problem: Dosage: Gouty Care (S-8) should be taken in the morning 30 ml of medicine with 60 ml of hot water. Same should be taken in the evening. Results can be seen in one week to four weeks. Asthma Dosage: Anti Ageing Support 60 ml with 60 ml of hot water in empty stomach, in the morning and evening dosage should be taken two hours before meals. Diseases Of Bones And Joints Osteoarthritis, rheumatic arthritis or any related problems: Dosage: Ortho support () 30 ml in 60 ml of hot water should be taken in the morning in empty stomach and in the evening,, 30 ml in 60 ml hot water, should be taken before dinner. Results can be seen within a week. Incurable pains in any part of the bone viz. pelvic, neck, chest bone, spondylitis pain and other spondylitis related diseases like eye disease (Iritis): Dosage: medicine, 30 ml in 60 ml of hot water in the morning on empty stomach, Kidney care () in the afternoon between 12 to 1 PM before lunch, 30 ml with 60 ml hot water and in the evening between 5 PM to 7 PM or before dinner and medicine 30 ml with 60 ml hot water should be taken. Results can be seen in one to two weeks. Heart And Cardiovascular Diseases Hypertension (High blood pressure): Dosage and Administration: Anti Ageing () medicine 30 ml in 60 ml of hot water in the morning between 5 AM to 7 AM in empty stomach and Cardiovascular Care () 30 ml with 60 ml of hot water in the evening between 5 PM to 7 PM or before dinner. Results can be seen within one week to two weeks. Multiple arteries blockage where open heart surgery is difficult: Dosage: Anti Ageing () Cardiovascular Care () medicine, should be consumed twice a day in empty stomach. Each medicine s dosage is 30 ml medicine with 60 ml of hot water in the morning in empty stomach and in the evening before dinner. While consuming the medicines, a gap of 5-10 minutes should be observed from one medicine to another one. Results can be seen in three days to one month.

6 Gangrene problem: Dosage and Administration: Anti Ageing () 30 ml with 60 ml of hot water and after 5 to 10 minute gap 30 ml with 60 ml of hot water in an empty stomach. Similarly, on the evening before dinner the same dosage should be taken. Results can be seen after fifteen days to thirty days. Liver Disease Liver cirrhosis/ Fatty liver/ liver enlargement: Dosage: Anti Ageing () Liver Care (S-4) and should be consumed twice a day in empty stomach. Each medicine s dosage is 30 ml medicine with 60 ml hot water in morning on an empty stomach and evening before dinner. While consuming the medicine a gap of 5-10 minutes should be observed from one medicine to another one. Results can be seen after one month Body Itching due to Liver disease: Dosage and Administration: Liver Care (S-4), Renal Care, () and, should be consumed twice a day in empty stomach. Each medicine dosage is 30ml medicine with 60ml hot water, in the morning on empty stomach and in the evening same dosage should be taken before dinner. While consuming the medicine a time gap of 5-10 minutes should be maintained between one medicine to another. Results can be seen within one week to four weeks. Loss of appetite (For regaining appetite): Dosage: Digest Care (3) should be consumed twice a day on empty stomach. Medicine dosage is 60 ml in 100 ml of hot water in the morning between 5 AM to 7 AM and in the evening between 5 PM to 7 PM or before dinner. Results can be seen in three days to one week. Gastrointestinal Diseases A c i d i t y / G a s t r i c / C o n s t i p a t i o n / P i l e s problems: Dosage and Administration: Gastro Support (S-6) 60 ml of medicine with 60 ml hot water should be taken in morning on an empty stomach between 5 AM to 7 AM, and in the evening between 5 PM to 7 PM or before dinner. Results can be seen in 5 minutes to 30 minutes. Irritable Bowel Syndrome / Ulcerative Colitis/ or Any incurable bowl/ intestine problem: Dosage: Gastro Care (S-6) and Anti Ageing Care () medicine should be consumed on an empty stomach, twice a day in the morning between 5 AM to 7 AM in an empty stomach, 30 ml of each medicine should be taken in 60 ml of hot water by giving a time gap of 5 to 10 minutes from one medicine to another, similarly in the evening between 5 PM to 7 PM. All the 2 medicines should be taken by giving a gap of 5 to 10 minutes from one medicine to another one. The results can be seen in fifteen days to thirty days.

7 Kidney Diseases Acute Renal Failure ARF/ Chronic Kidney Disease (CKD) / Liver Cirrhosis with CKD problems: Dosage: Cardiovascular Care () should be taken in the morning on an empty stomach, Liver Care (S-4) and should be consumed. The dosage is 30 ml of each medicine in 60 ml of hot water by giving a time gap of 5 to 10 minutes from one medicine to another (all the 3 medicines should not be mixed). In the afternoon before lunch, only one medicine Cardiovascular Care () 30ml should be taken in 60 ml of hot water and in the evening Cardiovascular Care (), Liver Care (S-4) and should be consumed. The dosage is 30 ml of each medicine in 60 ml of hot water by giving a time gap of 5 to 10 minutes from one medicine to another.( If there is a gas symptom 30 ml gastro care (s-6) should be taken, without diluting in water).the results can be seen in fifteen days to thirty days. Reduction of creatinine in marginally higher to normal (1.5to 3): Dosage: 60 ml of medicine with 60 ml hot water in the morning on an empty stomach between 5 AM to 7 AM, and in the evening between 5 PM to 7 PM or before dinner. Results can be seen within a month. Removal /dissolving of kidney stone: Dosage: Three medicines i.e. Anti Ageing (), Liver Care (S-4) and should be taken on an empty stomach twice a day. In the morning between 5 AM to 7 AM on an empty stomach, 30 ml of each medicine should be taken in 60 ml of hot water, observing a time gap of 5 to 10 minutes from one medicine to another. Similarly in the evening between 5 PM to 7 PM, all the 3 medicines should be taken by giving a gap of 5 to 10 minutes from one medicine to another one (All the medicines should not be mixed together and taken). Results can be seen within two to three weeks (Results can be seen in two week to four weeks.). Prostrate problem: (Age related prostate enlargement): Dosage: and Immune Care (S- 7) in the morning 30 ml of medicine with 60 ml of hot water by giving 5 to 10 minutes gap from one medicine to another. Similarly, both the medicines should be taken in the evening. Results can be seen in one week to four weeks. Gynecological problems Dysfunctional Uterine Bleeding, Uterine and Ovarian cyst: Dosage: Gynic Care (1) and Immune Care () should be consumed twice a day on an empty stomach. Each medicine s dosage would be 30 ml with 60 ml of hot water with 5 to 10 minutes time gap from one medicine to another one. And in the evening, before dinner, both the medicines should be taken in the same way. Results may be seen within two weeks to four weeks.

8 General Health Disease / Ailment / Disorder Miracle Drinks Morning Afternoon Evening General Health (Youth) Anti-Ageing () Skin Psoriasis Loss of Appetite S-4 S-4 Infertility in Male & Female Anti Ageing () & & Prostate Problem (Age Related Enlargement) Ortho Care () Parkinson s Syndrome Tinnitus Anti Ageing (), &, & ---- Membranous Neuropathy, S-4 &, S-4 & ---- Pimple, Hair Fall, Skin Glow, Increase in Energy Level Anti Ageing () Migraine Gastro Support (S-6) S-6 S-6 Improvement Of Testosteron Level Anti Ageing () & & Erectile dysfunction (Due to Atherosclerosis) Anti Ageing () & & Urinary Tract Infection Anti-Ageing() & &

9 Diseases of Bones & Joints Disease / Ailment / Disorder Miracle Drinks Morning Afternoon Evening Joint Pain & Body Pain Ortho Care () & & Osteoarthritis Rheumatoid Arthritis Ortho Care() Gastro Care (S-6) S-6 Backache Twice Disc Bulge Twice Spondylitis Related Pains (Pelvic, Neck or any Part of the Body) Twice Flax Drinks Spondylitis Related Disease Like Lritis Twice Diseases of Heart &Vessels Hypertension Anti Ageing () Twice Multiple Artery Blockage Anti - Ageing () Renal Support (S -5) Twice, &, & Flax Drinks Gangrene Anti Ageing (S -1) Immune Care() & &

10 Disease / Ailment / Disorder Miracle Drinks Morning Afternoon Evening Varicose veins Paralysis Twice Diseases of Liver Hepatitis B Anti Ageing () S-4 Liver Cirrhosis / Fatty Liver / Liver enlargement / Liver Cyst Anti Ageing () Liver Support (S -4) Renal Support (S -5), S-4 & S-4, S-4 & For Prevention of Liver Disease S-4 S-4 S-4 Gastrointestinal Diseases Acidity / Gastric / Ulcers / Constipation / Piles Gastro Support (S-6) S-6 S-6 Irritable Bowel Syndrome / Ulcerative Colitis / Any Incurable bowel or Intestine Problems Gastro Support (S-6) S-6 & S-6 & Kidney Diseases Kidney Stone Degeneration of Kidney Creatinine level 1.5 to 3 Anti-Ageing(), S-4 &, S-4 &, S-4 &, S-4 &

11 Disease / Ailment / Disorder ** Acute Renal Failure/ Chronic Kidney Disease (Those who are Undergoing Dialysis ) Miracle Drinks Morning Afternoon Evening, S-4 &, S-4 & Kidney Cyst Anti Ageing () Liver Support (S -4) Renal Support (S -5), S-4 &, S-4 & Disease of Dyslipidemia Thyroid (Hyper / Hypo) / High Cholesterol Anti-Ageing () Gynaecological Problem Gynaec Problem (PCOD / Cyst / Breast Lumps Urinary Tract infection Anti Ageing() & & Prevention of Neoplastic / certain types of Cancer Liver Cancer Immun Care () Twice Miracle Soup & & Blood Cancer Anti Ageing () Immun Care () Twice Miracle Soup & & Bone Cancer / Other Concerned Diseases Twice Miracle Soup Endocrine Problems Diabetic (Due to Stress) - Type1 & 2 Sugar Care (0) Gastro Care (S-6) 0 S-6

12 Disease / Ailment / Disorder Miracle Drinks Morning Afternoon Evening Neuropathic Diabetes Sugar Care (S -10) CardiovascularSupport (S -3) 0 & Uncontrollable Sugar Patients of Herts / Any Surgery Cardiovascular Support (S -3) Liver Health Support (S -4) Renal Support (S -5), S-4 &, S-4 & Diabetic Ulcers Anti- ageing () & & Pulmonary Disease Asthma Anti Ageing () Acute Lung Disease Anti Ageing () Twice Flax Drink Sarcoidosi Anti Ageing () Twice Important Notes 1) All the medicines should be taken on empty stomach or 30 minutes before food. 2) 30ml medicine with 60ml hot water except for kidney patients. 3) **Acute Renal Failure / Chronic Kidney Disease patients should not take flaxseed drinks 4) Other than cancer patients should be taken once in the morning before breakfast 5) Cancer Patients & Erectile dysfunction (Due to atherosclerosis) should be taken twice in a day i.e. morning before breakfast & Evening before dinner. In flaxseed drink preparation add one table spoon (15 gram) cold pressed flax oil.

LECOM Health Ophthalmology

LECOM Health Ophthalmology Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable

More information

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 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

More information

First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age

First Name. Profession. Weight lbs. Weight 1 year ago lbs. Min. Adult Weight lbs. at age Maximum Weight lbs. at age Date Time Dietary consultation involves a health profile whose 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. A

More information

HORMONE BALANCE QUESTIONNAIRE FOR MEN

HORMONE BALANCE QUESTIONNAIRE FOR MEN HORMONE BALANCE QUESTIONNAIRE FOR MEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a personal

More information

Top 26 Health Benefits Kalonji Seeds and Kalonji Oil Black Seeds

Top 26 Health Benefits Kalonji Seeds and Kalonji Oil Black Seeds Top 26 Health Benefits Kalonji Seeds and Kalonji Oil Black Seeds Deblina Biswas Health Almost all of us have come across the terms Kalonji and Kalonji oil but how many of us really know what it is and

More information

Initial Consultation

Initial Consultation Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention

More information

MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM

MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM MOUNT CARMEL RADIATION ONCOLOGY NEW PATIENT SELF HISTORY/SELF ASSESSMENT FORM Name: Date Reason for Consultation: Physicians involved in your care: Best Contact Phone #: Can we leave a message: YES NO

More information

Consultation Intake Form. Name: Age: Sex: M F T Address: Phone: (day) (evening) Birth date: Present physical complaints:

Consultation Intake Form. Name: Age: Sex: M F T Address: Phone: (day) (evening)   Birth date: Present physical complaints: Consultation Intake Form Date: Name: Age: Sex: M F T Address: Phone: (day) (evening) e-mail: Birth date: What would you like help with at this time? Present physical complaints: Onset and length of symptoms:

More information

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - - ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:

More information

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please

More information

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email

More information

Apple Cider Vinegar Research has shown Apple Cider Vinegar cure high cholesterol, diabetes, sore throats and heart burn.

Apple Cider Vinegar Research has shown Apple Cider Vinegar cure high cholesterol, diabetes, sore throats and heart burn. Home Remedies Winter home remedy drink What you need: Ginger juice one cup Lemon Juice one cup Garlic Juice one cup Apple cider Vinegar one cup How to make: Crush ginger and garlic separately Squeeze to

More information

Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age

Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age Health Profile ALTH 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

More information

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

ANY FAMILY HISTORY OF ANEURYSM OR DVT? NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK

More information

Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?

Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work):   Shall we add you to our e-newsletter? 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:

More information

NEW PATIENT HEALTH HISTORY

NEW PATIENT HEALTH HISTORY NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there

More information

Natural Balance strives to offer efficacious, holistic, natural health-care, in a personalized, caring and supportive manner.

Natural Balance strives to offer efficacious, holistic, natural health-care, in a personalized, caring and supportive manner. - What do you do at Natural Balance? - What do you treat? - Do you treat children? - Why use a Herbalist? - How fast do these remedies take to work? - Can I take these remedies with these pharmaceutical

More information

Cell Phone #: Home Phone #: ** Address (prefer your forever address):

Cell Phone #: Home Phone #: ** Address (prefer your forever address): NEW PATIENT QUESTIONNAIRE * Some of this information is required by the CMS (Centers for Medicare and Medicaid Services). Your demographic answers will never affect your care. Today s Date: **Date of Birth:

More information

Patient Name Date of Birth Age. Other phone ( ) . Other

Patient Name Date of Birth Age. Other phone ( )  . Other GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages

More information

Ayurvedic Intake Form

Ayurvedic Intake Form Ayurvedic Intake Form Name: Today s Date Date of birth: Time of birth: Place of birth: Place of childhood: Other Places lived: Current address: Home phone: Work phone: Email address: Occupation: Age: Sex:

More information

HORMONE BALANCE QUESTIONNAIRE FOR WOMEN

HORMONE BALANCE QUESTIONNAIRE FOR WOMEN HORMONE BALANCE QUESTIONNAIRE FOR WOMEN Name: Date: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Date of Birth: Age: Height: Weight: Primary Care Doctor: Health History Do you have a

More information

Surgical History Please list all operations and dates:

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:

More information

PATIENT HISTORY FORM

PATIENT HISTORY FORM PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:

More information

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure

More information

Dr. Miller s Detox Tea Detailed Product Information

Dr. Miller s Detox Tea Detailed Product Information Dr. Miller s Detox Tea Detailed Product Information LurraLife is honored the join forces with Dr. Miller to bring his original Holy Tea formula to market as Dr. Miller s Detox Tea. For more than twenty-five

More information

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166 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

More information

Last Name: First Name: Address: Apt/Unit #: City: State: Zip: Best Contact Phone Number: Date of Birth: Age: Profession:

Last Name: First Name: Address: Apt/Unit #: City: State: Zip: Best Contact Phone Number:   Date of Birth: Age: Profession: Health Profile Our 30/10 program is intended to help participants with their personal weight loss efforts. We are not a medical facility, and our staff cannot give you medical or psychological advice.

