Name (First Name and Last Initial ONLY) Date. Occupation. Education. Date of Birth Age Gender. How did you hear about AHE NYC World Student Clinic?
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- Isaac Stevens
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1 Name (First Name and Last Initial ONLY) Date Occupation Education Date of Birth Age Gender How did you hear about AHE NYC World Student Clinic? Family History Age If passed, cause of death Father Mother Siblings Children Page 1 of 8
2 Circle Items that apply to blood relatives, and list relationship. Alcohol/drug problem Allergy/Asthma Anemia Arteriosclerosis Arthritis Binge Eating/Bulimia Bleeding Problem Cancer Diabetes Epilepsy/seizure Heart Disease Skin Disease Gonorrhea High Blood Pressure High Cholesterol Kidney Disease Liver Disease Mental Illness Obesity Stroke Suicide Thyroid Disease Tuberculosis Ulcer Syphilis Please circle all that apply to you and list approximate dates. Acne Endometriosis Nightmares AIDS Fibroids (uterine) Overweight Alcohol/drug problem Gallbladder Panic Attack Allergies Glaucoma Pelvic Infection Anemia Gout Periodontal Disease Antibiotics (1x a year) Hearing Problems Phlebitis Anorexia/Bulimia Heart Attack Pneumonia Anxiety Heart Failure Premenstrual Tension Page 2 of 8
3 Arthritis Hemorrhoids Prostrate Problems Asthma Hepatitis Psychotherapy Back Problems Herpes Rheumatic Fever Binge Eating Hernia Scarlet Fever Bladder infections High Blood Pressure Seizures/epilepsy Blood clots High Cholesterol STI s Breast lumps Hives Sinusitis Bronchitis Insomnia Sleep Disorder Cancer Kidney Infection/stones Steroid Use Cataract (s) Liver Disease Stroke Chemical Sensitivity Menstrual Problems Suicide Attempt Chronic Fatigue Mental Illness Syphilis Colitis Migraine Thyroid Problem Depression/Anxiety Mononucleosis Tuberculosis Diabetes Mumps Ulcer Ear Infection Neurological Problem Vaccine Reaction Eczema Warts Page 3 of 8
4 Surgery: List all procedures and approximate dates Hospitalizations: Reasons/Dates Accidents, Traumatic Injuries, Broken Bones: Current Health Problem/Diagnosis: Male Female Enlarged prostate? Date of last menstrual period: Decreased urine stream? Length of cycle Unable to interrupt stream? Length of period Dribbling after urination? Age menstruation began: Pus or drainage from penis? Menopause? Genital swelling? Number of pregnancies Rash/eruptions? Number of live births Problems with sexual function? Number of abortions/miscarriages Vaginal discharge? Spotting between periods? Page 4 of 8
5 Painful intercourse? Issues with fertility? Problems with sexual function? Lifestyle Prescription Medications (List prescribing doctor) Vitamins/Mineral Supplements Allergies Food Allergies (include method of testing) Food Cravings Alcohol/Recreational Drug Use Do you drink alcohol or use drugs? How much/often? Page 5 of 8
6 Caffeine Do you drink coffee or tea? Cigarettes Do you smoke now or did you in the past? How much/often? How much/often? Diet Soda/Artificial Sweeteners Describe your use: Refined Sugars/Processed Foods: Describe your use: Hobbies Living Situation How often do you do them? Exercise: Describe the ways you get your body moving. Do you feel you get enough physical activity? Food: Do you feel you eat a healthy and well-balanced diet? Do you need guidance/support? Page 6 of 8
7 Worry/Anxiety: Do you have particular issues that worry you? How does this impact your life? Healthy Relationships: Do you have a supportive family/community? Unhealthy Relationships: Have you been a victim of domestic abuse or troubling relationships? Spiritual Life: Do you have a spiritual practice? Is your spiritual life fulfilling and satisfactory? Intimacy: Are you satisfied with your sexual/intimate life? Anything else? Please indicate any topics you want to address in your consultation. Page 7 of 8
8 Life Changes In the past year, what changes have occurred in your: Personal Life: Family Life: Social Life: Work Life: Sex Life: Page 8 of 8
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
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
Welcome to About Women by Women
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MGH Beacon Hill Primary Care New Patient Form
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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)
Medical History Form
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MedStar Medical Group at Forest Hill 1517 Rock Spring Road, Suite C Forest Hill, Maryland Phone (410) Fax (410)
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LAKES INTERNAL MEDICINE
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PATIENT INFORMATION FORM (WOMEN ONLY)
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Medical History Form
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Initial Consultation
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Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
GIDEON G. LEWIS, M.D.
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Patient Information. How did you hear about the BIHC: If you were referred, please state by whom: If yes, by whom: Date of last visit: DD/MM/YYYY
Dr. Kelly Gillis, ND Doctor of Naturopathic Medicine Patient Information Date of initial appointment: DD/MM/YYYY Name: Address: Age: Date of Birth: DD/MM/YYYY Sex: M F Gender (if different than sex): Occupation:
Patient Health History
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UnityPoint Clinic - Cardiology
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Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
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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
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:
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
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Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
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