PATIENT INFORMATION. Emergency Contact Name Relationship. Kalin Davidov, L. Ac., M.S.TCM. Marital Status Phone (cell) Address City State Zip
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1 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 Phone (home) Occupation Phone (work) Family Physician Referred by Phone Phone Emergency Contact Name Relationship Phone Chief Complaint How long you ve had the condition. Other Complaints How long you ve had the conditions. What kinds of treatments have you received? List any Hospitalizations & Surgeries Date Place List medications being taken (including dose) Signature Date
2 Kalin Davidov, L. Ac., M.S.TCM 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 Gastrointestinal [ ] Nausea [ ] Constipation [ ] Diarrhea [ ] Vomiting [ ] Gas [ ] Belching [ ] Bad Breath [ ] Blood in Stools [ ] Black Stools [ ] Abdominal Pain or Cramps [ ] Rectal Pain [ ] Hemorrhoids [ ] Indigestion [ ] Chronic Laxative Use [ ] Acid Reflux [ ] Ulcer [ ] Colitis
3 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 1st Menstruation [ ] Unusual Character (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 Flash/Night Sweats [ ] Frequent changes in emotion [ ] Osteoporosis Musculoskeletal [ ] Neck Pain [ ] Muscle Pains [ ] Knee Pain [ ] Back Pain [ ] Muscle Weakness [ ] Foot/Ankle Pain [ ] Hand/Wrist Pain [ ] Shoulder Pain [ ] Hip Pain 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 Are you allergic to any of the following? ( ) 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 Do you consume: Coffee: [ ] moderate [ ] medium [ ] heavy Tea: [ ] moderate [ ] medium [ ] heavy Alcohol: [ ] moderate [ ] medium [ ] heavy Tobacco: [ ] moderate [ ] medium [ ] heavy Family History (please include the relation) [ ] Migraines [ ] Stroke [ ] Heart Disease [ ] High Blood Press [ ] Allergies [ ] Mental Illness [ ] Asthma [ ] Gall Stones [ ] Arthritis [ ] Cancer [ ] Diabetes [ ] Thyroid Disease [ ] Glaucoma [ ] Epilepsy Signature Date
4 Kalin Davidov Acupuncture Consent to Treatment I hereby request and consent to the performance of Acupuncture treatments and other Oriental Medicine procedures on me (or on the patient named below, for which I am legally responsible) by the licensed Acupuncturist named below. I understand that methods or treatments may include, but are not limited to, Acupuncture, moxabustion, cupping, bleeding, electrical stimulation, Tui Na Massage, Gua Sha, Plum Blossom, Chinese or Western Herbal Medicine, nutritional counseling and/or supplementation. Acupuncture attempts to normalize physiological functions, to modify the perception of pain and to treat certain diseases of dysfunction of the body. I have been informed that Acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that last a few days. There have been very rare instances reported of fainting, infection and scarring. There have been extremely rare instances of spontaneous miscarriage and pnuemothorax. There may be some bruising after cupping. I do not expect the Acupuncturist to be able to anticipate all risks and complications. I wish to rely on the Acupuncturist to exercise correct judgment during the course of the procedure which the Acupuncturist feels at the time, based on the facts then known, and is in my best interests. initials The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine. I understand the same herbs may be inappropriate during pregnancy and will inform my practitioner immediately of pregnancy status. If I experience any gastro-intestinal reactions to the herbs I will inform the Acupuncturist immediately. initials I have been informed that I have a right to refuse any form of treatment. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its consent, and by signing below I agree to the above named procedures. I also understand there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I understand it may be necessary for my practitioner to contact another one of my health care providers in order to coordinate medical treatment, to discuss any emergency situation and/or to share appropriate medical information. My signature gives my practitioner permission to release my medical records for the reasons listed above. I agree to pay the full charge for any missed or forgotten appointments without 24-hour notice of cancellation. initials I agree to pay all charges incurred for services rendered, over and above insurance coverage.
5 By signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment: Patient s name Patient s signature Date signed Date of Birth Are you pregnant? Kalin Davidov, L.Ac, D.OM. Name of Licensed Acupuncturist To be completed by the patient s representative, if the patient is a minor, or physically/legally incapacitated. Name of Patient Patient s Representative Relationship of Authority of Patient Witness
6 COLORADO MANDATORY DISCLOSURE STATEMENT Kalin Davidov, Center for Neuromuscular Massage Therapy 3955 E. Exposition Ave. # Education and Experience Kalin Davidov earned his Master of Science in Traditional Chinese Medicine from the Colorado School of Traditional Chinese Medicine in April This three-year program consists of 2,850 hours of education including over 700 hours of clinical practice. Kalin's training includes adjunct therapies such as Acupuncture, Moxibustion, Chinese massage, Cupping, Plum Blossom, Auriculotherapy, and dietary and lifestyle recommendations. Kalin is certified as a Diplomate in Acupuncture and Traditional Chinese Medicine by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in April This includes certification in Clean Needle Technique and Chinese Herbology. He is a licensed acupuncturist in Colorado. None of these licenses, certificates, or registrations has ever been suspended or revoked. This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the proper cleaning and sterilization of needles and the sanitation of acupuncture offices. Only single-use, disposable, factory-sterilized needles are utilized. Fee Schedule Intake Consultation and Treatment Follow-up Treatment Herbal Consultation only $40 $110 + cost of herbs $75 + cost of herbs Patient s Rights The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if know. The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Registration Office, 1560 Broadway, Suite 1350, Denver, Colorado 80202; (303) I have read and understand this document. Patient s or Guardian s Signature Date
7 24 HOUR CANCELLATION POLICY Center for Neuromuscular Massage Therapy, Inc has a 24-hour cancellation policy. This means as a patient or client, you need to notify the clinic twenty-four hours in advance if you are unable to keep your scheduled appointment. Your therapist sets aside time for you, and does not get paid if you do not either keep your appointment, cancel, or pay the late cancellation fee. We certainly understand that situations can arise over which you have no control. However, if appointments are missed without notice, more than once, you will be charged a cancellation fee of $35. YOUR INSURANCE COMPANY WILL NOT PAY THIS FEE. It will be your responsibility, and billed directly to you. Thank you for your consideration of our time, and of other clients who would benefit from that time. Signed Date
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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
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
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
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
Worthington Optimal Wellness Acupuncture Patient Health History Form
Worthington Optimal Wellness Acupuncture Patient Health History Form Rita Ghodsizadeh, L.Ac, Dipl.Ac. B.A. 6180 Linworth Rd., Worthington, OH 43085 Office # 614-848-5211 ; cell # 614-309-1898 www.acupuncturehealscolumbus.com
Healing Arts Acupuncture & Traditional Chinese Medicine
Healing Arts Acupuncture & Traditional Chinese Medicine New Patient Intake Patient Name Date General Information Address City State Home Phone Occupation Zip Work Phone Date of Birth Mobile Phone E-mail
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
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:
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
Name Today s Date Birth Date. Age Gender M / F Address City. Zip Cell/Home Phone:
Name _Today s Date Birth Date Age Gender M / F Address City State Zip Email: Cell/Home Phone: Work Phone: Can we leave detailed message: Cell: yes / no Email: yes /no Work: yes /no Place of Employment
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
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
Naturopathic & Acupuncture Intake Form (Age 14+)
Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair, B.Sc., ND 86 Norfolk St., Guelph 519-827-0040 Contact Information Naturopathic & Acupuncture Intake Form (Age 14+) Name: Gender: Age: Birth Date (dd/mm/yy):
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:
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
An Hao Natural Health Care Clinic 2348 NW Lovejoy St. Portland, OR
Edythe Vickers, N.D., L.Ac. Loren Lubin (Resident) Rachel Eppinga, N.D., L.Ac. Heather Krebsbach, N.D., L.Ac. Angela Read, L.Ac. Patient Intake Form Page 1 An Hao Natural Health Care Clinic 2348 NW Lovejoy
15901 Central Commerce Drive, Suite 102 Pflugerville, Texas (512)
15901 Central Commerce Drive, Suite 102 Pflugerville, Texas 78660 (512) 494-4050 PATIENT INFORMATION Full Name (Print): Sex: M / F Date of Birth: (MM/DD/YY) / / Age: Street Address: City: State: Zip Code:
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:
6365 Shier Rings Road, Suite A Dublin, OH fax Acupuncture Form
6365 Shier Rings Road, Suite A Dublin, OH 43016 614.764.4001 fax 614.764.4002 www.dublinfamilychiropractic.com Acupuncture Form Name Date of Birth Gender: M F Address City State Zip Cell Phone Employer
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
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:
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:
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 MEDICAL HISTORY INTAKE FORM
Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information: