Dr. Rajsree Nambudripad, MD, ABIHM Dr. Roy Nambudripad, MD NEW PATIENT HISTORY FORM
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1 Dr. Rajsree Nambudripad, MD, ABIHM Dr. Ry Nambudripad, MD NEW PATIENT HISTORY FORM Name Date File N. Phne number Hme address City State Zip Date f birth Age Sex M F Height Weight Emplyer Occupatin Wrk phne Wrk address City State Zip Marrital status M S D W Number f children Bys Girls Name f spuse Referred by Spuse s emplyer Spuse s ccupatin If patient is a child, please fill ut abve wrk infrmatin fr parent, r whever is financially respnsible. Medical Insurance: Yes N Insurance C. Name Our ffice des nt bill insurance, but if yu have a PPO insurance, we prvide superbills that yu can file with yur insurance cmpany t get reimbursement directly. Our dctrs have pted ut f Medicare. We try t use yur insurance (including Medicare) fr lab r imaging tests when pssible. What is yur main prblem? Hw lng have yu had this prblem? Please describe in detail. What d yu believe caused this cnditin? What are yur health gals?
2 List yur medical prblems in rder f severity and describe any past treatments. 2 What medicatins d yu take? Please list all medicatins (prescriptin and ver the cunter), vitamins, and herbal supplements. Include dses if yu knw them. What fds allergies r sensitivities d yu have? Please describe the reactin as well. What medicatin allergies r sensitivities d yu have? Please describe the reactin as well. What envirnmental allergies d yu have? Please describe the reactin as well. Have yu ever had an anaphylactic reactin? Yes N. If yes, please describe the situatin. What surgeries have yu had? Please include the dates r yur age at the time f surgery. Have yu ever been hspitalized? Fr what reasn?
3 Describe any childhd illnesses (fr example - childhd asthma). 3 D yu currently smke? Yes N. If yes, hw many cigarettes per day? Have yu ever smked in the past? Yes N. If yes, fr hw many years D yu drink alchl? Yes N. Number f drinks per week r mnth Type f alchl cnsumed (beer, wine, hard liqur): Is alchl an imprtant part f yur scial life? D yu currently use marijuana? Yes N Prir marijuana use? Yes N Have yu ever used ther drugs like ccaine, herin, amphetamines, etc? Please describe any past and present life stressrs. Fr example, include any traumatic events, stress frm relatinships, stress frm wrk, and financial hardships. Hw many hurs f sleep d yu get per night? D yu have difficulty falling asleep? staying asleep? D yu feel rested upn awakening? Hw d yu relax? What are yur hbbies? D yu exercise? Yes N Hw ften? Regularly Infrequently Seldm What type f exercise? Regarding yur diet: I have n dietary restrictins. I am vegetarian. I am vegan. I fllw a gluten-free diet. I avid certain fds. Please list the fds yu avid: What is yur current weight? What is yur gal weight? Please describe yur typical diet as belw: Breakfast: Lunch: Dinner:
4 4 Dessert: Snacks: Beverages: D yu skip meals? Skip breakfast? Hw ften d yu eat in restaurants? D yu cnsume fast fd? D yu prepare yur wn fd? Wh prepares yur fd? D yu buy rganic fds? D yu avid GMO (genetically mdified) fds? What type f ckware d yu use (stainless steel, cast irn, nn-stick, ceramic)? Hw many caffeinated beverages d yu drink per day? D yu crave sugar r carbs? D yu d late night snacking? Are yu an emtinal eater (eat when sad, lnely, depressed r bred)? Wh is yur primary care dctr? Office lcatin: When was yur last physical exam? List yur ther dctrs and health care prviders (specialists, acupuncturists, chirpractrs, etc). Health Maintenance Issues: When was yur last: Clnscpy Flu sht Tetanus sht Chlesterl checked General bld tests Family Histry: Fr Wmen: When was yur last: Mammgram PAP Smear Last menstrual perid Are yu pregnant nw? Yes N Please tell us if yur family members have had heart disease, cancer (specify type), diabetes, allergies, autimmune disease (specify type), lung disease, skin issues, hrmnal issues, heavy metal txicity, r any ther health issues. Mther s age Health prblems Father s age Health prblems Sibling s age Health prblems Sibling s age Health prblems Sibling s age Health prblems Sibling s age Health prblems
5 Any recent camping r travel utside the United States? Where did yu g? 5 D yu have any mechanical devices in yur bdy, like shunts, hearing aids, pacemaker, ear tubes, implants, IUD, etc? Expsures: D yu suspect mld expsure in yur hme r at wrk? D yu dry clean yur clthes? D yu use plastic cntainers t stre yur fds? D yu have dental fillings r rt canals? D yu read ingredients labels n ltins and csmetics? D yu use green huse cleaning prducts? D yu suspect txin expsure frm anther surce? Fr pediatric patients, please describe vaccine schedule (rutine schedule, mdified r delayed, r n vaccines) and prvide cpy f immunizatin card. Any adverse reactin t any immunizatin? Please elabrate n anything else yu feel is imprtant fr yur dctrs t knw in rder t prvide the best care.
6 Please Check any Current r Recent Symptms: 6 General Weight lss Weight gain Fatigue Fever Chills Weakness Truble sleeping Skin Hives Eczema Psriasis Other rash Lumps Acne Itching Dry skin Clr changes in skin Hair lss Abnrmal hair grwth Premature graying Dandruff Nail changes Head, Ears, Nse Headaches Head injury Sensitivity t light Sensitivity t sunds Decreased hearing Ringing in the ears (tinnitus) Earache Ear drainage Prblems with visin Watery r itchy eyes Flaters in visin Glaucma Cataracts Nasal cngestin Pstnasal drip Nse bleeds Sinus pain r infectins Sneezing Dry muth Harseness Thrush Muth sres Bad breath Dental decay Bleeding gums Gum disease Sre thrat Harseness Neck Symptms Lumps in neck Swllen glands Pain in neck Stiffness in neck Breasts Breast lumps Breast pain Breast discharge Lungs Asthma Dry cugh Prductive cugh Cughing up bld Shrtness f breath at rest Wheezing Painful breathing Heart Chest pain r discmfrt Chest tightness Irregular heart beat Shrtness f breath with activity Difficulty breathing when lying dwn Swelling in legs Sudden awakening frm sleep with shrtness f breath High bld pressure Lw bld pressure GI tract Difficulty swallwing Heartburn Increased appetite Decreased appetite Nausea Vmiting Cnstipatin Diarrhea Bld in stls Yellw skin r eyes Abdminal pain Blating Hemrrhids Urinary Tract Frequent urinatin Burning with urinatin Incntinence Bld in the urine Prstate abnrmalities Reprductive Vaginal r penile discharge Sres in genital regin Sexually transmitted diseases Yeast infectin Pain with intercurse Decreased libid PMS (premenstrual syndrme) Infertility Irregular menses Heavy menses Painful menses Vascular Calf pain when walking Leg cramping Varicse veins Musculskeletal Muscle pain Jint pain Stiffness Back pain Swelling f jints Injury t jints Redness f jints Hip pain Knee pain Shulder pain Neurlgic Dizziness Fainting Seizures Weakness Numbness Tingling Tremr Migraine headaches Brain fg Daytime drwsiness Hematlgic Anemia Easy bruising Cuts heal slwly Bleeding prblem Hrmnal Intlerance t heat Intlerance t cld Frequent urinatin Excess thirst Ht flashes Mental Health Depressin Anxiety Memry lss Suicidal thughts Biplar disrder Attentin deficit Anger utbursts Cmpulsive behavir Emtinal imbalances Hyperactive Phbias Other Craving fr sweets Craving fr salty fd Craving fr spices Crave cffee r caffeine Crave sur r bitter
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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
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
205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date:
205 W Giaconda Way, Suite 135 Tucson, AZ, 85704 (520) 219-2400 www.forever-able.com info@forever-able.com Name: Birth date: Age: Today s Date: Address: Email: Home phone: Mobile phone: May we add you to
o New or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe.
MEDICATION GUIDE FLUOXETINE CAPSULES, USP (fl xʹ e teen) 10 mg and 20 mg Read the Medicatin Guide that cmes with fluxetine capsules befre yu start taking it and each time yu get a refill. There may be
Influenza (Flu) Fact Sheet
Influenza (Flu) Fact Sheet What is the flu? The flu is a cntagius respiratry illness caused by influenza viruses. It can cause mild t severe illness, and at times can lead t death. Sme peple, such as lder
Package leaflet: Information for the user. GASTROGRAFIN GASTROENTERAL SOLUTION Sodium amidotrizoate and meglumine amidotrizoate
Due t regulatry changes, the cntent f the fllwing Patient Infrmatin Leaflet may vary frm the ne fund in yur medicine pack. Please cmpare the 'Leaflet prepared/revised date' twards the end f the leaflet
MEDICATION GUIDE REVLIMID (rev-li-mid) (lenalidomide) capsules What is the most important information I should know about REVLIMID?
MEDICATION GUIDE REVLIMID (rev-li-mid) (lenalidmide) capsules What is the mst imprtant infrmatin I shuld knw abut REVLIMID? Befre yu begin taking REVLIMID, yu must read and agree t all f the instructins
Medication Guide MORPHINE SULFATE (mor-pheen) Oral Solution (CII)
Medicatin Guide MORPHINE SULFATE (mr-pheen) Oral Slutin (CII) IMPORTANT: Keep Mrphine Sulfate Oral Slutin in a safe place away frm children. Accidental use by a child is a medical emergency and can cause
What is Asthma? A collaborative effort of Children s Hospital of Pittsburgh of UPMC and The Pennsylvania Child Welfare Resource Center
A cllabrative effrt f Children s Hspital f Pittsburgh f UPMC and The Pennsylvania Child Welfare Resurce Center What is Asthma? Jennifer E. Wlfrd, DO, MPH, FAAP Children s Hspital f Pittsburgh, Divisin
List the health concerns that brought you into this office
New Practice Member Applicatin Name Date f Birth / / Age Male/Female Address City State Zip Cell Phne Hme Phne Cellular Prvider Email Address Occupatin Emplyer s Name Single / Married / Divrced / Widwed
Health History Questionnaire Date: / /.
Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s
PATIENT INFORMATION. effective for the treatment of the flu in people with long-time (chronic) heart problems or breathing problems.
PATIENT INFORMATION capsules, fr ral use fr ral suspensin What is TAMIFLU? TAMIFLU is a prescriptin medicine used t: treat the flu (influenza) in peple 2 weeks f age and lder wh have had flu symptms fr
EAST VALLEY DERMATOLOGY CENTER
EAST VALLEY DERMATOLOGY CENTER Adult and Pediatric Dermatlgy VALLEY SKIN CANCER SURGERY PATIENT INFORMATION RECORD Please Use Black Ink Only Patient Infrmatin Patient s Name Last First Middle Initial Address
MEDICATION GUIDE Pioglitazone and Metformin Hydrochloride (PYE o GLI ta zone and met FOR min HYE-droe- KLOR-ide)Tablets, USP
MEDICATION GUIDE Piglitazne and Metfrmin Hydrchlride (PYE GLI ta zne and met FOR min HYE-dre- KLOR-ide)Tablets, USP Read this Medicatin Guide carefully befre yu start taking piglitazne and metfrmin hydrchlride
Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT
Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT 801 623 8253 1291 South 1100 East #202 Salt Lake City, UT 84105 www.peakacupunctureclinic.com info@peakacupunctureclinic.com CLIENT INFORMATION Client Name: If Patient
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:
Naturopathic Medicine Intake Form Adults (16+)
Naturopathic Medicine Intake Form Adults (16+) Name: Date of birth: Gender: Address: City: Postal Code: Home Phone: Mobile/Work: Email: Marital status: Spouse/Partner s name: Emergency Contact: Phone Number:
Welcome to the UCLA Center for East- West Medicine Primary Care
Instructions: Welcome to the UCLA Center for East- West Medicine Primary Care We ask a lot of questions because we really want to get to know you! Please take your time with the paper work and return it