Dr. Michelle Mackay Patel, ND
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- Natalie Warren
- 5 years ago
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1 NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight: 1) Name of Primary Caregiver: Relationship to Child: Address: City: Province: Postal Code: Phone # (H): (Cell): (W): 2) Name: Relationship to Child: Address: City: Province: Postal Code: Phone # (H): (Cell): (W): Remind me of appointments by phone? (Please circle) YES / NO Child s Primary Care Provider (ie. Pediatrician, Medical Doctor): Contact Information: Please list other health care professional the child is currently working with: Practitioner Name: Practitioner Type: Phone: Practitioner Name: Practitioner Type: Phone: Practitioner Name: Practitioner Type: Phone: HEALTH INFORMATION Child s current health concerns, listed in order of preference: 1) 3) 2) 4) How would you rate your child s overall health? Poor Fair Average Good Excellent How would you rate your child s overall energy? Poor Fair Average Good Excellent IMMUNIZATION HISTORY (please check) Vaccine Date Adverse Reactions (e.g. fever, nausea, vomiting, seizures, behaviour changes,etc.) MMR (measles, mumps, rubella) Polio DPT (diphtheria, pertussis, tetanus) 1
2 Influenza (Flu) Smallpox Haemophilus influenza B Hepatitis B Hepatitis A Tetanus booster Pneumococcal (pneumonia) Meningococcal (meningitis) Varicella (chicken pox) Rotavirus Other: CHILDHOOD ILLNESSES (please check) Chicken pox Measles Mumps Rubella Scarlet fever Pneumonia Whooping cough Rheumatic fever Roseola Bronchiolitis/Bronchitis Strep throat Ear infections Mononucleosis Impetigo Other Surgeries and Hospitalizations (include dates and details): Date (s) Comments MEDICATIONS: Please list all current medications (prescription and over-the counter): Medication Dose/day How long have you been taking?
3 4. 5. Please list all vitamins/minerals, herbs or homeopathics: Supplement and Brand Dose/day How long have you been taking? Approximately how many times has your child been treated with antibiotics? Has your child ever had an adverse reaction to a medication? Y / N If Yes, please explain: ALLERGIES: Please list all of your child s allergies (medications, seasonal, foods, animals etc.): PRENATAL / NATAL HISTORY (if child was adopted please provide as much information as possible) The health of birth parents at conception (please circle): Mother: Poor Fair Average Good Excellent Father: Poor Fair Average Good Excellent Mother's age at child's birth: Number of Children: Total number of pregnancies (including those that were not full term): Father s age during pregnancy: Mother s health during pregnancy? (please circle) Poor Fair Average Good Excellent Were any of the following experienced during pregnancy? (please check) Comment Bleeding Nausea Vomiting Cravings Physical trauma Emotional trauma Stress 3
4 Depression High Blood Pressure Thyroid problems Gestational diabetes Toxemia Illness Weight gain (how much?) X-rays Travel Other Did Mother use any of the following during pregnancy? Tobacco How much and how often? Alcohol How much and how often? Recreational Drugs (please specify): Prescription Medications (please specify): Over the counter medications (please specify): Supplements (please specify): Were there any fertility issues surrounding the child s conception Y/N? (If Yes, please specify): Briefly describe Mother s diet during pregnancy (including medications and supplements): CHILD S BIRTH HISTORY Term: (please circle) Full Premature: wks Overdue: wks Weight at birth: Length at birth: Birth: (please check any that apply) Vaginal birth C-section Induction Epidural Antibiotics Vacuum Were there any complications with the birth? Y or N Details: Forceps Hospital birth Home Birth OB/GYN Midwife Doula Did the Mother experience Post-Partum Depression? Y or N Details: 4
5 Did your child have any of the following problems shortly after birth? Birth abnormality Cerebral palsy Colic Birth injuries Seizures Fever Blue baby Jaundice Rashes Other (explain): DIET How was your infant fed: Breastfed: How long? Formula: Type (please circle): MILK SOY OTHER: Other? What foods were introduced before 6 months? (please also specify approximate month) What foods were introduced between 6-12 months? Does your child have any food intolerances or allergies? Please list. Does your child have any dietary restrictions (religious, vegan/vegetarian, etc.)? Describe a typical days diet: Breakfast Snack Lunch Snack Dinner Beverages (including quantity) DEVELOPMENT Describe your child s health in the first year? Age your child began: Sitting Crawling Walking Talking Describe your child's sleep patterns How would you describe your child s temperament? 5
6 SOCIAL HISTORY Parents: Married: Separated: Divorced: Single Parent: Child lives with: Other s living in the home: Mother s Occupation: Father s Occupation: F/T or P/T F/T or P/T Day Care/School Is the child in: (circle) School Daycare Homecare Other: On average how much time does the patient spend at day care/school? Describe your child s behaviour and performance at school (include teacher comments and relationships with other children): How many hours per day does the child spend: Watching Television Reading Playing Videogames Surfing the Internet Playing Outside Doing Homework Organized Sports/Lessons HRS Briefly describe the child s personality and general disposition: ENVIRONMENT Describe your living environment (ex: house, apartment, new, old): Is the child exposed to any of the following (circle all that apply): cigarette smoke pets mold chemicals (ex: paint) How is the child s home heated? Natural Gas Oil Electric Wood Other: How would you describe the emotional climate of your home? 6
7 FAMILY HISTORY Please provide age and health concerns for the following biological family members. If deceased, please indicate the age of death. Mother: Father: Siblings: Maternal Grandparents: Paternal Grandparents: Please indicate if there is a family history of any of the following: Condition Relative Condition Relative Alcoholism Diabetes Allergies Drug abuse Alzheimer s disease Heart condition Arthritis High blood pressure Asthma Kidney disease Cancer (indicate type) Osteoporosis Depression Stroke Other mental illness Suicide Bleeding disorders Infertility Glaucoma Thyroid Conditions 7
8 REVIEW OF SYSTEMS Please CHECK if your child is currently experiencing any of the following symptoms OR write a P if they experienced it in the past GENERAL SYMPTOMS: EARS/EYES/NOSE/THROAT: CARDIOVASCULAR: Headache Tonsillitis Heart murmur Head injury Sore Throat Irregular heart beat High fevers Enlarged Glands Irregular Heart Beat Chills Ear discharge Bleeding gums Night Sweats Ear infections Anemia Dizzy spells Mastoiditis GASTROINTESTINAL: Fainting Hearing loss Bloating Excessive Fatigue Nose bleeds Excessive thirst Nervousness/Anxiety Ear ache Excessive hunger Loss of Weight Nasal Discharge Reflux Allergies Nose bleeds No appetite Nightmares Sensitivity to light Belching Sleep problems Bad breath odor Gas (flatulence) Cries easily Canker sores Nausea Unusual fears Bleeding gums Vomiting Spells Motion/car sickness MUSCLE & JOINT: Stomach Aches SKIN: Spinal scoliosis Abdominal Cramps Change in mole(s) Muscle weakness Constipation Hives / allergic reactions Joint Pains Diarrhea Acne / skin eruptions Painful tailbone Jaundice Itching (ears, skin, rectum) Flat feet Irritable Bowel syndrome Bruising easily KIDNEYS/REPRODUCTIVE: RESPIRATORY: Dryness Inability to control urine Asthma Sensitive skin Frequent urination Wheezing Eczema Painful urination Cough Body odor Bedwetting Frequent colds Hair loss Kidney infection OTHER: Bloody urine Is there anything additional that you feel is important that has not been covered above? Thank you for taking the time to fill out this form. It will help contribute to a treatment protocol that will better your child s healthcare needs. 8
Dr. Michelle Mackay Patel, ND
NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight:
Avicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s email address: Date of Birth: Gender: How did you hear about this clinic?
Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
Dr. Michelle Mackay Patel, ND
NATUROPATHIC ADULT INTAKE PERSONAL INFORMATION: First Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: What is your current gender identity? Male Female Transgender Male/Transman/FTM Transgender
Dr. Jeannie Doig, HBSc, ND Naturopathic Physician Port Alberni (250)
Child Intake Form Child s name Age Date of Birth Date Sex M F Who is filling out this form (name and relation)? Contacts (in order of preference): Name Phone h Address w other Relationship to Child Name
Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
Successful healthcare and preventive medicine require a healthy relationship between provider and patient. Your responses to the following questions will significantly contribute to your doctor's understanding
CHILD INTAKE (Please Print Clearly)
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Patient Intake Form - Child. Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling out this form? (name, relationhip):
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Head to Heal Centre for Naturopathic Medicine & The Bowen Technique
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NATUROPATHIC CHILD INTAKE FORM (0-12 years old)
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Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine
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PEDIATRIC HEALTH HISTORY FORM. Patient Name: DOB: / / Height: Weight: Lbs. Parent (s) Name: Address:
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CARY HOLISTIC HEALTH, LLC. Thank you for scheduling an appointment with Cary Holistic Health. Maggie Thibodeau, ND
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Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
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Child Intake Form. In case of emergency, contact: Relationship: Phone:
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Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor
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tel: (905) fax: (905) CHILD Questionnaire (to be answered by the mother if possible)
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*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
OKANAGAN HEALTH & PERFORMANCE Inc.
