DIRECTIONS & PARKING. Robert Gramlich, MD Homeopath 8939 S. Sepulveda Blvd., Ste. 530 Los Angeles, CA Office (310)
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1 DIRECTIONS & PARKING Robert Gramlich, MD Homeopath 8939 S. Sepulveda Blvd., Ste. 530 Los Angeles, CA Office (310) From the North: Take 405 South, exit Howard Hughes Parkway and make a right onto Howard Hughes off the ramp. Turn right at bottom of ramp back onto Howard Hughes and up the hill to Sepulveda Blvd. Get in the left-hand lane to turn left onto Sepulveda Blvd. From the South: Take 405 North, exit Howard Hughes Parkway and continue going straight from the ramp. Get into the left-handed lane to turn left onto Sepulveda Blvd. North and South Continued from Sepulveda Blvd. The building is located on the right-hand side of Sepulveda Blvd, on the northwest corner of Westchester Parkway and Sepulveda Blvd. in the H.B. Drollinger (olive and grey) building. From Sepulveda Blvd. pass through La Tijera Blvd. and turn right at H.B. Drollinger way. This light will turn you into the strip mall. There will be a Ralphs and a CVS in the parking lot. The best parking is above the CVS on the rooftop. You will be able to park there free for up to 3 hours or more. You can take the (slow) elevator or stairs down to ground level. After exiting the elevator continue to walk to the far right of the parking structure. You will see the building and walk through an alleyway to the courtyard of our building. Stay to the right thru the glass door and onto the elevator to the 5 th floor. Pediatric Intake Forms
2 Pregnancy: Was prenatal care received before the sixth month of pregnancy? Please indicate if any of the following problems occurred during pregnancy: High Blood Pressure Diabetes of sugar in urine Protein in urine German Measles Gonorrhea or Syphilis Drug or Alcohol dependence Nausea (morning sickness) Weight loss Cigarette smoking Other problems during pregnancy: Please list any Medications taken during pregnancy: Birth History: Birth Place: Home Hospital Name (city-state): Birth: Vaginal Anesthesia Cesarean Forceps Birth weight: List any problems during labor or delivery: Did the baby have any problems at birth?(breathing, premature,ect)? Did the baby stay in the hospital longer than the mother? Childhood:
3 Was/is the child breast feeding, and until what age? Indicate at what age the child entered these developmental stages: Teeth Walk Talking Indicate if this child has had any of the following problems in the first three years of life: High Fevers Excema Frequent colds Mumps Convulsions Diaper Rash Croup Measles Bronchitis Tonsilitis Whooping cough Ear Infections Asthma Frequent colds Pneumonia Chicken Pox Other Past Medical Problems: Has your child ever been hospitalized or had a surgical operation. If so, please list: Current Medical Illnesses: Please list your child s current medical problems, including those conditions which have brought him or her to Homeopathic treatment: Immunizations: Please indicate the kind of immunizations and age at which was given: DIPTHERIA: MEASLES: PERTUSSIS: MUMPS: TETANUS: POLIO: RUBELLA: HEPATITIS: Medications: Allergies to medications:
4 If your child uses or has used any of the following, Please list the name and dosage. Topical Ointments: Antibiotics: Antihistamines: Vitamins: Non-Prescription: Other Medication: Has your child ever been treated with any form of Cortisone (steroids), either pills, sprays, ointments or injections? Health Questionnaire: Indicate if this child has been bothered by any of the following problems: Headaches Shortness of breath Hay fever Convulsions Eyes crossing Wheezing/asthma allergies to animals Visual problems coughing spells Warts Wears Glasses Chest pains Excema/skin rashes Eye Irritation Burping/gas Recurrent fevers Ear infections Abdominal pain Tiredness Difficulty hearing Vomiting Few friends Tugging at ears Diarrhea Shyness Ear drainage Food allergies Fears Dental problems Pain w/urination Easily upset Early tooth decay Bed wetting Temper fits Frequent colds Daytime wetting Fighting Nose bleeds Discharge from penis or vagina Nasal congestion high/low appetite Lying sore throats Weight gain/loss Difficult behavior Tonsilitis Bleeding problem biting/hitting School or learning problems overly clinging Family History: Please list the other family member and any medical problems they may have had?
5 List of illness/disease- Please indicate if any and who has had any of these from the list: Family Members: List of illness/diseases: Name/age/illness/disease: Father - Allergies Mother Arthritis 1Brother Asthma 1Sister Cancer 2Brother Diabetes 2Sister Heart and High BP 3Brother Mental Illness 3Sister Skin Disorders Weight Problems Father s Father Tuberculosis Father s Mother Mother s Father Mother s Mother Dear Patient, Please be advised that I am not a medicare provider. I do not take MediCal, Disability, or Assignment from Insurance carriers. Patient Signature and Date: 1. Notify us 24hours (one full business day) before in order to cancel or reschedule an appointment. This allows us time to book another appointment and plan our schedule a day in advance. If not you will be charged in full for the visit. 2. Please call and leave a brief message (vm is only 60sec long) including your phone number incase we do not have it readily available. Any questions or message can and will be answered as soon as possible. Doctor Gramlich is available for emergency or serious issues by robgramlich@sbcglobal.net Please take into consideration follow up visits are scheduled for a purpose so please use the address wisely.
6 Patient Signature and Date:
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New Pediatric Patient Information
Arden Yingling, L.Ac., MAcOM (TX #AC01588) 9300 US 290, Austin TX 78736 512.640.9778 arden@songbirdacupuncture.com songbirdacupuncture.com New Pediatric Patient Information Child's Name Today s Date Birth
Sandra Cross RNCP, RBIE. First Name: Last Name: Age: Birth Date: Sex: Male Female
Sandra Cross RNCP, RBIE ADULT INTAKE FORM First Name: Last Name: Age: Birth Date: Sex: Male Female Street Address: City: Province: Postal Code: Phone: (Home) (Work) (Cell) May we leave a message? Yes No
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
Enrollment Application
Enrollment Application Please complete this application and return to: 11040 Colorado Blvd. Thornton, CO 80233 If you have any further questions, please contact us at: Fax: 303-920- 2147 Phone: 303-920-2142
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
Women s and Men s Health Intake Form Comprehensive Physical Therapy Center
Name: (Last, First) DOB: Date: Age: Referring Physician: Next Physician Appointment: Today s visit: What is the main reason you came to the office today? When did it start? What treatments have you had
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
Vaccines for Children
Vaccines for Children 12 24 old Our goal is to offer your family the best care possible, which includes making sure your child is up to date on all vaccines. DTaP (Diptheria, Tetanus, Pertussis) Vaccine
Instructions: Please bring these forms to your Physical Examination & TB Test and have the Doctor fill them out. (Where applicable)
Instructions: Please bring these forms to your Physical Examination & TB Test and have the Doctor fill them out. (Where applicable) 1. The physician s examination certification form. Ask your doctor to