N E W C L I E N T Q U E S T I O N N A I R E
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- Baldric Lee
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1 V A N E S S A Y O U S S E F, BSc (Kine), ND Madison Clinic 4950 Yonge St, Concourse Level, Unit 2 Toronto, Ontario M2N 6K1 Phone: vanessayoussefnd@gmail.com N E W C L I E N T Q U E S T I O N N A I R E Name Date Birth Date Address dd/ mm/ y y y y Age Home Work Cell City Province Postal Code Marital Status single common-law married divorced widowed re-married Occupation present Occupation past Family Doctor Other Health Care Practitioners Address: Please state your primary reason for attending our clinic. Please list the first time you noticed the condition and describe any factors that you suspect may have played a role in its onset and perpetuation. Regarding your chief concern, have any treatments, diets or therapies brought you real improvement or relief? Please list any other health concerns Please list any significant illnesses that you have had in the past
2 Page 2 of 6 Have you ever been hospitalized? Please indicate reason and year. Any significant adult trauma, grief or stress (e.g. accidents, falls, emotional, etc.)? Any significant childhood trauma, grief or stress? Please list all drugs and/or supplements that you are currently taking. Include dosage. Please describe the type and frequency of your exercise. Please indicate your frequency of use of the following. Alcohol day week month Pop (regular) day week month Antacids day week month Pop (diet) day week month Cigarettes/Cigars day week month Salt day week month Coffee day week month Sugar day week month Drugs day week month Tea day week month Microwave day week month TV (hrs) day week month Pain Relievers day week month Computer (hrs) day week month Did you ever smoke? Use alcohol excessively? Use recreational drugs to excess? Please give details and when you quit: Do you have any allergies (i.e. food, environmental, drug, etc)? Did you have a flu shot this year? YES NO How many times total?
3 Page 3 of 6 Have you received any other vaccinations in the last 5 years? YES NO Which ones and when? Do you have any pets (include number and type)? Where do you live? Apartment House How long have you lived there? How old is your home? Have you done any renovations recently? Who do you live with? What do you do in your spare time? Any hobbies? Family History Please indicate, where applicable, if anyone in your family currently has or has had any of the following conditions: Maternal Paternal Father Mother Brothers Sisters G.Mother G.Father G.Mother G.Father Age (if living) Health (G=good, P=poor) Anemia Asthma, Hayfever, Hives Cancer Cystic Fibrosis Diabetes Epilepsy Rheumatoid Arthritis Osteoarthritis Heart Disease High Blood Pressure Kidney Disease Mental Illness Alcoholism Stroke Tuberculosis Other Cause of Death Age (at death)
4 Page 4 of 6 C O N F I D E N T I A L H E A L T H A P P R A I S A L For the following, please place a in the space if you currently have the symptom, a P if it has been a problem in the past. VITALITY Low stamina Low ambition Fatigue Energy drop during the day When? Poor Sleep Insomnia Feel un-refreshed on waking Unexplained weight gain/loss EYES Double vision Blurring Sensitive to light Cataracts Glaucoma Failing vision Frequent conjunctivitis/ styes Spots in front of eyes Dark circles under eyes HAIR Thin Excess loss Graying Excess growth Prematurely gray Grows slowly Thinning eyebrows, underarm, pubic hair SKIN / NAILS Dryness/Cracking Itching Pimples/ Acne Boils Blotchy/ White Patches Eczema Psoriasis Dandruff Increased pigmentation Easy bruising Spots on nails Nails brittle/ split Bite nails Fungal infection of nails EYES Watering Burning Redness Dryness Discharge Itching EARS Loss of hearing Ringing in the ears Wax build up Frequent earaches NOSE Itching Loss of smell Discharge Sneezing Sinusitis Polyps Prone to nose bleeds MOUTH / LIPS Jaw clicks Cold sores Lips cracking Canker sores Peculiar taste in mouth Bad breath Impaired taste/ smell TEETH Cavities Loose teeth Dentures/ Bridges Root canal Sensitivity to hot/cold Bleeding gums Gum disease
5 Page 5 of 6 TEETH Grinding teeth Braces RESPIRATION Hayfever Asthma Coughing Bronchitis Shortness of breath Frequent sore throats Frequent colds/ coughs Phlegm Pneumonia CIRCULATION / BLOOD Dizziness Cold hands/ feet Swelling hands/ feet Varicose veins Low/ high blood pressure Anemia Fainting CARDIOVASCULAR Heart disease Palpitations Angina Heart murmurs Chest pain/heaviness NEUROLOGICAL Headaches Migraines Forgetfulness Convulsions / seizures GASTRO - INTESTINAL Poor appetite Large appetite Heartburn Indigestion Belching Excessive flatulence Bloating after eating Nausea/ Vomiting Ulcer Constipation Diarrhea Hemorrhoids Cravings Strong thirst No thirst Stomach pain, burning, aching after eating Digestive problems subside with rest Hungry shortly after eating Anal itching Pain under right side of rib cage Fatty foods cause indigestion History of worms/parasites Number of daily bowel movements MUSCULO-SKELETAL Weakness Stiffness Aches Twitching Cramps Numbness/tingling Prone to sprains Joint pain Joint swelling Bursitis Arthritis Unsteady/lose balance URINATION Dribbling Difficult Increased frequency of urination Blood in urine Painful urination Urination at night Unable to hold urine Kidney stones Bladder infection
6 Page 6 of 6 FOR MALES Frequent / urgent urination Weak / delayed urinary stream Urge to urinate several times per night Dripping after urination Lack of sex drive Impotence Difficulty attaining / maintaining erection Painful testicles Genital rash Low sperm count Low sperm motility FOR FEMALES Age at first period Length of cycle Length of period Irregular periods Bleeding between periods Menstrual clots Breast tenderness Irritability / mood swings Bloating during period Vaginal discharge Ovarian cysts Uterine fibroids Venereal disease Breast lumps Yeast infections Menopause Number of pregnancies Number of live births Type of birth control
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Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
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
Patient Intake Form for Acupuncture Treatment at Infinite Healing
Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age:
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Name: Age: Gender: Name: Age: Gender: Name: Age: Gender:
Naltrexone Pellet Insertion Intake Form Name: Date of Birth: / / Contact Information: Phone: E-Mail: Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Why are
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
Birch Wellness Center
Dr. Kelly Brown drkbrownnd@gmail.com Birch Wellness Center 34 Carlton Street, Winnipeg, Manitoba R3C 1N9 204 505 0325 (f) 204 505 0327 Full Legal Name: (Last, First) / Preferred Name: Date of Birth: Age:
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:
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:
Balanced Healing Acupuncture, LLC
Balanced Healing Acupuncture, LLC Intake Form NAME: Last First: GENDER: Date of Birth / / Age Email Address Address City State Zip Code Preferred Phone Number Cell Home Work Preferred Method of Communication: