WELLNESS HISTORY. Patient s Name: Date
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- Blaze Henry
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1 u:\share\sr dr\wellness history WELLNESS HISTORY Patient s Name: Date 1) Have you ever been to Acupuncturist? Yes No If Yes: Currently In the past, When: Did it help? What treatment did you receive? If No: What have you heard: It helps It hurts Expensive It feels good Not real doctors You have to keep on going forever It helps only temporarily Other 2) Please check any or the following symptoms you have experienced in the last 6 months: Headaches/Migraines Elbow/Wrist/Hand pain Herniated /Degenerated Disc Dizziness / Vertigo Carpal Tunnel Syndrome Restless Leg Syndrome Neck pain Tingling/Numbness Fibromyalgia Mid back pain Lower back pain Arthritis/Osteoarthritis Arm/ Shoulder pain Sciatica (pain in leg) Stenosis (nerve canal narrowing) Sinus/Allergies Hip/Leg pain Chronic Fatigue / Tiredness Insomnia Knee/Ankle/Foot pain Tremor disorder Balance Problems Scoliosis (curved spine) Digestive problems High Blood Pressure Ringing in ear Whiplash Diabetes (high blood sugar) Females: Infertility / Menstrual problems High Cholesterol Other A) Which of the above is the worst? How long have you had this condition? How often do you get it? How long does it last when you have it? Where is it located exactly? What type of pain is it? Sharp Dull Burning Aching Other Does it radiate or travel anywhere? Is this problem: Getting worse Staying the same Getting better-please explain Describe how this condition feels at its worst What kinds of activities make this problem worse? (sitting, standing, sports, hobbies) Is there anything that temporarily helps this condition? Do you feel this condition will go away on its own and not return?
2 B) Which of the above conditions is the next worst? How long have you had this condition? How often do you get it? How long does it last when you have it? Where is it located exactly? What type of pain is it? Sharp Dull Burning Aching Other Does it radiate or travel anywhere? Is this problem: Getting worse Staying the same Getting better-please explain Describe how this condition feels at its worst What kinds of activities make this problem worse? (sitting, standing, sports, hobbies) Is there anything that temporarily helps this condition? Do you feel this condition will go away on its own and not return? u:\share\sr dr\wellness history ) Since the time you began suffering from these problems, what have you tried to do to get rid of them that has not worked permanently? Prescription Medications: Results Injections: Results Over-the-counter Medications: Results Massage: Results Exercise: Results Physical Therapy: Results Acupuncture: Results Home remedies: Please explain Other: Please explain 4) Describe how the above condition(s) affect you when they are at their worst: Moody Irritable Lose patience with others Less fun to be with Help less around the house Feel Nauseous Restricted in motion Have to lie down Don t want to do anything Other Interrupts sleep - Explain Restricts daily activities- Explain Hinders recreational activities-explain They have no affect on me 5) Is there anything else that these problems are preventing you from doing, either totally
3 or partially, that you would really like to be doing again? Please explain: 6) What is your current occupation or past occupation (if retired)? What type of work is involved mostly? (lifting, sitting, standing, etc) 7) Are you less productive on your job because of these health problems? Do you enjoy your work less because of these problems? Do you have to take more breaks? 8) Healing occurs when you are asleep and sleep is essential to a proper immune system. Having problems with sleep is a complicating factor, which makes healing more difficult. Do you have: 1) Trouble falling asleep due to being uncomfortable? 2) Not enough restful sleep? 3) Awaken in the middle of the night? 4) Waking earlier than you normally would? 9) When was the last time you woke up feeling good? 10) Is this problem negatively impacting your relationships with your loved ones, friends, colleagues, or others? 11) Have you had to just learn to live with these problems? 12) Do you feel the quality of your life has decreased as a result of these problems? 13) If these problems are left untreated, do you feel they will get worse? How do you feel that would affect you? (develop arthritis? become bedridden? or become unable to function normally?, etc.) 14) Comparing your health now to 5-10 years ago, do you feel your overall health is: Improving Getting Worse Staying the Same 15) What would life be like if you got these problems corrected and they didn t return? u:\share\sr dr\wellness history
4 16) Would you feel younger if you didn t have these problems? How many years younger would you feel? 17) We believe that a person s health is more important than anything else. Without your health, you can t enjoy life. No matter how much money or material possessions a person has, they would always want their health first. Do you agree that your health should be your top priority? 18) Do you feel it s time to do something about this problem? Yes No 19) On a scale of 1 to 10, 10 being the most committed and 1 being the least committed, please rate your commitment to getting your health problems handled: Please circle one: (low priority) (top priority) 20) Please check off which tests you have had in the past: MRI neck when low back when CT SCAN neck when low back when X-RAYS neck when low back when For X-rays: Were they taken: Standing Seated or Lying down Other: when Other: when PLEASE FILL OUT NEXT PAGE Check off any of the following symptoms you currently have or recently had: u:\share\sr dr\wellness history
5 CONDITION Frequency CONDITION Frequency ADD/ADHD - learning problems Heart Murmur Allergies Hemorrhoids Allergies - Food High Cholesterol Anemia Hypersomnia (sleeping too much) Aneurysm Hypoglycemia (low blood sugar) Arteriosclerosis Hardening of the Arteries Infertility / Uterine problems / Miscarriages Arthritis / Joint pain / DJD / Osteoarthritis Insomnia Asthma / Emphysema Irregular Heart Rate Auto-Immune Disease Joint Cramps / Pain Bed wetting Kidney Problems Bladder / Urination Problems Libido Decreased Bloating Liver problems Blood Pressure-high / low Low Resistance to Infections Bronchitis / cough / Breathing problems Male = Prostate problem / Impotence Cancer Memory Loss (loss of concentration) Candida Albicans / Yeast Infections Menopause / Hot flashes Chest Pain / Pneumonia Numbness / Tingling Colds (chronic) / sore throat / Tonsillitis Constipation Osteoporosis / Osteopenia Over / Under Weight Depression PMS / Menstrual problems / cramps Diabetes (high blood sugar) Poor Circulation / Cold hands or feet Diarrhea / Digestive Problems / Colitis / Gas Psoriasis Dizziness / Vertigo / Imbalance / Falling Rapid Heart Rate Ear Infections / Earaches Seizures Eye Trouble / Vision difficulty Shingles Edema / water retention (swelling feet) Shortness of Breath Epilepsy Sinus Problems Failed Back/ Neck/ Wrist Surgery Skin Disorders / Eczema / Hives / Acne Fainting Spells Stiffness Fatigue / Exhaustion / Low energy Stomach Problems / Nausea / Indigestion Fibromyalgia Thyroid Disorder Gall bladder problems TMJ Headaches (non-migraine) Ulcer Headaches - Migraine Varicose veins Hearing problems Weakness or cramps in legs Heart Disease Cardiovascular Disease Weight gain / loss Please list any other complaints or concerns here that you wish you could get rid of, even if you wouldn t necessarily think that it s something we could help you with: What Prescribed Medications are you currently taking? What Over-The-Counter Medications are you taking? What Supplements are you taking? Do you have a pacemaker? Yes No Do you have a history of: Cancer? Date Gall Stones? Date Heart Attack? Date Stroke? Date Surgery? -For Date -For Date Other u:\share\sr dr\wellness history
6 1) Do you take various vitamins, minerals, herbs or homeopathic remedies without being absolutely sure what really you need? 2) Have you ever been tested to find out what vitamins or minerals you really need? 3) Did you know that taking vitamins, minerals or herbs taken randomly can cause Nutritional Deficiencies? 4) Do you have trouble losing weight or keeping it off? 5) Do you eat less than you used to but still can t lose weight? 6) Would you like to know if your metabolism has slowed down, causing lack of energy, weight gain or trouble losing weight? 7) Would you like to find out how to slow down your aging process naturally from the inside out? 8) Would you like to find out if underlying Nutritional Deficiencies or Imbalances are causing any health problems? 9) Would you like to find out what are the best foods for YOU based on testing? 10) Would you like to watch the video that explains the program to find the answers to these questions? u:\share\sr dr\wellness history
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Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Current Health Information
Name: : / / Current Health Information List your health concerns below: Health Concerns: (List according to severity) Rate of Severity 1 = Mild 10 = Unbear able When did the Symptom s Start? Are the Symptoms
CURRENT HEALTH CONDITIONS. Patient Name: Date:
Patient Name: Date: Is this your first pregnancy? 0 Yes 0 No - If not, please tell us about your previous pregnancy and/or birth experience(s). (Duration, frtervent/ons, etc) Do you plan to follow the
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
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:
Please fill out this form as completely as possible. This information will determine how we treat your pain problem.
Name Date of birth Age Please fill out this form as completely as possible. This information will determine how we treat your pain problem. Primary care physician Referring physician Today s WHERE is your
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
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
Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny. Section 1: Today s Date: Date of Birth: Age:
Baylor Physical Medicine and Rehabilitation NEW PATIENT QUESTIONNAIRE For Dr Benoy Benny Dear Patient: Please complete this questionnaire before you come for your appointment. Be sure to call us as soon
Primary Health Concerns Please use the following to best describe the primary reason you are seeking medical care today.
Patient Intake Form 30 E. 60 th Street #302 - New York, NY 10022 New Patient Special Consultation Notes: For: (OFFICE USE ONLY) Full Name (First, Last) Date Referral: How did you hear about us? Who should
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:
Chiropractic Case History/Patient Information. Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone:
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Tassin Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
Acupuncture Patient Health History
Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender/Preferred pronoun: Marital status (please circle one): Single Married Domestic Partnership
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
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
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S. Chiropractic Care
Basic Information Full Name: Address: City: State: Zip: Cell: Home: Work: Date of Birth: Sex: O Male O Female Marital Status? O M O W O D O S Email: Occupation: Emergency Contact: Phone: Children: O No