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II. Goal and Expectations (Please tell us your goals and expectations.) III. Childhood Illnesses (Please check those illnesses that you have had.
Natural Health and Wellness Center The path to a healthier, more vital you. PEDIATRIC HEALTH HISTORY QUESTIONNAIRE SUCCESSFUL HEALTH CARE AND PREVENTION ARE ONLY POSSIBLE WHEN THE PROVIDER HAS A COMPLETE
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
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Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona 85258 480-767-7119 Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about
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Inner Balance Acupuncture
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Eastern Body Therapy
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New Patient Intake Form Pickering Chiropractic Health Centre 1154 Kingston Road Pickering ON, L1V 1B4
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Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
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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
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
What do you feel are your child s strengths at this time?
PEDIATRIC 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
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
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Remember to bring copies of any recent lab work or medical records as well as any supplements or medications your child is currently taking.
Hello and Welcome! I know you have choices when it comes to your child s care and I am dedicated to providing my patients with the best care possible. Before your scheduled appointment, please carefully
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
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Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
Pediatric Case History Form
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NEW CHILD PATIENT INTAKE FORM
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MEDICAL HISTORY (To be filled in by patient)
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Initial Consultation
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Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
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MEDICAL DATA SHEET For Patients 18 years of age and older
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Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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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
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
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
HILLCREST CENTRE FOR HEALTH 832 St. Clair Ave W. Toronto, ON M6C 1C1 Tel: Fax:
Adult Intake Name Date of first visit Date of birth (M/D/Y) Gender M F Address: E-mail Address: May we add you to our mailing list? (Your email address will not be shared): Y N Telephone number: Home:
What else would you like to see changed in his/her health?
Simmonds McMurrer Naturopathic Medicine Dr.Kali Simmonds,N.D. Dr.Lana McMurrer,N.D. Dr.Nara Simmonds,N.D. 34 Queen Street, 2nd Floor Charlottetown, PE C1A 4A3 Tel.902.894.3868 Fax.902.894.4054 www.simmondsmcmurre.com
RHEUMATOLOGY PATIENT HISTORY FORM
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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
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
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
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
NEW PATIENT INFORMATION *All information provided is kept in strict confidence
NEW PATIENT INFORMATION *All information provided is kept in strict confidence Name: Date: Address: Telephone: (home) (cell) (work) E-mail: Emergency contact: (name) (relationship) telephone: (home) (cell)
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
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
Pediatric Health Intake
Date (MM/DD/YY) / / PERSONAL INFORMATION GW Center for Integrative Medicine 908 New Hampshire Avenue, Suite 200, Washington, DC 20037 Tel 202-833-5055, Fax 202-833-5755 Pediatric Health Intake Child s
PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING. *(Please circle answer where ever there is a multiple question.)
1 Dr. Stephen Maltais ND, Naturopathic Doctor 88 Dover Mills Road, Port Dover, ON. N0A 1N1 Phone: (519) 583-1234 E-mail: docmaltais@kwic.com www.dovernaturoapth.com INTAKE FORM FEMALE (16 years of age
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4
Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: 905-793- 8868 Fax: 905-793- 8957 630 Peter Robertson Blvd, Brampton ON L6R 1T4 ADULT INTAKE FORM Name: (Last) (First) (Preferred Name) Address:
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM
Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
Date of Birth Work Phone # ( ) Home Phone # ( ) Emergency Contact # ( )
Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. It should take 15-20 minutes. Contact Information: Name Occupation
Family Naturopathic Clinic
Mark Orbay, B.Sc., N.D. Doctor of Naturopathic Medicine 265 Carling Avenue, Suite 610 Tel: (613) 230-6100 Fax: (613) 230-0070 Name: Phone (Home) Address: (Office) Date of Birth: / / Age: (Month) (Day)
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,
Ageless Acupuncture Patient Health History
Ageless Acupuncture Patient Health History Name: Date: By what name would you like us to refer to you?: Street Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell Phone: How early/late
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
GIDEON G. LEWIS, M.D.
GIDEON G. LEWIS, M.D. Date: LAST Name: FIRST Name: MIDDLE Initial: Address: City: State: Zip Code: Date of birth: / / Social Security #: - - Sex: M F Marital Status (Circle): Single Married Divorced Widowed
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
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
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
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for