CASE HISTORY KEY. - digestive disturbance AF Betafood, Gastrex, Cataplex AC. - Digestive, hypochlorhydria AF Betafood, Zypan, Phosfood
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- Osborne Williamson
- 5 years ago
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1 CASE HISTORY KEY (Clinical significance, system invlved, prduct cnsideratins ) Primary Cncern: Cnsistent: Mnth: Headaches: Basal Temples - digestive disturbance AF Betafd, Gastrex, Cataplex AC - uterus/prstate imbalance Utrphin, Prstx Cluster Crwn TMJ Frntal Migraine: - CSF imbalance - Calam - Liver, Gallbladder AF Betafd, Livaplex - Sinus Thymex, Allerplex - Digestive, hypchlrhydria AF Betafd, Zypan, Phsfd Ears: Prdrmal Hallucinatins Phtphbia Olfactin/nausea Nise - Infectin, Parasites, Anemia Thymex, Zymex II, Multizyme, Wrmwd, Frtil/B12, Chlrphyll, Ferrfd Ring Hiss Pund Plug Pp Ache Drain - Infectin Thymex, SSO - Eustachian cngestin Thymex, SSO, Cngaplex - Cngestin Thymex, SSO, Cngaplex - Otitis Externa Thymex, SSO, Zymex, 50/50 white vinegar/alchl drps
2 Itch - Yeast Zymex, Zymex II Lss Dizzy - Infectin, neurlgical Thymex, Flic Acid - Infectin, fd allergy Thymex, SSO Tngue: Wax Thick Cated - Yeast - Zymex ph Salivary Urine - Acidsis Calcium, Organic Minerals, Glutamine, SP Greenfd - Acidsis - Arginex Eyes: Burn Tear Ache Red Dry Film Itch Blur Flaters Spts Tired Puffy Stye Twitch Circles - Infectin, Allergies - Cngaplex - Allergies - Antrnex - Strain - Iplex - Infectin - Cngaplex - Infectin - Cngaplex - Infectin - Cngaplex - Allergies - Antrnex - Strain - Iplex - Lymphatic cngestin in vitreus humr - Cngaplex - Gallbladder AF Betafd - Strain - Iplex - Gallbladder AF Betafd - Infectin - Cngaplex - Magnesium - Liver, Kidneys Albaplex, Livaplex Sinus: Dry - Infectin - Allerplex Drain - Allergies - Antrnex Plug - Infectin, Fd Allergies - Allerplex Pst Nasal Drip:
3 White - Infectin Strep - Cngaplex Yellw - Infectin Staph - Thymex Green - Infectin - Allerplex Gray - Infectin chrnic - Allerplex Brwn - Brnchial infectin with ld bld Allerplex, Brncafect Bld - Infectin - Thymex Clear - Allergy - Antrnex Sneezing - Infectin, Allergy Thymex, Antrnex Smell lss - Infectin Allerplex, Thymex Taste lss - Infectin Allerplex, Thymex Thirst - Dehydratin Trace Minerals Thrat: Sre Harseness - Infectin, Cngestin - Cngaplex - Infectin - Cngaplex Cugh Dry Prductive Allergies - Allergy Allerplex, Antrnex - Infectin treat by clr f mucus - Antrnex, Allerplex URI Fever Chills Halitsis Cankers Blisters Flu Neck Stiffness Shulder Tensin Chielsis Dry muth Cld Hands/Feet - Infectin Cataplex AC, Sesame Seed Oil - Thyrid, Infectin SSO, Thyrid Cmplex, Symplex F/M - chrnic sinus infectin Thymex, SSO/gastric fermentatin Zypan, Cataplex AC - achlrhydria Cataplex AC, AF Betafd, Zypan, Calam - lw calcium Cataplex F Tablets, Immuplex, Calam - Cataplex AC, Arginex, SSO, Thymex, Cngaplex, Echinacea - Lymphatic cngestin - Cngaplex - Lymphatic cngestin - Cngaplex - B deficiency Cataplex B/G - Cngaplex/ Achlia AF Betafd, Chline - Thyrid Symplex F/M, Thytrphin, Thyrid Cmplex (Medi)
4 Sweaty Hands/Feet Gums Teeth Glands Dysphagia - Adrenals Symplex F/M, Drenamin, Drenatrphin, Eleuther, Rhdila - Capillary fragility Cyruta Plus, Cataplex C, Cllagen C, Bident - Bne matrix Calcifd, Bident - Infectin Thymex, Cngaplex, Immuplex, Cyruta Plus - Fd allergies, gallbladder AF Betafd Chest: Tensin - Heart Cardiplus, Vasculin, Magnesium Tight - -,, Pressure - -,, Heavy - -,, Anxiety - -,, Cngestin - -,, Pain - -,, Sternal - Bne marrw fatigue SSO, Bist, Arginex Sharp Heart Pain Angina Cardiplus, Vasculin, Cataplex E2, Cataplex G/B Palpitatins MVP Tachycardia Arrhythmias Cardiplus, Vasculin, Cataplex B/G, Organic Minerals, Drenamin Cardiac dystnia - Cardiplus, Vasculin, Magnesium, Organic Minerals Adrenals/Thyrid Symplex F/M, Cardiplus, Magnesium Bradycardia Adrenals, Thyrid - Murmur Arm pain - Cardiac dystnia Cardiplus, Vasculin, Magnesium, Organic Minerals - Angina Cardiplus, Cataplex G/B, Minchex, Organic Minerals Shrtness f Breath: Cnstant Exertin Asthma - Cardiac Cardiplus, Vasculin - Pulmnary - Allerplex - fd allergy (usually milk) Thymex, SSO Wheeze - Air hunger - Acidsis Calam, Calcium Yawning - Acidsis -,
5 DIGESTION Heartburn - Reflux Gallbladder AF Betafd Indigestin Aches - Cataplex AC, Lact Enz Cramps -, Nausea -, Queasy -, Blating Gas Belch Ulcer Hiatal Hernia - Gallbladder AF Betafd, Chline, Livtn - Gallbladder, CHO fermentatin AF Betafd, Chline, Phase II diet - Gallbladder AF Betafd, Chline, Livtn - Stmach infectin Okra Pepsin, Cngaplex, Lact Enz, Cats Claw - Reflux, fd allergies Ligaplex II, AF Betafd, Chline Bwels: Regular Incmplete - minimum daily, maximum fllwing each meal - Achlia AF Betafd, Chline, Cataplex AC Sluggish (every days) less than daily - Achlia Cramps Laxative - Achlia, inflammatin Magnesium, AF Betafd - Achlia AF Betafd, Cataplex AC, replace laxatives with Clax (Medi) Suppsitries - Achlia Enemas Clnics Bulk - Achlia - Achlia - Achlia, lack f peristalsis Fecal Cnsistency: Sft Ribbns Mucus Nrmal - Diarrheic Cataplex AC - Spasm in cln due t infectin Zymex, Zymex II, Multizyme - Allergy/Infectin Cataplex AC, Lact Enz - well frmed
6 Hard - Achlia Pebbles Dry Pain Diarrhea - Achlia - Achlia - Achlia - Allergy/Infectin Cataplex AC Hemrrhids: Cnstipatin - Achlia Histry Current Swllen Burn Bld Distend Itch Sting Ache Cramping - predispses t future episdes with liver cngestin - Liver cngestin (all gut bld drains t the liver) AF Betafd, Cllinsnia - Liver cngestin Cllinsnia, AF Betafd - Allergy/infectin Cataplex AC - Liver cngestin AF Betafd, Cllinsnia, Chlrphyll - Liver cngestin AF Betafd, Cllinsnia - Parasites Zymex II, Multizyme, Wrmwd - Parasites/Infectin/Allergy - Achlia - Achlia, Mineral depletin AFBetafd,Magnesium,Organic Minerals,Calcium Prstate: Histry - Predispses future episdes Current Burn - Infectin/Yeast Zymex, Zymex II, Immuplex, Prst-x Ache - / Pain - / Restrict Benign Prstatic Hypertrphy (BPH) Prst-x, Lact Enz, Palmettplex, Tribulus Dribble - Emissin - Swelling -
7 Vagina Burn Itch Dry Pain - Bwel dysbisis Lact Enz, Infectin Cataplex AC - Yeast/Infectin - Zymex - Depressed hrmnes Symplex F, Utrphin, Ovatrphin, Ovex, Drenamin - Pain upn citus Hrmnal depletin Wild Yam Cmplex, Tribulus, Evening Primrse Oil Bld - Vaginal atrphy Estrgen Dminance Livaplex, Cruciferus, Chelc(Medi) Discharge (Vaginal) Clear White Yellw Green Brwn Odr - Nrmal - Yeast - Zymex - Yeast/Infectin Zymex, Cataplex AC - Trichimnas Zymex, Zymex II, Cataplex AC - Old bld Hrmnal imbalance Symplex F - Yeast - Zymex Menses: Regular Irregular - Chaste Tree regulates Prlactin & LH Early - Chaste Tree, Symplex F Late - White Peny, Symplex F Skip - Hrmnal imbalance Symplex F, Hypthalmex, Utrphin, Tribulus BC pill LMP Flw Heavy - Hrmnal Balance, Chlrphyll Mderate - Nrmal Light - Lng - Anemia Chlrphyll, Frtil/B12, Ferrfd, Femax Brief - Stress Magnesium, adrenal supprt - Drenamin Cramps
8 Mild - Lw calcium tetany - Calam Med - Lw Magnesium- Magnesium Severe - Hrmnal imbalance - Cramplex Back - Hrmnal imbalance Symplex F, Utrphin, Ovatrphin Lw Abdminal Puffiness Uterine swelling - Utrphin Fluid: Face Hands Feet Bdy Breast Tenderness Acne Pre-menses Mid Pst Sptting - Kidney Arginex, Calam - Kidney - Kidney - Kidney - Prlactin imbalance Chaste Tree, Symplex F - Hrmnal Imbalance Symplex F, Utrphin, EPO - Hrmnal - Hrmnal - Hrmnal - Anemia Chlrphyll, Frtil/B12 Clts - Anemia -, PMS: Md swings - Hrmnal Symplex F, Utrphin Irritable - Depressin - Breast Fluid Tired - Prlactin Chaste Tree - Kidney - Calam - Adrenal Drenamin, Eleuther Ovulatin: Pains - Inflammatin Fd allergy Cataplex ACP
9 Cysts Discharge - Hrmnal imbalance Symplex F, Utrphin - Yeast - Zymex Regular - On time Hrmnal Symplex F, Chaste Tree, White Peny, Tribulus (Day 5 t 14) Irregular Fibrids - Same as abve - Hrmnal Symplex F, Utrphin / Anemia Chlrphyll, Frtil/B12 Breast Feeding Fibrsis Lump Discharge Prsthesis Reductin Tender - Supprt prductin Fengre, Cataplex B - Cngestin avid stimulants, Albaplex, Chaste Tree, EPO - Lymphatic Albaplex, Chaste Tree - Hrmnal Symplex F, Utrphin, Chaste Tree - Autimmune risk - Hrmnal Symplex F - Prlactin imbalance Symplex F, Utrphin, Chaste Tree Menpause Natural - Adrenals take ver fr vary reductin Drenamin, Eleuther, Withania Surgical (partial/cmplete) Adrenals Drenamin, Eleuther, Withania, Wild Yam, EPO Hrmnes Patch Ht Flashes Frmicatin Cramps - use f HRT Cruciferus t assist liver t prevent estrgen dminance - type f HRT Cruciferus - Hrmnal adrenal Symplex F, Utrphin, EPO, Tribulus, Wild Yam - Hrmnal - Utrphin - Muscle physilgy Magnesium, Organic Minerals (Ptassium), Calcium Aches - -, Anxiety: - -, Legs - Feet - Arms - Hands -
10 Rash Acne Dry Itch Fungus Patch Fluid Cellulite Nails Spts - Fd allergy eliminatin, Antrnex - Parasites/Infectin Zymex II, Multizyme, Wrmwd, Thymex, Sesame Oil - Dry skin Liver AF Betafd, Livaplex - Fd Allergy - Immune depressin Zymex, Immuplex, Echinacea, Astragulus - Liver spts, Psriasis AF Betafd, Livaplex, Zymex II - Kidneys Albaplex, Arginex, AC Carbimide - Prtein bund fluid Zypan, Albaplex, Arginex, n prtein after 4 PM - Prtein status Prtefd, Nutrimere, Circuplex - Circulatin Zinc Liver, Chezyn, Circuplex Hair Lss - B Vitamins Cataplex G/B, Parasites Zymex II, Anemia Frtil/B12 Limp - B Vitamins Cataplex G/B Urinatin: Ncturnal /night /week - shuld be zer shws lack f liver strength shunting all wrk t the kidneys AF Betafd, Livaplex, Chelc Frequency - Kidney strength Albaplex, Arginex Urgent - Bladder Albaplex, Arginex Burn - Infectin Arginex, Cranberry Cmplex Pain - Infectin Albaplex, Arginex, Cranberry Odr - Infectin Albaplex, Arginex, Cranberry Spasm - Infectin -,, Leak - Prlapse Ligaplex II UTI - Infectin Albaplex, Arginex, Cranberry Sleep: Difficulty Falling Asleep Calcium, Cataplex G, Minchex, Prtefd Insmnia - Prtefd, Cataplex G, Nutrimere Interrupted( /night) Cataplex G, Prtefd, Nutrimere sleep craving Fatigue Adrenals Drenamin, Cataplex B