More information

Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age

Weight: lbs. Weight 1 year ago: lbs. Min. Adult Weight: lbs at age Health Profile ALTH PROFILE Dietary consultation involves a health profile whose 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

More information

Honey and Cinnamon Interesting Drug Combination!!!

Honey and Cinnamon Interesting Drug Combination!!! Honey and Cinnamon Interesting Drug Combination!!! Subject: Honey and Cinnamon - Interesting Drug Combination Bet the drug companies won't like this one getting around. Facts on honey and cinnamon: It

More information

Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex

Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex Sharon Lunn LCPH, MCPH, HMA, MARCH, RT Registered Homeopath & Colon Hydrotherapist Clinic at: Harold Wood, Essex 07932 553334 www.sharonlunn.co.uk HEALTH QUESTIONNAIRE (In strictest confidence) Full name

More information

Do you exercise? Yes No If yes, what kind? How often?

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.

More information

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome: MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer

More information

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1 Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma

More information

Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address:

Patient Profile Patient Name: DOB: Address: City: State: Zip: Spouse/Significant Other: Children's names and ages: Patient Employer: Address: Patient Profile Patient Name: DOB: Address: City: State: Zip: Phone# (H): (W): Other: Email: May Dr. Strong to leave medical information on your answering machine/voicemail? YES NO May Dr. Strong to send

More information

Integrative Consult Patient Background Form

Integrative Consult Patient Background Form Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a

More information

Date of Birth: Age: Gender: M F. Race/Ethnicity: American India Asian African American White Hispanic Other

Date of Birth: Age: Gender: M F. Race/Ethnicity: American India Asian African American White Hispanic Other Welcome! Please complete this new client paperwork and return to us at least 48 hours prior to your appointment. This will allow our medical team to review your case in advance of your arrival. If you

More information

We are a leading manufacturer and exporter of a safe and effective range of Ayurvedic Drugs And Herbal Drugs. Further, we also offer clinical

We are a leading manufacturer and exporter of a safe and effective range of Ayurvedic Drugs And Herbal Drugs. Further, we also offer clinical We are a leading manufacturer and exporter of a safe and effective range of Ayurvedic Drugs And Herbal Drugs. Further, we also offer clinical treatments like therapeutic & health care treatment for curing

More information

ABOUT THE MAKERS OF AVALIFE TM

ABOUT THE MAKERS OF AVALIFE TM HERBAL RANGE Recognised as one of the oldest systems of healing on the planet, herbal medicine traces its routes back to the earliest civilisations. The variety of plants and their therapeutic properties

More information

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit? ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT

More information

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status

More information

Stay Healthy, Stay Thin and Stay Energized!

Stay Healthy, Stay Thin and Stay Energized! Stay Healthy, Stay Thin and Stay Energized! Stay Healthy - Your Daily Anti-Oxidants with NuVerus Plus NuVerus Plus is a new kind of SuperFood geared toward today s lifestyles. NuVerus Plus not only tastes

More information

Nutrition Questionnaire

Nutrition Questionnaire Nutrition Questionnaire This office deals with the health, vitality and longevity of the individual. The following questions will help us to more accurately design a personalized program to allow you to

More information

INTEGRATED HEALTH KARE AND DISEASE BASED MEDICAL YOGA

INTEGRATED HEALTH KARE AND DISEASE BASED MEDICAL YOGA INTEGRATED HEALTH KARE AND DISEASE BASED MEDICAL YOGA By: Prakash Kalmadi M.B.B.S., F.A.G.E (Man) DR. PRAKASH KALMADI Founder & Director KARE Ayurveda & Yoga Retreat Medical Director International Academy

More information

Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain:

Last Name: First Name: MI: 1. Have you recently had any major family changes: If yes, please explain: Adult Medical Questionnaire Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully

More information

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency

More information

* CC* PATIENT QUESTIONNAIRE

* 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

More information

PATIENT INFORMATION Please print clearly and complete all blanks

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

More information

NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE

NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-

More information

LAKES INTERNAL MEDICINE

LAKES INTERNAL MEDICINE LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education

More information

Patient Information. Insurance Information

Patient Information. Insurance Information Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:

More information

Enemy in the Mirror. About the Speaker: Richard W. Bunch, PhD, PT, CBES 8/29/2018. The West Point Principle No Excuse Sir!

Enemy in the Mirror. About the Speaker: Richard W. Bunch, PhD, PT, CBES 8/29/2018. The West Point Principle No Excuse Sir! Enemy in the Mirror Richard W. Bunch, Ph.D., P.T. Behavioral-Based Ergonomic Specialist About the Speaker: Richard W. Bunch, PhD, PT, CBES Founder and CEO of WorkSaver Systems Army Veteran -Attended West

More information

Date of Birth: City: State: Zip: Home phone: Who is your primary care physician?

Date of Birth: City: State: Zip: Home phone: Who is your primary care physician? PERSONAL INFORMATION Name: Address: Date of Birth: Mobile phone: City: State: Zip: Home phone: Email: Who is your primary care physician? Phone: How did you hear about The Nebraska Medical Center Bariatrics

More information

PATIENT HISTORY FORM

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

More information

New Patient Intake Form

New Patient Intake Form 501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work

More information

The Campbell M Gold Newsletter Vol. 07 - Issue 18 Campbell M Gold Consultant Self-Help and personal Development through New Thinking, and Hypnosis and Subliminal Programs Welcome to this special newsletter

More information

New Patient Medical History Form

New Patient Medical History Form New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring

More information

PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT

PLEASE FILL OUT THIS FORM COMPLETELY. SUBMIT TO THE ABOVE ADDRESS WE WILL CONTACT YOU FOR AN APPOINTMENT Date: Bariatric Services Digestive Health Center Oregon Health & Science University 3303 SW Bond Avenue CHH6D Portland, OR. 97239 Phone: (503) 494-1983 Fax: (503) 418-3683 Email: w8reduce@ohsu.edu www.ohsuhealth.com/surgicalweightreduction

More information

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire

Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed

More information

Medical History Form

Medical History Form Medical History Form Full Name Title: Mr/Mrs/Ms/Miss Address Date of Birth Date Telephone: Mobile: Email: How did you hear about the Garden of health? G.P s Name and Address Are you currently seeing your

More information

In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed.

In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed. Name: SS# In your own words, please write the reason you are here. Please be specific, putting in dates as necessary. Use the back of the form if needed. Patient Medical, Surgical and Family History Review

More information

Nutrition Consultation Intake Form Please write or print clearly

Nutrition Consultation Intake Form Please write or print clearly Artemis in the City, LLC Danielle Heard, MS, MS, HHC Clinical & Functional Nutritionist ph: 866-330-5421 fx: 212-535-3234 www.artemisinthecity.com Nutrition Consultation Intake Form Please write or print

More information

Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-9 months?

Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-9 months? What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy or Danville Are you a Christie registered patient? Yes No Have you had labs (lipid

More information

ITG Diet Health Status Intake Form

ITG Diet Health Status Intake Form Health Status Intake Form Date: Last Name: First Name: D.O.B: Address: City: ST: ZIP Phone: Cell: Email: Age: HT: WT: BMI: Fat %: Occupation: Sex: M F Marital Status: M S D W How did you hear about the

More information

Risk Management Plan Etoricoxib film-coated tablets

Risk Management Plan Etoricoxib film-coated tablets VI.2 Elements for a Public Summary VI.2.1 Overview of disease epidemiology Osteoarthritis (OA): OA is a condition in which the cartilage of the joints is broken down. This causes stiffness, pain and leads

More information

Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months?

