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- Curtis Willis
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1 Have you ever had or are you currently experiencing any of the following? Acne Anorexia Anemia Asthma Bleeding Tendency Blood Disorder Bruising Tendency Cancer-Active Cancer- Remission Cardiac Disorder Cold Sores Current Cold/Flu Diabetes Epilepsy/ Seizures Hepatitis Type High Blood Pressure High Cholesterol HIV Infection Currently Kidney Disease Leukopenia Liver Disease Low Blood Pressure Lupus/ SLE Lymph Disorder Migraines Multiple Sclerosis Pacemaker/ Electrical Implant Poor Wound Healing Respiratory Disease Rheumatoid Arthritis Raynaud Scleroderma Shingles Sjogrens Skin Rash Currently Staph Infection/MRSA Stroke Thyroid Disorder Please list any other conditions: If you answered yes to any of the above questions, please state how this medical condition is being managed. ame of Physician, ame of Medications, other Treatments, etc. I attest that the above information is accurate to my knowledge and will alert FP@PD if any information about my health changes. Client Signature: Witness Signature:
2 HORMOE QUESTIOAIRE ame: DOB: PROGESTEROE MILD MODERATE SEVERE 9 10 Difficulty Concentrating Can t Sleep (Insomnia) Depressed or Unhappy Anxious Headaches Moodiness/Emotional Swings Painful and Swollen Breasts Weight Gain/Bloating PMS ESTROGE ight Sweats Memory Loss Hot Flashes Vaginal Dryness Dry Hair/Skin Incontinence Frequent Urinary Infection Inability to Reach Orgasm Painful Intercourse TESTOSTEROE Loss of Libido Lack of Desire to be Intimate Loss of Motivation Flat Mood Diminished Well Being GEERAL WELL BEIG Change of Bowel Movement Change of Weight Change of Stress LEVEL How many per day? Increase: es/o Decrease: Current stress level:
3 Medications/Supplements Medications/Supplements Reason for taking Date Began Dose Have you had any allergic reaction to the following? Local anesthetics (ex: Lidocaine) Penicillin or other antibiotics Sulfa drugs Latex Sedatives Blood Iodine Aspirin Drugs Food Other If yes, what happens? Please list any relevant family history: List es() o () Past (P) regarding use of the following: Steroids: P Smoking: P If yes, for what condition and what dosage? If yes, how much per day? **Smoking in any amount compromises the healing process and may negatively affect the outcome of your treatment. Analgesics: P Caffeine: P Ounces per day if es: Alcohol: P If yes, How much per week? Recreational Drugs: P
4 PATIET IFORMATIO AD ITAKE FORM First Middle Last DOB: Age: Address: City: State: Zip: Telephone: Work umber: OK to or Leave Message? / Location: How did you hear about us? Ethnic Background: Marital Status (please circle) Married Single/Divorce Widow Living with Significant other If emergency please contact: Contact number: Relationship to you: PATIET MEDICAL HISTOR State the reason(s) for your visit and describe any symptoms you are experiencing: Immunizations/Surgeries (including tonsils, gallbladder, appendix, cosmetic): Procedure ear
5 o es Do you take any prescription or over the counter medications? (Include herbal supplements) Please list: o es Do you currently, or have you ever had any of the following conditions? Resolved Controlled Uncontrolled Medication Allergies (specify) Severe Food Allergies (specify) Autoimmune Disorder (Lupus, RA, Psoriasis) or other (please list) HIV or AIDS Hypertension or Hypotension Heart Condition (past or present) (specify) Blood Clotting Disorder (specify) Diabetes Type 1 Type 2 Herpes Simplex Cold sores/fever Blisters Genital Staph Infection (specify) Asthma (specify) Child Adult Both Hepatitis (circle those that apply) A B C D Kidney Disease (specify) Skin Cancer (specify type, location, & date) Cancer (specify type & date) Thyroid Disease hyper hypo other Shingles (specify location and last episode) Seizures (specify last episode/frequency) Wounds that stay brown after healing Keloid Disorder (scars that grow beyond the border of the wound) Slow Wound Healing Sensitive Skin (specify) Electrical Implants (Pacemaker, etc. Please specify) Metal Implants (ot including dental fillings) (specify location) Previous complications with Cosmetic Laser Treatments or Injections? (Specify) euromuscular or eurological Disorder (Specify) Connective Tissue Disease (Ehlers Danios, etc.) (Specify) Anaphylaxis (specify) Tattoos/Permanent Make-Up (specify location) WOME: Currently Pregnant or Breastfeeding WOME: Abnormal Menstrual Cycle / POS WOME: Trying to become pregnant A OTHER HEALTH CODITIO OT LISTED ABOVE (specify) **The above health questionnaire is accurate. I agree to disclose all changes to my health at future visits. Print ame: Signature: Date of Birth: PA/P/MD Signature:
Date: Name: Age: DOB: Address: City: Zip: Home Phone: Mobile Phone: If you are not able to take a call is it ok to leave a message and with whom?
Patient Intake Form Date: Name: Age: DOB: Address: City: Zip: Home Phone: Mobile Phone: If you are not able to take a call is it ok to leave a message and with whom? Work Phone: Occupation: E-mail: Referred
PATIENT DEMOGRAPHIC SHEET
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PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
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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
Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer
Patient Name of Birth Sex Age How do you wish to be addressed Single Married Separated Divorced Widowed Minor Home Address City State Zip Home Phone # Cell phone # Email Fax # Driver s License # Work Address
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:
MEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
GETTING STARTED INTRODUCTORY FORM
GETTING STARTED INTRODUCTORY FORM I am interested in: In office consultation Questions regarding my appointment: Phone consultation Skype consultation I am interested in the: Getting Started Program Getting