Intake Form. Your Information: Emergency Contact: Medication, Supplements and/or Vitamins: List of surgeries or major injuries:
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- Osborne McGee
- 5 years ago
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1 our Information: ame: Address: Home Phone: DOB: City: Postal Code: Cell: our Occupation: How did you hear about me: Emergency Contact: Contact ame: Phone #: Relationship: Medication, Supplements and/or Vitamins: List of surgeries or major injuries: Chief Complaint: 1
2 Informed Consent of Traditional Chinese Medicine Treatment I, hereby request and consent to the performance of Traditional Chinese Medicine (TCM) procedures on me or the patient for whom I am legally responsible for by my TCM practitioner including, but not limited to: Acupuncture, electro-acupuncture, Moxibustion, ear seeds Cupping, guasha Tuina (Chinese massage), acupressure, Qi gong, (exercise), ang Shang Fa (life style and diet therapy) Please visit web site for description and details about different techniques. Possible side effects of acupuncture may include: Drowsiness Bruising Minor bleeding Fainting In less than 3% of patients symptoms may become worse for 1-2 days following the treatment. 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 the opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I also understand that there is always a possibility of an unexpected complication and I understand that no guarantee can be made concerning the results of treatments. I intend this consent to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment. Consent to Disclose Personal Health Information Physician ame: Location: May I contact your physician and/or Health Care Provider? (Consent to Disclose Personal Health Information) ou may withdraw your consent at any time and or limit the information that may be shared. Cancellation Policy: Unplanned issues or emergencies come up for all of us. A minimum 24 hours notice is required for appointment changes or cancellations. Patient or Patient s Representative Signature Date Date 2
3 Do you have chills & fever: Do you experience pain? Do you perspire? Where? Do you perspire after slight exertion? Type of pain? Do you perspire at night? How is your appetite? Do you perspire spontaneously during the day? How much water do you drink? Do you have any chest pain? Do you prefer hot of cold drinks? Do you ever have palpitations? Do you sip or gulp? Sip Gulp Do you ever have anxiety? Do you have any bloating/gas? Do you ever have asthma? Do you have any belching or acid reflux? Do you ever have a cough/phlegm? Do you have any food cravings? How is your hearing? Do you experience abdominal pain? Do you have ringing in the ears? Do have constipation? How is your vision? Do have diarrhea? Blurry vision umber of bowel movements per day: Red eyes ight blindness Any undigested food, mucous or blood in your stool? Floaters Any pain or difficulty when urinating or defecation? Dry eyes What colour is your urine? How is your energy level? Fair How many times do you urinate after bedtime? Do you experience dizziness? How many hours of sleep do you get? Do you experience headaches? Do you feel rested in the morning? What time of day? Troubles falling asleep? Where on the head? Troubles staying asleep? Character of aches? Childhood health history? Family health history: 3
4 SKI & HAIR Rashes Itching Eczema Psoriasis Boils/Cysts Acne Hives Warts Colour changes ew/changed moles Lumps Dandruff Hair loss Change in hair texture ail changes MOUTH & THROAT Dental cavities Mercury fillings Gum problems Grinding/Clenching Ulcers/sores Loss of Taste Pain/Soreness Frequent Sore throat Hoarseness Tonsillitis Phlegm/Mucous Cold sores Enlarged glands Jaw pain/clicking Facial pain/tics OSE & SIUSES Allergies Loss of smell Post nasal drip osebleeds Sinus infections Sinus pain asal congestion Sleep apnea Snoring asal Polyps EES Impaired vision Glasses/contacts Far-sighted ear-sighted Double vision Colour blindness ight blindness Sensitivity to sun Pain Redness Itching Discharge Blurring Excessive tearing Spots/Floaters Blind spot Glaucoma Cataracts RESPIRATOR Cough Sputum Coughing blood Wheezing Asthma Bronchitis Pneumonia Emphysema Tuberculosis Difficulty breathing Pain with breathing Shortness of breath (SOB) SOB lying down SOB at night CARDIOVASCULAR High blood pressure Low blood pressure Irregular heart beat Fast heart beat Slow heart beat Palpitations Murmurs Angina Chest pain Swelling of limbs Cold hands or feet Thrombophlebitis Blood clots Varicose veins Elevated cholesterol Past ECG test Heart tests BLOOD & LMPHATIC Anemia Easy bruising/bleeding Slow clotting Fatigue/weakness Pallor (paleness) Swollen lymph nodes Past transfusions HEAD & ECK Headache Injury Lumps Swollen glands Swollen lymph nodes Goitre Pain/stiffness EARS Ringing Discharge Pain/Aches Deafness Infections Wax build-up Ear tubes 4
5 GASTROITESTIAL Heartburn/acid reflux Indigestion Poor/change in appetite Poor/change in thirst Difficulty swallowing Abdominal pain/cramps breath Diarrhea Constipation Incomplete bowel movements Vomiting blood Spitting blood Chronic laxative use Rectal pain Rectal bleeding Rectal incontinence Hemorrhoids Blood in stool Black, tarry stools Undigested food in stool Mucous in stool Hernia Ulcer Candida Intestinal worms Liver disease Gall bladder stones/disease Jaundice Anal itching Anal fistula Anal fissures Food allergies GEITOURIAR Frequent urination Pain/burning on urination Urgency to urinate Urinary incontinence Hesitancy with urination Recurrent urinary tract Infections Kidney infection Kidney stones Blood in urine Low back pain Flank (side) pain EDOCRIE Excessive urination Excessive sweating Heat intolerance Cold intolerance Thyroid disease Excessive thirst Excessive hunger Diabetes Hypoglycemia Hormone Therapy Rapid weight gain Rapid weight loss Insomnia MUSCULOSKELETAL Back pain Muscle spasms/cramps Muscle weakness Arthritis Tendonitis Jaw pain/stiffness Joint pain/stiffness Joint swelling Bursitis Fractures Osteoporosis Sciatica EUROLOGICAL Dizziness Seizures Fainting Paralysis Stroke Poor memory Loss of balance Concussion umbness/tingling Tremors Speech difficulty Poor coordination Confusion Dementia Learning difficulties Involuntary movements FEMALE REPRODUCTIVE Heavy menses Light menses Irregular periods Painful periods Bleeding between periods Menstrual blood clots Vaginal discharge Vaginal itching Vaginal sores east infections Painful intercourse Low libido sexual difficulty Fibroids Ovarian cysts/pcos Endometriosis Hysterectomy Menopause Difficulty conceiving Birth control/protection Form: MALE REPRODUCTIVE Testicular masses Testicular pain Hernia Prostate problems Discharge or sores Low libido Erectile dysfunction Premature ejaculation Low sperm count sexual difficulty EMOTIOAL/PSCHOSOCIAL Depression Anxiety Mood swings or Irritability Phobias Hyperactivity Aggression Alcohol/Drug Abuse 5
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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
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
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:
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
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 HISTORY QUESTIONNAIRE
1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synergyspineinjury.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014
MALE MEDICAL HISTORY FORM (please circle answers/complete blanks) rev 2/2014 Name: Date of Birth: Today s Date: Where did you get healthcare before? May we request records? Y N (requires signed release)
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
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
ADULT INTAKE FORM - NATUROPATH Date:
ADULT INTAKE FORM - NATUROPATH Date: Name Date of Birth Gender (please circle) F M Weight (current) lbs Marital Status Single Married Divorced Partnership Height (inches or cm) Widowed Other Do you have