Emergency Information
|
|
|
- Alexander Brown
- 6 years ago
- Views:
Transcription
1 109 Hinton Ave. #10 Wilmington, NC Patient Name Age Male/Female Date of Birth / / Height Weight S. S. # - - Marital Status Phone (H) ( ) - Phone (W) ( ) - Address City State Zip Cell Phone ( ) - Employer Occupation Spouse s Name Date of Birth / / Contact Number ( ) - Employer Primary Care Physician Phone (W) ( ) - Referred By Phone ( ) - Emergency Information Please indicate who to notify in case of emergency Name Phone (H)( ) - Relationship Phone (W)( ) - Phone (C)( ) -
2 Patient Name Date / / Chief Complaint(s) (please indicate how long you ve had the condition(s)). Other Complaint(s) (please indicate how long you ve had the condition(s)). What kinds of treatment have you received? List any Hospitalizations & Surgeries Date (mm/dd/yyyy) Place List Medications being taken (include dose)
3 Confidential Patient Health History Name: Date: / / Please check if you have had (in the past three months); General [ ] Anemia [ ] Poor Appetite [ ] Tremors [ ] Fatigue [ ] Localized Weakness [ ] Poor Balance [ ] Fever [ ] Bleed or Bruise Easily [ ] Cravings [ ] Weight Loss [ ] Peculiar Tastes or Smells [ ] Weight Gain [ ] Sweats [ ] Strong Thirst (hot or cold drinks) [ ] Alcoholism [ ] Chills [ ] Sudden Energy Drop [ ] Tetanus Shot [ ] Drug Addiction [ ] Poor Sleep Habits [ ] Frequent cold/flu Skin and Hair [ ] Rashes [ ] Open sore [ ] Recent moles [ ] Itching [ ] Acne [ ] Loss of Hair [ ] Dandruff [ ] Corns [ ] Hives [ ] Change in hair/skin texture [ ] Warts [ ] Nail Problems [ ] Ulcerations [ ] Psoriasis [ ] Dry skin [ ] Eczema Head, Eyes, Ears, Nose and Throat [ ] Dizziness/Vertigo [ ] Concussions [ ] Migraines [ ] Poor Vision [ ] Eye Strain [ ] Eye Pain [ ] Cataracts [ ] Night Blindness [ ]Color Blindness [ ] Ringing in ears [ ] Blurry Vision [ ] Earaches [ ] Sinus Problems [ ] Poor Hearing [ ] Spots in front of eyes [ ] Grinding Teeth [ ] Nose Bleeds [ ] Recurrent Sore Throats [ ] Nasal Congestion [ ] Hoarseness [ ] Facial Pain [ ] Headaches Cardiovascular [ ] High Blood Pressure [ ] Myocarditis [ ] Coronary Heart Disease [ ] Low Blood Pressure [ ] Pneumatic Heart Disease [ ] Difficulty in Breathing [ ] Palpitations [ ] Chest Pain [ ] Hardening of Arteries [ ] Irregular Heartbeat [ ] Varicose Veins [ ] Phlebitis [ ] Mitral Stenosis [ ] Swelling of Hands/Feet [ ] Blood Clots [ ] Mitral Prolapse [ ] Fainting [ ] Cold hands/feet Respiratory [ ] Cough [ ] Coughing Blood [ ] Pain w/ Deep Breath [ ] Bronchitis [ ] Pneumonia [ ] Production of Phlegm [ ] Difficulty breathing lying down [ ] Asthma [ ] Pleurisy [ ] Emphysema
4 Gastrointestinal [ ] Nausea [ ] Constipation [ ] Diarrhea [ ] Vomiting [ ] Gas [ ] Belching [ ] Bad Breath [ ] Blood in Stools [ ] Black Stools [ ] Abdominal Pain or Cramps [ ] Rectal Pain [ ] Hemmorrhoids [ ] Indigestion [ ] Chronic Laxative Use [ ] Acid Reflux [ ] Ulcer [ ] Colitis Genitourinary [ ] Bed Wetting [ ] Blood in Urine [ ] Frequent Urination [ ] Kidney Infections / Stones [ ] Painful Urination [ ] Bladder Infections [ ] Genital Herpes [ ] Venereal Disease [ ] Prostate Problems [ ] Cystitis [ ] Incontinence Pregnancy and Gynecology Number of Pregnancies Age at 1 st Menstruation [ ] Unusually heavy/light Number of Abortions Time between Menstruation [ ] Vaginal Sores Number of Births Duration of Menstruation [ ] Vaginal Discharge Number of Miscarriages First Date of Last Menstruation [ ] Breast Lumps [ ] Use of Birth Control [ ] Irregular Periods [ ] Painful Periods/Cramps [ ] Clots [ ] Endometriosis [ ] Uterine Fibroids [ ] Hot Flashes/Night Sweats [ ] Frequent changes in emotion Musculoskeletal [ ] Neck Pain [ ] Muscle Pains [ ] Knee Pain [ ] Back Pain [ ] Muscle Weakness [ ] Foot/Ankle Pain [ ] Hand/Wrist Pain [ ] Shoulder Pain [ ] Hip Pain [ ] Osteoporosis Neuropsychological [ ] Seizures [ ] Dizziness [ ] Loss of Balance [ ] Areas of Numbness [ ] Lack of Coordination [ ] Poor Memory [ ] Concussion [ ] Depression [ ] Anxiety [ ] Bad Temper [ ] Easily susceptible to stress [ ] ADD [ ] Difficulty Concentrating Infection [ ] Measles [ ] Mumps [ ] Whopping Cough [ ] Rheumatic Fever [ ] Tuberculosis [ ] Typhoid Fever [ ] Malaria [ ] Chicken Pox [ ] Scarlet Fever [ ] Small Pox
5 Other Are you allergic to any of the following? If yes, please specify ( ) Medicine ( ) Food ( ) Herbs ( ) Others Do you have or are you any of the following? ( ) Pacemaker ( ) Electric Implants ( ) Metal Implants ( ) Severe Bleeding Disorders ( ) Pregnant ( ) HIV Positive ( ) Hepatitis A/B/C Social History No Yes When Started When Stopped Amount Coffee Tea Alcohol Tobacco Other Family History (please include the relation) [ ] Migraines [ ] Stroke [ ] Heart Disease [ ] Allergies [ ] Asthma [ ] Arthritis [ ] Diabetes [ ] Glaucoma [ ] High Blood Pressure [ ] Mental Illness [ ] Gall Stones [ ] Cancer [ ] Thyroid Disease [ ] Epilepsy Comments Please tell us of any other problems you would like to discuss: Patient Signature Date / /
6 Bodytech Acupuncture & Sports Medicine 109 Hinton Ave. #10 Wilmington, NC (910) I,, herby authorize the private practitioners of Bodytech to perform the following specific procedures as necessary to facilitate my diagnosis and treatment: Acupuncture: insertion of special disposable needles through the skin into underlying tissues at specific points on the surface of the body. Massage: Manipulation of tissues as by rubbing, stroking, kneading, or tapping with the hand or an instrument for therapeutic purposes. Heating Lamp or Pad: produces heat on the acupoints and meridians. Electrical Acupuncture: use of electrical device to produce electrical stimulation on the acupuncture needles. Herbs: may be given in the form of pills, powders, tinctures, pastes, or plasters. Herbal formulas may include shell, mineral, and animal materials. Moxa: indirect burning on an acupoint using stick, string, or ball moxa to relieve symptoms. Dietary Advice: based on traditional Chinese Medical Theory. I recognize the potential risks and benefits of these procedures as described below: Potential Risks: discomfort, pain, infection, or blistering at the site of the procedure; temporary discoloration of the skin; nausea, loose bowel movements, abdominal cramping; and aggravation of the symptoms prior to the acupuncture treatment. Potential Benefits: drugless relief of present symptoms and improved balance of bodily energies, which may lead to prevention or elimination of the present problem and the strengthening of the constitution. Notice to Pregnant Women: We do not use labor stimulating acupuncture points unless specifically for the induction of labor. A treatment to induce labor requires a letter from the primary care provider authorizing or recommending such a treatment. All female patients must alert the practitioner if they know or suspect that they are pregnant. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by Bodytech Acupuncture & Sports Medicine or any of its personnel regarding cure or improvement of my condition. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. I understand that a record will be kept of my health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or if it is required by law. I understand that I may look at my medical record at any time and request a copy of it by paying the appropriate fee. I understand that my medical record will be kept for a minimum of three years, but no more than eight years after the date of my last treatment. / / Date Signature of Patient, Patient Representative, or Guardian
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
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
PATIENT INFORMATION. Emergency Contact Name Relationship. Kalin Davidov, L. Ac., M.S.TCM. Marital Status Phone (cell) Address City State Zip
Kalin Davidov, L. Ac., M.S.TCM PATIENT INFORMATION Patient Name Date of Birth / / SSN Male Female Height Weight Marital Status Phone (cell) Address City State Zip E-mail Phone (home) Occupation Phone (work)
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
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
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
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:
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:
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
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
Acupuncture & Herbal Therapies
Acupuncture & Herbal Therapies 2520 Central Ave. St. Petersburg, FL 33712 (Phone) 727-551-0857 (fax) 727-202-6896 Last Name: First Name: Male/Female: Date of Birth: Address: City: State: Zip: Home Phone#:
Health History Questionnaire
Health History Questionnaire Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Mobile Phone: Email: Date of Birth: Place of Birth: Height: Weight: Relationship Status: Employer: Single
Patient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation
Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth
Eastern Body Therapy
2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security
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
Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042
Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042 Date: Name: Sex: M F Date of Birth: Drug Allergies: Address: City: State: Zip: Phone Numbers ( ) ( ) ( ) Home
Oriental Medicine Questionnaire
Oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Occupation: Height: Weight: Who referred you to this office? 1.What brought you
Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History
Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History Name: Date: PRESENT HEALTH CONCERNS: Please list your most important health concerns in order of their
Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star **
Date: Name: Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Email: Date of Birth: Place of Birth: Age: Employer
2. Approx. Date of Onset: 3. Approx. Date of Onset:
Healthy Balance Lisa A. Dulac, L.Ac. Acupuncture Patient Intake Form Present Health Concerns: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: 2.
Avery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
New You Acupuncture Wellness Center Oriental Medicine - Acupuncture - Herbs - Homeopathy
Patient Contact Information Form Your privacy is being protected per HIPPA guidelines. No information will be given out without your expressed consent. Please indicate any of the following methods of communication
Average Daily Diet: Morning Afternoon Evening
Average Daily Diet: Morning Afternoon Evening Habits: Cigarettes Coffee Tea Cola Alcohol Drugs Sugar Salt Other Family Medical History: Diabetes Cancer High Blood Pressure Heart Disease Stroke Seizure
Mayflower Acupuncture LLC
536 Hopmeadow St. Simsbury, CT 06070 Phone: (860) 413-2118 Email: Forms@mayfloweracupuncture.com Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this
HIPAA Acknowledgement and Appointment Reminder Form
HIPAA Acknowledgement and Appointment Reminder Form I acknowledge that I have been provided access to Salado Acupuncture s Notice of Privacy Policies. I understand that I have the right to review Salado
CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form
Consent for Treatment Form
Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
Mayflower Acupuncture LLC
Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this form as completely as you can. All information provided here will be held in strictest confidence.
New Patient Intake Form
New Patient Intake Form Today s Date: / / Name: Birthdate: / / Address: City / State: Zip: Home Phone: Email: Cell Phone: Work Phone: Male Female Ht Wt Occupation: Referred by: Reason for visit today:
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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
ACUPUNCTURE QUESTIONNAIRE
ACUPUNCTURE QUESTIONNAIRE CHIEF COMPLAINT: PAIN EVALUATION Pain Scale: no pain 0 1 2 3 4 5 6 7 8 9 10 severe pain 1 Mark each area where you are having pain according to the pain scale above. HISTORY HEALTH
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
Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:
NAME _ Please take the time to fill this form out completely. The more information we have, the better we can assist you, and will make better use of your initial visit. What is the main problem you would
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:
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION
PERSONAL INFORMATION NAME: TODAY'S DATE: ADDRESS HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: PHONE: HOME MOBILE WORK EMAIL ADDRESS: EMERGENCY CONTACT: STATUS: SINGLE MARRIED DIVORCED WIDOWED OTHER: NUMBER
Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:
Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship
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:
If you have any questions, feel free to contact us at 475- WLNS (9567) or
UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH
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
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
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
Life Essentials TCM Center, Jing Shen, L.Ac., O.M.D Wild Horse Creek Road Ste 140, Chesterfield, MO
Life Essentials TCM Center, Jing Shen, L.Ac., O.M.D. 17269 Wild Horse Creek Road Ste 140, Chesterfield, MO 63005 636-5364070 Name: Health History Questionnaire Today's Date: Address: e-mail: City: State:
PATIENT INFORMATION. GENERAL INFORMATION Have you had acupuncture before? Yes No Have you used Chinese herbal medicine? Yes No
PATIENT INFORMATION PATIENT INFORMATION Date Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address
Acupuncture & Oriental Medicine of Sturbridge 48 Main Street, Sturbridge MA PHONE: FAX:
Acupuncture & Oriental Medicine of Sturbridge 48 Main Street, Sturbridge MA 01566 PHONE: 508.347.0055 FAX: 508.347.7576 EMAIL: aoms@charter.net HEALTH HISTORY Name Date DOB Age Height Weight Referred By
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:
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:
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Minister Medical ^Acupuncture
Minister Medical ^Acupuncture t^wellness Clinic What is acupuncture? Acupuncture is a therapy in which fine needles are inserted into specific points on the body. Is acupuncture safe? Acupuncture is generally
Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060
Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
New Patient Information
Kairos Acupuncture, Chinese Herbs, & Bodywork LLC 262-323-9022 kairosacupuncture@hotmail.com acupuncturewestbend.com New Patient Information Name Today s Date Street Address Apt. City State Zip Preferred
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
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
Rockwood Natural Medicine Clinic
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
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information
Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Email: Emergency Contact:
NEW PATIENT QUESTIONNAIRE
Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program
Midwest Acupuncture Clinic th St. Urbandale, IA (515)
Name: Street: City: State: Zip: Home Phone: Work Phone: Cell Phone: Fax Number: E-Mail Address: Date of Birth: Social Security #: Occupation: Emergency Contact: Marital Status: Age: Height: Approx Blood
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
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:
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:
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
Health History New England Community Acupuncture
Health History New England Community Acupuncture Name: Contact - Cell: Street: Home: City: Work: State: Zip: Email: DOB: Height: Occupation: Age: Weight: Physician: Emergency Contact - Name & Phone Number:
City: State: Zip: Address: Home Phone: ( ) City: State: Zip: Work Phone: ( )
Advanced Acupuncture Inc. II Dr. Nikki N. Medghalchy, DAOM, L.Ac., M.Ac., Dip (NCCA) O.M Natalie Lehmann, L.Ac, MAcOM 17704 Jean Way Ste. 105, Lake Oswego, Oregon 97035 Tel: (503) 908-0157 Fax: (503) 908-0187
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
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
Dear Valued Patient, Revised 09/24/2018 UC Health Integrative Medicine Page 1 of 5
UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
Parental Information (if patient is a minor)
709 West Leuda St. 6221 Colleyville Blvd, Suite 100 Fort Worth, TX 76104 Colleyville, TX 76034 Phone: (817) 927-5111 Phone: (817) 421-2922 Fax: (817) 927-7112 Fax: (817) 416-8397 Client Information First
Hollenbach Family Chiropractic 250 Main Street Madison, NJ ACUPUNCTURE OFFICE POLICIES
Hollenbach Family Chiropractic 250 Main Street Madison, NJ 07949 ACUPUNCTURE OFFICE POLICIES Patient Name: Patient Date of Birth: Appointments and Scheduling Treatments are by appointment only. Emergency
Patient Admittance Form
Patient Admittance Form Mah Chiropractic Clinic 7222 Edgemont Blvd. N.W. World Health Club Calgary, AB. T3A 2X7 Phone: (403) 241-1886 Fax: (403) 241-0995 Name: (Family) (First) (Initial) Sex: Male Female
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
NorthPointe Medicine, P.C.
NorthPointe Medicine, P.C. Patient Information Name: Today s Date: Male Female Date of Birth: Age: _ Blood Type: Phone: Home# Work# Cell# Address: City: State: Zip: Email Address: Marital Status: Single
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
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
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:
NEW CLIENT HEALTH INFORMATION (REVISED 04/2014)
NEW CLIENT HEALTH INFORMATION (REVISED 04/2014) Sojourns practitioners work in collaboration with each other. We discuss care options at a daily meeting. We feel that we can offer the most to our patients
Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name
Healthworks Nutrition Centre. Naturopathic Medical Questionnaire. Name Date of First Visit. Address. Province Postal Code. Telephone # (home) (work)
Healthworks Nutrition Centre Naturopathic Medical Questionnaire PERSONAL INFORMATION Name Date of First Visit Blood type # of Children Address City Province Postal Code Telephone # (home) (work) E-mail
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:
Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
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
Placer Private Physicians: Patient Health Questionnaire [2]
![Placer Private Physicians: Patient Health Questionnaire [2]](/thumbs/87/96006031.jpg "Placer Private Physicians: Patient Health Questionnaire [2]")
Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
To: New patients for acupuncture and Oriental medicine
To: New patients for acupuncture and Oriental medicine Thank you for your interest in becoming an acupuncture and Oriental medicine patient. As part of your first visit to our clinic, you will take part
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
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