New Patient Profile. Date of first visit: Title (Mr, Mrs, Ms) First name. Surname. Home address. address. Phone (home/work) Mobile: Phone:
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1 New Patient Profile Title (Mr, Mrs, Ms) First name Date of first visit: Surname Home address Suburb Postcode: address Phone (home/work) Date of birth Occupation Emergency contact Your GP Mobile: Marital Status: Hours/week: Phone: Phone: GP address/clinic Private health fund Do you give permission for us to contact your GP if necessary Yes / No Are you seeing any seeing any other health care professionals? Yes / No How did you hear Advertising/Radio Drive/walk past about us? Please Brochure/Flyer Internet/Yellow Pages/Seminar circle Referred by: (Please name friend/gp/etc) Other (Please specify) What are your main health concerns? Please prioritise for us 1. 2.
2 What are your wellness & health goals/reason for this visit? Could you be pregnant? Yes No Do you have any allergies? Yes / No Please list Medications/vitamins/supplements: Environmental: Food: - Gluten - Dairy - Sulphur (e.g. eggs, garlic, cabbage) - Sulphites (e.g. red wine)
3 - Soy Further detail on type of reaction:
4 List any Pharmaceutical medications you are currently taking Medication Daily Dose How long have you been taking this medication? List any Nutritional/vitamin/herbal supplements you are currently taking Supplement Daily Dose How long have you been taking this medication? Health Systems Check (Tick if you experience any of the following symptoms) Head - headaches - migraine - dizziness - fainting Eyes - eyestrain - light sensitivity - blurred vision - watering - red eye - painful eye Mouth, teeth & gums - toothache - lost or loose teeth - abscesses - ulcers - mercury fillings - bleeding gums - grinding teeth Skin, hair, scalp, nails - acne - eczema - psoriasis - hair loss - dandruff - excess sweating - itching - redness Neck, shoulders & arms - aching - tension - arm pain - tingling - cold hands &feet - joint pains - numbness Ears, nose and throat - deafness - ear noises - wax, ear aches - sinusitis - loss of sense of smell - blocked nose - frequent colds - hayfever - allergies - sneezing - swollen glands - nose bleeds Chest - pains - tightness - breathing difficulty - coughs - wheezing - palpitations
5 - taste change Digestive system - acidity - burning - bleeding - indigestion - nausea - sugar cravings - loss of taste - finger nails chip or peel easily - sweat has a strong odour Urinary system - thirst - frequent going to toilet, day or night - burning - infections - restricted flow - change in urine colour or smell - blood in urine Female system - menstrual irregularities - cramps - PMT - menopause - hot flushes - loss of libido - discharges - infections - infertility - breast lumps - breast tenderness - bad breath - vomiting - bloating - constipation - diarrhoea - haemorrhoids - fissures - change of stool colour - flatulence - excess belching Male system - erection concerns - lower back pain - sciatica - joint pains - prostate problems - waking in night to urinate - change in urine stream stopping/starting Nervous system - weakness - poor coordination - loss of balance - memory loss - difficulty concentration - numbness - coldness Emotional Health - depression - anxiety - restlessness - excess worry - nightmares - insomnia - mood swings
6 General medical history Details of operations What? When/date? Any complications? Details of major illnesses What? When/date? Details of childhood illnesses What? Approx. age? Have you taken antibiotics in the past? If so, when was the last time and what did you take them for? Have you been prescribed and taken oral flagyl, tetracycline, antacids, antifungals or steroids? Please elaborate where required:
7 Family History 1. Place a tick ( ) in the appropriate place if a family member suffers from this problem 2. Place a cross (x) in the appropriate place if a family member has passed away from this illness. If you know their age at the time they passed away please include this information Condition Mother Father Siblings Maternal G mother Maternal G father Paternal G mother Paternal G father Section 1 - Diet Tell us about your diet. What do you eat on a daily basis? Dietary evaluation of a typical day On rising Breakfast mid morning
8 Dietary evaluation of a typical day Lunch Mid afternoon Dinner Dessert: Snack/supper Bedtime 1a. How much water do you drink a day? 1b. How many cups of tea/coffee do you drink in a day. Do you drink energy drinks? 1c. Do you every drink soft drink? If so what and how many bottles/cans per week. 1d. How much alcohol do you drink each day? What do you drink and how many days a week do you drink? 1e. Is there anything you just don t eat ever? If so what is it and why don t you eat it. 1f. What foods make you feel good?
9 2. Sleep 2a. Do you have any issues sleeping? 2b. If you do, is it staying asleep or falling asleep that s the issue. How long has this been going on? 2c. Do you have difficulty waking up? Please detail any other issues you are having: 3. Energy What are your energy levels like? If 0 is no energy and 10 is the best what would you rate your energy on average each day? 0-10 scale Is your energy consistent? Ie: does your energy fluctuate during the day or is it consistent through the day. If it does fluctuate what is your best time of the day and what is the worst? 3. Weight 3a. Are you happy with your current weight? 3b. If not do you want to gain/lose weight? 3c. Do you have a history of eating disorders? Please detail. 3d. What is your ideal weight 3e. How long have you had weight issues? 4. Gut issues 4a. Do you suffer from nausea? 4b. If so when, how often a week 4c. is there anything that you think brings it on? 4d. Do you suffer from pain in the stomach/bowel area? 4e. Do you suffer from vomiting? 4f. Do you suffer from burping? 4g. Do you suffer from wind? 4h. Do you suffer from bloating? 4i. If you eat fatty food do you feel sick/queasy?
10 Please details any issues you have had with digestion in the past: 5. Bowels 5a. How often do you go to the toilet to pass a stool on a daily basis? 5b. Do you every miss a day ie: have constipation? If so how many days would you skip? 5c. Do the stools float or sink? 5d. What colour are they? Light brown, mid brown, dark brown, yellowish, greenish? 5e. Is there any blood / mucous in the stool? 5f. Do you suffer from constipation/diarrhea or both? 5g. Do you use laxatives? Please detail any issues you have had with your bowels in the past: 6. Immune system/ respiratory system 6a. How many colds or flu do you get a year? 6b. How long does it normally take you to recover? 6c. Have you every smoked? Or do you smoke? Now? How many do you smoke a day. 6d. Have you every taken recreational drugs? If so what? How often, and do you still take them now? 6e. Do you every suffered swollen glands, hayfever, sinus, post nasal drip (ie: feel like something is always dripping down the back of your throat) 6f. Have you ever had asthma? 6g. Do you every get short of breath? 6h. Do you get nose bleeds 6i. Do you ever get a cough? Please detail any history: 7. Kidneys 7a. Do you get thirsty a lot? 7b. Do you have to get up through the night to go to the toilet to urinate? If so how many times? 7c. Have you had any issues with your bladder? 7d. Has your urination changed at any time? Do you get urgency? Do you urinate a lot? 7e. Have you ever seen blood in your urine? 7g. Do you every see blood in the urine? 7h. Have you had recurrent cystitis or urinary tract infections? Please detail any issues you ve had in the past:
11 8. Female reproductive system 8a. At what age did you get your period? 8b. Are you still menstruating? If not at what age did you go through menopause? 8c. If you are still getting your period, is your cycle regular ie: does it come every 28 days. If not please detail 8d. How many days do you bleed? 8e. What is the blood flow like? Heavy / light? 8f. Do you get any clots in the blood flow? 8g. Do you get any PMS symptoms (ie: sore breasts, mood changes, pain, anxiety, cramps). Please detail. 8h. Are your pap smears up to date? When was your last one? Have they all been clear? 8i. Have you ever had wart viruses/infections? 8j. Have you ever had recurring thrush? 8k. What is your contraceptive method? 8l. Have you had any pregnancies? If so how many? 8m. Have you had any issues trying to conceive? Please detail any reproductive health issues: 9. Male reproductive system 9a. Have you had any issues with sexual dysfunction? 9b. Have you had any issues with infections? 9c. Have you had any issues with conceiving? Please detail any previous health issues: 10. Cardiovascular system/circulation 10a. Have you had any issues with your heart? 10b. Have you had any chest pain/ palpitations? 10c. Do you suffer from cold hands/fee 10d. Do you or anyone in your family suffer from varicose veins. 10e. Do you get dizzy on standing? 10f. you re your blood pressure usually high or low?
12 11. Musculoskeletal system 11a. Do you get cramps in your legs/feet regularly 11b. Do you get back pain, stiffness? 11c. Do you ever get tingling, numbness, pins and needles? Please detail: 12. Skin 12a. Do you have any issues with your skin dry, eczema, psoriasis, warts, how do you heal?) 13. Exercise How much exercise do you do a week. Please list and time you spend doing it. 14. Relaxation What do you like to do to relax? 15. Anxiety 15a. Do you suffer from anxiety/panic attacks? 15b. On a scale of 0 (no anxiety) and 10 (panic attack) what is your anxiety level? 15c. What symptoms do you get ie: sweating, shaking, fear of going outside, dizziness, vomiting, blurred vision? 15d. How long has this been going on? 15e. Was there something that started it? 15f. Is there anything that makes it better? 15g. is there anything that makes it worse? Please detail:
13 16. Depression 16a. Rate your mood. (if 0 is bad depression, whereby you cannot get out of bed and you just want to hide from the world and 10 is feeling extremely happy, how would you rate your mood? 16b. Do you get foggy head 16d. Do you get a thick, cannot think, blocked head? 16e. How long has the depression been going on? 16f. Was there anything that started it? 16g. Have you ever been on medication in the past for depression? If so what and when? 16h. What are the significant stressors in your life? 17. Before you got sick where there any significant changes? New house? New job? Travel? Death in the family? Is there anything else you think we should know? Please list any additional information you feel is relevant below:
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/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
GoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
HOW DID YOU HEAR ABOUT US?
427 Bloomfield Ave. Ste. 306 Montclair, NJ 07042 Phone: 973-746- 2848 Fax: 973-746- 2088 HOW DID YOU HEAR ABOUT US? Eastern School of Acupuncture and Traditional Medicine Student Clinic Intake Form Intake
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
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
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.
Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell
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
ACUPUNCTURE INTAKE FORM
, ND ACUPUNCTURE INTAKE FORM Thank you for taking the time to complete the following new patient forms. Given this form is extensive, it plays an integral role in achieving our mutual goal of your optimal
Have you had all childhood diseases i.e.? chickenpox. Y N. Have you ever suffered from an infectious illness? i.e. glandular fever.
Acupuncture case history card Name: Date: Address: Ph No: (H) (W) (M) E-mail: Fax: D.O.B Sex: M F Marital Status: Occupation: Dr: Suburb: Referred by: Health fund Medical history For the following questions,
New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip
About You Pulley Chiropractic & Acupuncture, LLC Janine Pulley, D.C., L.Ac. 102 Peters Street, Suite 1, North Andover, MA 01845 P: 978-237-5106 * F: 978-420-4399 drjanine@pulleychiropractic.com * www.pulleychiropractic.com
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Mayflower Acupuncture LLC
536 Hopmeadow St. Simsbury, CT 06070 Phone: (860) 413-2118 Email: Forms@mayfloweracupuncture.com Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date:
205 W Giaconda Way, Suite 135 Tucson, AZ, 85704 (520) 219-2400 www.forever-able.com info@forever-able.com Name: Birth date: Age: Today s Date: Address: Email: Home phone: Mobile phone: May we add you to
METABOLIC ASSESSMENT FORM
METABOLIC ASSESSMENT FORM Name: Age: Sex: Date: PART 1 Please list the 5 major health concerns in your order of importance: 1. 2. 3. 4. 5. PART 2 Please circle the appropriate number 0-3 on all questions
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 INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS?
2 PHYSIOTHERAPIST Date of last visit MASSAGE THERAPIST Date of last visit SPECIALISTS Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS? WHAT IS THE PRIMARY REASON YOU ARE SEEKING CONSULTATION/TREATMENT?
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information
Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Email: Emergency Contact:
28-DAY CLEANSE GUT C.A.R.E. by Dr. Vincent Pedre. Pre-Program Medical Symptoms Questionnaire
28-DAY CLEANSE HAPPY GUT GUT C.A.R.E. by Dr. Vincent Pedre Pre-Program Medical Symptoms Questionnaire NAME ADDRESS EMAIL PHONE RATE EACH OF THE FOLLOWING SYMPTOMS BASED UPON HOW YOU HAVE FELT OVER THE
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