Are you a Christie registered patient? Yes No Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Are you a Christie registered patient? Yes No Monticello Have you had labs (lipid

More information

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact

More information

CONSULTATION ADMITTANCE FORM

CONSULTATION ADMITTANCE FORM CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK

More information

Liver Health: Do you have liver problems? Yes No If so, please specify:

Liver Health: Do you have liver problems? Yes No If so, please specify: Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their

More information

RHEUMATOLOGY PATIENT HISTORY FORM

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

More information

Top 10 Foods that Protect Cartilage and Prevent Arthritis

Top 10 Foods that Protect Cartilage and Prevent Arthritis Top 10 Foods that Protect Cartilage and Prevent Arthritis Deblina Biswas Treatments Arthritis is a common joint disorder that is caused due to inflammation of the joints. Although there are 100 different

More information

How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all

How much do you know about illnesses or health problems for your parents, grandparents, brothers, sisters, and/or children? 1 A lot Some None at all Family Health History Please answer each question as honestly as possible. There are no right or wrong answers to nay of the questions. It is important that you answer as many questions as you can. We

More information

I choose not to specify

I choose not to specify Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.

More information

Welcome to About Women by Women

Welcome to About Women by Women Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner

More information

Streamline Pharma Private Limited

Streamline Pharma Private Limited +91-8048603298 Streamline Pharma Private Limited https://www.indiamart.com/streamlinepharma-p-ltd/ Streamline Pharma pvt. Ltd. is domestic supplier of herbal health care products that cause no side effects.

More information

Lucas D. Brown, L.Ac. (312)

Lucas D. Brown, L.Ac. (312) Today s date: Mr. Miss Mrs. Ms. Dr. Birth date: (mm/dd/yy) Social Security Number: First name: Last name: Age: Email: Marital status: Single Divorced Married Separated Partner Widowed Street address: Apt:

More information

For the Patient: USMAVNIV

For the Patient: USMAVNIV For the Patient: USMAVNIV Other Names: Treatment of Unresectable or Metastatic Melanoma Using Nivolumab U = Undesignated (requires special approval) SM = Skin and Melanoma AV = AdVanced NIV = NIVolumab

More information

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715 Patient Packet Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715 Welcome Thank you for your interest in SSM Health Weight Management Services. Please complete the enclosed questionnaire

More information

TABLET CAPSULE( ALL ARE VEGETARIAN CAPSULES)

TABLET CAPSULE( ALL ARE VEGETARIAN CAPSULES) S.NO PRODUCT INDICATIONS PACKING 1 HEAL HERB 2 BP HERB 3 4 5 6 7 DIABETIC HERB GARLIC CAP CAOSULE) STRESS HERB HAIR HERB CARDIAC HERB TABLET USEFUL IN FRACTURE HEALING, PAIN & SWELLING CAUSED BY SPRAIN

More information

NEW PATIENT QUESTIONNAIRE

NEW PATIENT QUESTIONNAIRE NEW PATIENT QUESTIONNAIRE PLEASE PRINT Full name: Age: Preferred Contact number: Email address: Why are you here today? To establish primary care Annual exam Consultation from another doctor If consultation,

More information

I. ALL CLAIMS: HEALTH CARE PROFESSIONALS

I. ALL CLAIMS: HEALTH CARE PROFESSIONALS HCP Prescribing Information Date/Version January 2015 Version 2 Page: 1 of 5 I. ALL CLAIMS: HEALTH CARE PROFESSIONALS Indications and Usage Saxenda (liraglutide [rdna origin] injection) is indicated as

More information

Evolve180 / Ideal Northwest Health Profile

Evolve180 / Ideal Northwest Health Profile Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital

More information

The Health Benefits Of Cayenne By John Heinerman

The Health Benefits Of Cayenne By John Heinerman The Health Benefits Of Cayenne By John Heinerman HEALTH BENEFITS OF CAYENNE PEPPER - THEINDIANSPOT - HEALTH BENEFITS OF CAYENNE PEPPER It's the prince of spices that brings a unique flavour to dishes.

More information

Laser Vein Center Thomas Wright MD Page 1 of 4

Laser Vein Center Thomas Wright MD Page 1 of 4 Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber

More information

New Patient Information

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

More information

New Patient Paperwork

New Patient Paperwork New Patient Paperwork Date: Phone: Patient: Last Name First Name Initial Street Address: City/State/Zip Code: Sex: M F Age: Birthdate: Single Married Widowed Separated Divorced Email: Newsletter? Y N Insured

More information

Address Street Address City State Zip Code. Address Street Address City State Zip Code

Address Street Address City State Zip Code. Address Street Address City State Zip Code Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail

More information

MEDICAL/SURGICAL HISTORY FORM

MEDICAL/SURGICAL HISTORY FORM MEDICAL/SURGICAL HISTORY FORM / / Date: / / Surgical Patients Only: Please check the weight loss procedure that you are interested in: Gastric Bypass Lap Band Undecided Revision of Previous Surgery HT

More information

UNIT 1: INTRODUCTION AND HERBAL REVIEW

UNIT 1: INTRODUCTION AND HERBAL REVIEW INTERMEDIATE HERBAL COURSE OUTLINE UNIT 1: INTRODUCTION AND HERBAL REVIEW Lesson 1: Let s Get Started! Lesson 2: Introduction to the Intermediate Course Why Choose Herbs? An Ecological Relationship How

More information

Inlyta (axitinib) for Kidney Cancer

Inlyta (axitinib) for Kidney Cancer Inlyta (axitinib) for Kidney Cancer Inlyta is a medication used to treat advanced kidney cancer in adults when one prior drug treatment for this disease has not worked Dosage: 5mg taken twice a day How

More information

Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? I don t know

Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? I don t know What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Monticello Have you had labs (lipid profile & basic metabolic panel) done within

More information

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

Alivia Acupuncture Clinic, LLC. Address. City State Zip.  . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced

More information

Premium Specialty: Pediatrics

Premium Specialty: Pediatrics Premium Specialty: Pediatrics Credentialed Specialties include: Adolescent Medicine, Pediatric Adolescent, and Pediatrics This document is designed to be used in conjunction with the UnitedHealth Premium

More information

SITA AYURVEDIC CLINIC AND PANCHAKARMA CENTER. Healing Naturoholistically

SITA AYURVEDIC CLINIC AND PANCHAKARMA CENTER. Healing Naturoholistically SITA AYURVEDIC CLINIC AND PANCHAKARMA CENTER Healing Naturoholistically Ayurveda Origin of Ayurveda comes from ancient text of Atharva Veda focusing on holistic system to cure & heal through Wellness for

More information

Therapeutics Of Reishi gano (RG) & Ganocelium (GL)

Therapeutics Of Reishi gano (RG) & Ganocelium (GL) Therapeutics Of Reishi gano (RG) & Ganocelium (GL) Reishi Gano (RG) Reishi Gano is a kind of mushroom essence (ganoderma lucidum) widely known as King of Herbs. It is established to have great effect for:

More information

Patient Health History

Patient Health History Patient Health History This information is very important in your care. Please complete as carefully and accurately as possible. Name: Date: Height: inches Weight: lbs Age: Symptoms: 1. Type of symptoms

More information

For the Patient: USMAVPEM

For the Patient: USMAVPEM For the Patient: USMAVPEM Other Names: Treatment of Unresectable or Metastatic Melanoma Using Pembrolizumab U = Undesignated (requires special request) SM = Skin and Melanoma AV = Advanced PEM = Pembrolizumab

More information

Discussing TECENTRIQ (atezolizumab) with your healthcare team Talking to Your Doctor

Discussing TECENTRIQ (atezolizumab) with your healthcare team Talking to Your Doctor Discussing TECENTRIQ (atezolizumab) with your healthcare team Talking to Your Doctor TECENTRIQ DISCUSSION SUPPORT What is TECENTRIQ? TECENTRIQ is a prescription medicine used to treat: A type of bladder

More information

NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM

NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM NORTHWEST PROFESSIONAL OBSTETRICS & GYNECOLOGY, LTD. GYNECOLOGIC INTAKE AND HISTORY FORM Today s Date: Name: Date of Birth: Race: American Indian or Alaskan Native Asian Black or African-American More

More information