Address: Phone: Date of Birth: / / Major Complaints: 1) 3) 2) 4)

Size: px
Start display at page:

Download "Address: Phone: Date of Birth: / / Major Complaints: 1) 3) 2) 4)"

Transcription

1 Head To Heal Family Wellness Acupuncture Intake Form Patient Name: Address: Phone: Date of Birth: / / Major Complaints: 1) 3) 2) 4) Details regarding Major Complaint: Where is the problem located? When did it start? Have you had this pain before? When? How did it start? Is it getting worse? coming and going getting better How often does it bother you? Is there a pattern- Time of day Time of year/season What makes it better? Heat Cold Pressure Other What makes it worse? Heat Cold Pressure Other Describe the pain: Dull/Aches Shooting Other (pin prick, tight, squeezing, band sensation, expanding ) Does the pain radiate anywhere? Severity of pain out of 10 (10= worst pain) Skin: Do you have any skin conditions? Yes No Do you have: Dry skin Itchy Moist/clammy Burning changing moles or lumps cysts boils frequent skin rashes Acne hair loss/thinning dry scalp puffy skin wrinkles easy to bruise hives scars (from what?) Other Head: Do you get headaches? Yes No how often? What area of the head? Temples behind eyes at top of head Side(s) back one sided worse side

2 Do you have: memory loss? loss of balance dizziness Eyes: How is your vision? Any changes to your vision? Do you have? Blurred vision Redness Night blindness dry eyes decreased vision floaters: both eyes Lots few Ears: How is your hearing? any recent changes to your hearing Have you experienced deafness in either or both ears? Was the onset gradual or sudden Have you experienced ringing of the ears? if so, check the following: High pitched worse with pressure low pitched gradual onset better with pressure Have you had ear aches? ear discharges infections Nose: Nose bleeds frequently sinus trouble frequent colds other Throat: Sore throat (describe) hoarse difficulty swallowing teeth or gum problems swollen tongue Respiration and Voice: Are you a loud talker soft talker Do you need to constantly clear your throat? Do you get frequent coughs? If so, which kind: feeble(weak) asthma Dry cough with phlegm production that is too sticky to cough up Dry cough with small amounts of: phlegm blood tinged Cough with lots of phlegm persistent cough other Consistency of phlegm colour Breathing: difficulty wheezing mucus rattles when breathing troubles breathing at night do you need 2+ pillows when sleeping? Shortness of breath? Yes no when? If so, is it: worse on exertion? worse with a cough/asthma? Associated with: heart palpitations emotional problems loose stools low back pain/arthritis Chest: pain pressure palpitations heart disease Other Blood Pressure: high low

3 Digestion: how is your digestion? How many bowel movements do you have daily? Stool consistency: hard soft loose diarrhea undigested food blood mucus Do your stools: sink float Colour: honey brown grey black green red bloody streaked with red multiple colours other Check if appropriate: Loose stool: watery with mucus undigested food and cold symptoms undigested food, bloating and gas early morning diarrhea (around 5am) frequent with pain on defecation Constipation: dry and malodorous dry with fatigue dry with cold symptoms Alternating loose stools then hard dry then loose pain on defecation and anal burning heavy, bearing down sensation in the anus mucous stool hemorrhoids malodorous stool bloating red and swollen gums indigestion/ heart burn Belching sour regurgitation Urine: Colour: light dark other Excess urination urination at night infrequent or unable to urinate blood in urine frequent bladder infections water retention where? other Does your water intake equal your output? any incontinence? Thirst: How much water do you drink/day? litres Excess thirst No thirst Do you: chug or sip Temperature preference of beverages Appetite: Excess appetite Poor appetite Appetite keeps changing Feel tired or weak if meal missed What are your food cravings?

4 Female: Age started menses age stopped menses vaginal discharge: yellow clear white yellow thick itching odor resembling Menstrual pain? low back pain irregular menses no menses clots with menses size colour: purple-red black-red bright red brown flow at beginning of menses number of pads or tampons used per day heavy light bleeding Water retention where? breast tenderness moodiness Low sex drive high hot flashes when? food cravings Pregnant Last monthly period Last PAP test / / Form of birth control # of pregnancies # of deliveries # of miscarriages # of abortions # of cesareans any operations: cervix uterus ovaries any cysts fibroids endometriosis Male: Low sex drive lack of sex drive impotence ejaculation causing pain penile discharge? colour pain on urination Burning premature ejaculation prostate trouble other Do you get a daily morning erection? Yes no is it difficult to achieve an erection? Yes no Reproductive: Libido- high average low Has it increased decreased Have you experienced fertility issues? if so, which partner and what has been tested? Musculoskeletal: Pain in: neck shoulder between shoulders arms hands fingers hip knee big toe upper back mid back low back sore bones loss of grip swollen knees/elbows leg cramps at night leg weakness weak ankles stiff all over tingling? where? muscle spasm cramps loss of feeling where? painful joints bursitis other Neurological : Nervous depressed easily angered easily irritated frequent crying worry/anxiety mood swings memory confusion poor concentration suicidal tremors numbness /tingling coordination problems muscle weakness other

5 Temperature and Circulation: General temperature: Hot cold area: Neutral do you sleep with: feet out light covers no covers normal lots of covers do you need to wear many layers to keep warm do you like: warm drinks spicy foods are you cooler than others do you like cold, raw foods do you get a warm sensation around your chest, palms and soles of your feet all at the same time do you bleed easily do you have cold hands/feet Sweating: Rarely sweat excess sweating night sweat If you have night sweats do you wake in a full sweat, not aware that you were sweating, then it stops when awake or moving or do you sweat all night, you are aware of it, and it is due to the temperature of the room, and it does not change with moving Do you sweat spontaneously (not on exertion or with movement) do you find you are not sweating when others around you are? Sleep: Quality of sleep- poor good excellent Do you wake feeling refreshed? # of hours of sleep/night are you a morning person night person Is it hard to stay awake after eating do you nap Time how often do you need to nap? Do you have trouble falling asleep: with dizziness and /or heart palpitations with restlessness and dream disruption Following a big/late meal or with irritability Dreams: can t remember don t have them excess dreaming nightmares day dreaming Energy: Please rank your average daily energy out of 10 (10 = good) Mood: Please describe your mood The dominant emotion that you feel is: fear anger worry jealousy sadness grief depression joy other

6 Stress: None moderate severe cause How high is your stress out of 10 Nutrition: Do you: skip breakfast eat a snack hearty breakfast # meals per day biggest meal of the day is do you eat if you are worried or rushed # alcoholic drinks/week # cigarettes/day # of smoking years eat the same food mostly eat when not hungry snack at night hydrate without using water always add salt to meals eat until full eat many small meals throughout the day forget to eat I generally: make my own food eat out Thank you for taking the time to complete these forms. Patient s Signature Date Name (Please Print)

Head To Heal Acupuncture Intake

Head To Heal Acupuncture Intake Form Head To Heal Acupuncture Intake Patient Name: Date of Birth: / / Address: Phone: In case of emergency contact (name & #): Consent to treat with acupuncture (signature): Major Concerns: 1) 3) 2) 4)

More information

Symptom Review (page 1) Name Date

Symptom Review (page 1) Name Date v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each

More information

Patient Intake Form for Acupuncture Treatment at Infinite Healing

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:

More information

McKay Chinese Herbal Medicine & Acupuncture

McKay Chinese Herbal Medicine & Acupuncture McKay Chinese Herbal Medicine & Acupuncture Notice Receipt Acknowledgement ************************************************************************ Purpose: This form is used to confirm that an individual

More information

New Patient Medical History Intake Form

New Patient Medical History Intake Form New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd

More information

ACUPUNCTURE SPECIFIC INTAKE FORM

ACUPUNCTURE SPECIFIC INTAKE FORM ACUPUNCTURE SPECIFIC INTAKE FORM A naturopathic approach to medicine is holistic and seeks to understand all factors that may be affecting your health. Please answer the following questions to the best

More information

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist *All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:

More information

Emotional Relationships Social Life Sexually Recreation

Emotional Relationships Social Life Sexually Recreation Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we

More information

ACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date:

ACUPUNCTURE FOR HEALTH WENDY STALKER R.Ac. Dip.Ac. B.Sc. Name: Date of Birth: Date: Name: Date of Birth: Date: Address: Postal Code: Occupation: Telephone: Day: Cell Phone: E-mail address: Emergency Contact: Evening: Telephone: Male Female Where did you hear about Acupuncture for Health?

More information

205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date:

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

More information

NEW PATIENT HEALTH HISTORY

NEW PATIENT HEALTH HISTORY NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there

More information

Inner Balance Acupuncture

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:

More information

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166 Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By

More information

Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM

Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of

More information

Patient Intake Form. Relationship. Contact information

Patient Intake Form. Relationship. Contact information Acupuncture & Massage Therapy 895 rue St. Francois, Florissant 314 921-3366 Mary S. Wallis, L.Ac, L.M.T. National Board Certified in Acupuncture (NCCAOM) MO License No. 2007002923 Patient Intake Form Today

More information

PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS?

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?

More information

ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac

ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac ALIGN ACUPUNCTURE AND HERBS LLC Rebekah V. Michaels MAOM, Diplomate OM, Lic Ac. 617-835-2512 Patient Information and Health History Date: Name: Date of Birth: Street: City: State: Zip: Phone: (H) (W) )

More information

Lucas D. Brown, L.Ac. (312)

Lucas D. Brown, L.Ac. (312) Today s date: Mr. Miss Mrs. Ms. Dr. Birth date: (mm/dd/yy) Social Security Number: First name: Last name: Age: Email: Marital status: Single Divorced Married Separated Partner Widowed Street address: Apt:

More information

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 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:

More information

Initial Questions Form

Initial Questions Form Initial Questions Form 422 Broadway Denver CO 80203 (303)921-2993 Please answer as thoroughly as possible. This is detailed so that I can better understand what is going on with you as a whole person.

More information

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email

More information

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

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

More information

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

Alivia Acupuncture Clinic, LLC. Address. City State Zip.  . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced

More information

What do you believe is causing your most important health concern?

What do you believe is causing your most important health concern? Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to

More information

2. Approx. Date of Onset: 3. Approx. Date of Onset:

2. Approx. Date of Onset: 3. Approx. Date of Onset: Healthy Balance Lisa A. Dulac, L.Ac. Acupuncture Patient Intake Form Present Health Concerns: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: 2.

More information

Eastern Body Therapy

Eastern Body Therapy 2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security

More information

NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM NEW PATIENT INTAKE FORM Acupuncture * Herbs * Nutrition Located inside of Yoga 360 91 Bankview Drive Frankfort, IL 60423 815-806-0360/www.yoga-360.com lkacupuncture.com lizkelchak@gmail.com How To Prepare

More information

Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland

Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland Patient Information Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland 21014 410-913-8322 Patient Name: Date of Birth: Age: Male: Female: Single: Married: Separated:

More information

I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION

I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION PERSONAL INFORMATION NAME: TODAY'S DATE: ADDRESS HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: PHONE: HOME MOBILE WORK EMAIL ADDRESS: EMERGENCY CONTACT: STATUS: SINGLE MARRIED DIVORCED WIDOWED OTHER: NUMBER

More information

New Patient Specialty Intake Form Department of Surgery

New Patient Specialty Intake Form Department of Surgery This form contains questions specific to the Department of Surgery. If you are new to Baylor College of Medicine and have not been seen in any of our offices, please be sure to complete our New Patient

More information

Patient Intake Patient / Acupuncture Allergy Allergy Elimination

Patient Intake Patient / Acupuncture Allergy Allergy Elimination Patient Intake Patient / Acupuncture Intake Allergy Allergy Elimination Date 200 Name Date Of Birth M F Home Address City State Zip Home phone Cell phone E-mail Married Single Social Security # Occupation

More information

Balanced Healing Acupuncture, LLC

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:

More information

American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ (520)

American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ (520) American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ 85741 (520) 544-6603 Notes for new Patients: Your first session * Can you imagine not having to wait at a doctor's

More information

Medical History Form

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:

More information

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact

More information

!!!! Traditional & Contemporary Acupuncture! 19 Golden Ave, Toronto ON! ! Gregory Cockerill, R.

!!!! Traditional & Contemporary Acupuncture! 19 Golden Ave, Toronto ON! ! Gregory Cockerill, R. Traditional & Contemporary Acupuncture 19 Golden Ave, Toronto ON info@livehandacupuncture.com 416-899-3364 Gregory Cockerill, R.Ac First Name: Last Name: Birthdate: Gender: Female Male Address: Email:

More information

Oriental Medicine Questionnaire

Oriental Medicine Questionnaire Oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Occupation: Height: Weight: Who referred you to this office? 1.What brought you

More information

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:

More information

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 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

More information

Patient History Questionnaire

Patient History Questionnaire Patient History Questionnaire Date: Referred By: Name: DOB: Age: SSN: Home Telephone: Cell Phone: E-mail: Blood Pressure: Weight: Height: (Circle) R or L Handed (Check) Medication List Attached Emergency

More information

Patient Information & Health History

Patient Information & Health History Patient Information & Health History Name Date Date of Birth (mm/dd/yy) Age Male Female Address City Postal Code Occupation Phone (H) E-mail Phone (C) Married Single Divorced Widowed Phone (W) Spouse s

More information

ACUPUNCTURE INTAKE FORM

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

More information

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer

More information

Symptom Questionnaire

Symptom Questionnaire Symptom Questionnaire The following questionnaire is a general assessment of your health developed by Dr Royal Lee D.D.S. Each grouping represents a particular area of your body that may be causing you

More information

HOW DID YOU HEAR ABOUT US?

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

More information

Mayflower Acupuncture LLC

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

More information

LAST NAME FIRST NAME MI SEX BIRTH DATE AGE ADDRESS CITY STATE ZIP ( ) - ( ) - PHONE CELL PHONE ADDRESS DRIVER S LICENSE NO.

LAST NAME FIRST NAME MI SEX BIRTH DATE AGE ADDRESS CITY STATE ZIP ( ) - ( ) - PHONE CELL PHONE  ADDRESS DRIVER S LICENSE NO. Cathryn Aiken, L.Ac. 530 Traffic Way Arroyo Grande, CA 93420 T: 805.489.8592 F: 805.489.9509 www.arroyograndehealthandwellness.com aghealthandwellness@gmail.com PLEASE PRINT LEGIBLY TODAY S DATE: M / F

More information

If you have any questions, feel free to contact us at 475- WLNS (9567) or

If you have any questions, feel free to contact us at 475- WLNS (9567) or UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH

More information

Women s and Men s Health Intake Form Comprehensive Physical Therapy Center

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

More information

Johanna M. Hoeller, DC PS

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:

More information

Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT

Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT 801 623 8253 1291 South 1100 East #202 Salt Lake City, UT 84105 www.peakacupunctureclinic.com info@peakacupunctureclinic.com CLIENT INFORMATION Client Name: If Patient

More information

ADULT HEALTH HISTORY. May we you a monthly newsletter and/or other educational materials? Yes No

ADULT HEALTH HISTORY. May we  you a monthly newsletter and/or other educational materials? Yes No ADULT HEALTH HISTORY Name Date Address City State Zip code Phone, please circle your preferred number: (home) (cell) (work) E-mail Yes No (if you would like email appointment reminders) May we email you

More information

New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )

New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( ) New Patient Intake Form Personal Information Name Date Address City State Zip Occupation Referred by I prefer to be contacted by: Phone ( ) Email Marital Status: Married Single Divorced Widowed Partnered

More information

Pure Health Natural Medicine

Pure Health Natural Medicine Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell

More information

Name: Date of Birth: Age: Address: City State Zip

Name: Date of Birth: Age: Address: City State Zip 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?

More information

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome: MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer

More information

Patient Health History for Fertility

Patient Health History for Fertility Patient Health History for Fertility Name: Date: Address: City, State, Zip code Phones: Home Work: Cell: Email address: Date of Birth: Age: Occupation: Emergency contact: Ob/Gyn: Current Medications: What

More information

Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP

Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP Shiatsu Intake Form DATE PURCHASED PRODUCT/SERVICE FIRST NAME LAST NAME Date of Birth Age Height Weight Home Address City State ZIP Home Phone Cell Phone Email Name of Emergency Contact Would you like

More information

Minister Medical ^Acupuncture

Minister Medical ^Acupuncture Minister Medical ^Acupuncture t^wellness Clinic What is acupuncture? Acupuncture is a therapy in which fine needles are inserted into specific points on the body. Is acupuncture safe? Acupuncture is generally

More information

Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :

Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment : New Patient Questionnaire Date of appointment : Name: Address: Apt# City: State: Zip: Phone: Cell: Email: Age: DOB: Referred By: Your occupation: Allergies: To Medications: Other: Reason for Today s Visit:

More information

HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM

HISTORY OF PRESENT ILLNESS A. TELL US ABOUT YOUR PAIN PROBLEM 1 UT Health Austin Comprehensive Pain Management New Patient Questionnaire Thank you for scheduling a visit with the Comprehensive Pain Management Care Team. The responses you provide to these questions

More information

New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip

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

More information

Classical Acupuncture Health History Form

Classical Acupuncture Health History Form Classical Acupuncture Health History Form Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally, and

More information

Acupuncture For Life 2032 N. Broad St., Suite 3 Lansdale, PA Patient Intake Form

Acupuncture For Life 2032 N. Broad St., Suite 3 Lansdale, PA Patient Intake Form Acupuncture For Life 2032 N. Broad St., Suite 3 Lansdale, PA 19446 267-575-0592 Patient Intake Form Name (last, first) Date Address City / State / Zip Birth Date Home phone Work Phone Cell Phone Email

More information

Medical History Form

Medical History Form Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart

More information

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443)

! 30 E Padonia Rd, #305, Timonium, MD Phone: (410) Fax: (443) ! 30 E Padonia Rd, #305, Timonium, MD 21093 Phone: (410) 560-7404 Fax: (443) 705-0228 Email: info@waynebonliemd.com Today s Date: Patient Information Name: DOB: / / Address: City/Town: State: Zip: Home

More information

Acupuncture &Traditional Chinese Medicine Intake Form

Acupuncture &Traditional Chinese Medicine Intake Form SACRAMENTO 2801 K Street Suite 502 Sacramento, 95816 (916) 887-4660 SutterIntegrativeHealth.org Acupuncture &Traditional Chinese Medicine Intake Form Name: Have you had acupuncture before? Yes No Date

More information

Name Date. Street City ST Zip. Home Phone Cell. . Age Date of Birth Male Female HT WT. Occupation. Referred by. Emergency Contact Relation to

Name Date. Street City ST Zip. Home Phone Cell.  . Age Date of Birth Male Female HT WT. Occupation. Referred by. Emergency Contact Relation to HEALTH HISTORY QUESTIONNAIRE Healing Arts of Memphis 1541 Overton Park Ave. (Rear) Memphis, TN 38112 901 726 1485 Name Date Street City ST Zip Home Phone Cell Email Age Date of Birth Male Female HT WT

More information

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?: NAME _ Please take the time to fill this form out completely. The more information we have, the better we can assist you, and will make better use of your initial visit. What is the main problem you would

More information

Patient Health History Form

Patient Health History Form Thomas S. Burgoon, M.D. West Chester, PA 19382 Patient Health History Form Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient

More information

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. 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

More information

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone  . Date of Birth Occupation Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth

More information

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4 Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: 905-793- 8868 Fax: 905-793- 8957 630 Peter Robertson Blvd, Brampton ON L6R 1T4 ADULT INTAKE FORM Name: (Last) (First) (Preferred Name) Address:

More information

Ayurvedic Intake Form

Ayurvedic Intake Form Ayurvedic Intake Form Name: Today s Date Date of birth: Time of birth: Place of birth: Place of childhood: Other Places lived: Current address: Home phone: Work phone: Email address: Occupation: Age: Sex:

More information

CONSULTATION ADMITTANCE FORM

CONSULTATION ADMITTANCE FORM CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK

More information

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES

THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES abdominal pain acne aging process accelerated allergies, including asthma, hives, rashes, sinus congestion anemia (blood hemoglobin low) anorexia anovulatory (no ovulation) anxiety anxious depression appetite

More information

Headache Follow-up Visit Form

Headache Follow-up Visit Form !1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:

More information

Metabolic Assessment Form

Metabolic Assessment Form Metabolic Assessment Form Approach Wellness and Aesthetics 200 Forsythe Street Fayetteville, NC 28303 Office: (910) 322-7368 Fax: (910) 483-5796 www.tawellness.net Name: Age: Sex: Date: Part 1: Please

More information

Home Address: City: State: Zip Code: Referral Source (Therapist, Treatment Program, Etc...): Name: Age: Gender: Name: Age: Gender: Name: Age: Gender:

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

More information

Scottsdale Family Health

Scottsdale Family Health Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give

More information

Patient Health History Questionnaire

Patient Health History Questionnaire Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com

More information

Health History Questionnaire

Health History Questionnaire CLINICAL ACUPUNCTURE SERVICES Cathy D. Adelman, RN, LAc PO Box 91451 Tucson, AZ 85752-1451 (520) 822-6844 cdarnlac@hughes.net www.clinicalacupunctureservices.com Health History Questionnaire I. GENERAL

More information

28-DAY CLEANSE GUT C.A.R.E. by Dr. Vincent Pedre. Pre-Program Medical Symptoms Questionnaire

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

More information

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,

Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status

More information

DIAGNOSIS YES NO. KIDNEY YIN DEFICIENTY (Ki Yi- -) Do you have lower back weakness, soreness, or pain, or knee problems?

DIAGNOSIS YES NO. KIDNEY YIN DEFICIENTY (Ki Yi- -) Do you have lower back weakness, soreness, or pain, or knee problems? Answer yes or no to each of the following questions. Don t worry about what the symptoms mean; just note whether you experience them. If you have more than one--fourth to one--third yes re- sponses in

More information

Questionnaire for Lipedema Patients

Questionnaire for Lipedema Patients Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees

More information

HIPAA Acknowledgement and Appointment Reminder Form

HIPAA Acknowledgement and Appointment Reminder Form HIPAA Acknowledgement and Appointment Reminder Form I acknowledge that I have been provided access to Salado Acupuncture s Notice of Privacy Policies. I understand that I have the right to review Salado

More information

Parallel Chiropractic & Wellness Centre Acupuncture & TCM New Patient Questionnaire

Parallel Chiropractic & Wellness Centre Acupuncture & TCM New Patient Questionnaire Parallel Chiropractic & Wellness Centre Acupuncture & TCM New Patient Questionnaire The following information is helpful to the diagnostic procedure and enables us to provide you with better treatment.

More information

Augusta Acupuncture Clinic

Augusta Acupuncture Clinic Augusta Acupuncture Clinic Patient s Name Date How did you hear about us? MAIN COMPLAINTS: 1) 2) 3) 4) If you have a pain condition, on a scale of 1 to 10, what is it at its worst? How long have you suffered

More information

Dear Valued Patient, Revised 09/24/2018 UC Health Integrative Medicine Page 1 of 5

Dear Valued Patient, Revised 09/24/2018 UC Health Integrative Medicine Page 1 of 5 UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH

More information

55 S. Main Street, Driggs, ID (208)

55 S. Main Street, Driggs, ID (208) Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F

More information

METABOLIC ASSESSMENT FORM

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

More information

ACUPUNCTURE INTAKE FORM

ACUPUNCTURE INTAKE FORM ACUPUNCTURE INTAKE FORM This questionnaire is CONFIDENTAL and used to gather information to give you the most effective treatment possible. Name Address City State Zip Phone Home Work Cell Email Birth

More information

Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star **

Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Date: Name: Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Email: Date of Birth: Place of Birth: Age: Employer

More information

Naturopathic Medicine Intake Form Adults (16+)

Naturopathic Medicine Intake Form Adults (16+) Naturopathic Medicine Intake Form Adults (16+) Name: Date of birth: Gender: Address: City: Postal Code: Home Phone: Mobile/Work: Email: Marital status: Spouse/Partner s name: Emergency Contact: Phone Number:

More information

Mayflower Acupuncture LLC

Mayflower Acupuncture LLC Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this form as completely as you can. All information provided here will be held in strictest confidence.

More information

Health History Questionnaire Date: / /.

Health History Questionnaire Date: / /. Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:

More information

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning

More information

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work

More information