11 jlts Dreams - right/left brain integratin RNA, OPC Synergy, Gingk - Phase II sleep Cataplex G, Minchex, AF Betafd Nightmares - Gallbladder AF Betafd, Parasites Zymex II Night sweats Gallbladder AF Betafd, Livaplex Restlessness/ hrs per night Calcium, Magnesium Emtinal Well Being: Sad Grief - Adrenals Drenamin, Withania, Symplex F/M - Lungs Allerplex, Zymex II Depressin - Brain chemistry Minchex, Cataplex G/B Mdiness - Gallbladder AF Betafd Irritable - - Wrrisme - Gut lining Cataplex AC Angry Nervus Frustrated Anxiety - Liver - Livaplex - Adrenals - Drenamin - Liver AF Betafd, Livaplex - Adrenals Drenamin, Withania, Eleuther Panic - Adrenals -,, Cry Fear - Hrmnal Symplex F/M, Heart Cardiplus, Vasculin - Kidneys Albaplex, Arginex Shame - Hypthalamus Hypthalmex, Symplex F/M Appetite Lw - Gut lining irritatin Cataplex AC High - - Sweet - Glycemic regulatin reduce starches, mre prtein
12 Cffee - Adrenals Drenamin, Eleuther, Rhdila Tea - -,, Chclate Beer Wine CHO Spices Ice Cream Sda Stress - Hrmnal Symplex F/M, Drenamin - Yeast Zymex, Immuplex - Liver - Livaplex - Energy lack f prtein - Gut lining irritatin Cataplex AC - Gallbladder, Bile delivery AF Betafd - Gut lining irritatin Cataplex AC - Hrmnal, Adrenal Symplex F/M, Drenamin, Withania Energy: Lw Variable Up - Heart Cardiplus, Vasculin - Gallbladder AF Betafd, Hrmnal Symplex F/M - nrmal Slw t start (imprving/wrse) gut lining irritatin Cataplex AC am/pm/meals lw variable systems depending upn time f lw energy Exercise Memry Name Number Wrd - Endrphin imbalance Hypthalamus Hypthalmex, Symplex F/M - Brain integratin RNA, Gingk, OPC, Rhdila - Phsphrus Circuplex, RNA - Brain integratin - RNA Crdinatin - Brain Integratin RNA, Symplex F/M Cncentratin - - OPC Synergy, Rhdila Sexuality Flat - Hrmnal Symplex F/M, Tribulus, Drenamin Lw - -,, Nrmal Imptent Slw Healing - Nrmal - Adrenals ften blcked by medicatin - Zinc deficiency Zinc Liver, Chezyn, Catalyn
13 Bruising - Bld quality - Chlrphyll Arthralgia - Liver AF Betafd, Livaplex, Circulatin Circuplex, Cllinsnia Weight: (+/- lbs) Lw Carb lifestyle Overall (+/- ) - Gain r lss under care Height: - Skeletal Energy Bist, Calcifd BF% ( ) - bdy fat Phase II lifestyle reduces 6-8 lbs/mnth Pulse - Adrenals - Drenamin BP: / - Fd allergy eliminatin f allergen, Magnesium Chl. - Lipids Phase II lifestyle HDL - - Tri. - - preferably less than 90 Phase II Medicatins: - watch fr cntraindicatin Surgery - Identify future scar repair prjects Allergy - Keep nging list f knwn allergens, including supplement reactins
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*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
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:
N E W C L I E N T Q U E S T I O N N A I R E
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: 416-222-8235 Email: vanessayoussefnd@gmail.com N E W C L I E N T Q U E
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
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
Pediatric Health History Form
Pediatric Health Histry Frm Child s Name Date f Birth Mther s Name Father s Name Parent Cncerns - Please explain any ther cncerns r questins yu have abut yur child Des yur child have any allergies? Yes
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Medical History Intake Form
Medical History Intake Form What is your opinion of your overall level of health? Excellent Good Fair Poor In your opinion (not necessarily your health care providers), what are your most important health
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
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
Digestion Assessment Scorecard
Name Digestion Assessment Age Height Weight Based upon your health profile for the past 30 days, please select the appropriate number, from '0-3' on all questions (0 as least/never/no and 3 as most/always/yes).
NEW PATIENT FORMS FOR ADULT. Patient Last Name First Name Middle Name. DOB Age Race SSN. Sex Single Married Widowed Divorced
The Allergy and Asthma Center f Crpus Christi 1718 Braeswd Dr, Crpus Christi TX 78412 text: 361-992-8500 Fax: 361-992-6711 www.allergycrpustx.cm NEW PATIENT FORMS FOR ADULT Patient Last Name First Name
Metabolic Assessment Form Please list your five major health concerns in your order of importance.
Metabolic Assessment Form Please list your five major health concerns in your order of importance. 1. 2. 3. 4. 5. Please check the appropriate number on all questions below, using zero as least/never to
Healthy Habits CANDIDA QUESTIONNAIRE
Healthy Habits CANDIDA QUESTIONNAIRE Name:... Date: This questionnaire is designed for adults; the scoring system is not appropriate for children. It lists factors in your medical history which promote
SYSTEMS SURVEY FORM. Doctor
Patient Birth / / Approx Weight SYSTEMS SURVEY FORM INSTRUCTIONS: Fill in only the circles which apply to you. Leave blank if you don't have the problem. Fill in the circle marked 1 for MILD symptoms (occurs
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 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:
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Personal Information Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
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:
HORMONE QUIZ Time to get clear about your symptoms
HORMONE QUIZ Time to get clear about your symptoms WHAT SYMPTOMS ARE YOU EXPERIENCING? Follow the instructions in each of the 4 categories, count your scores, discover how to interpret your symptoms and
Dr. Rajsree Nambudripad, MD, ABIHM Dr. Roy Nambudripad, MD NEW PATIENT HISTORY FORM
Dr. Rajsree Nambudripad, MD, ABIHM Dr. Ry Nambudripad, MD NEW PATIENT HISTORY FORM Name Date File N. Phne number Email Hme address City State Zip Date f birth Age Sex M F Height Weight Emplyer Occupatin
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
Review of Systems. Name: Date of birth: Today s Date:
1 Review of Systems Name: Date of birth: Today s Date: YOUR HEALTHCARE TEAM Please list all healthcare practitioners you are currently being treated by: Name Type of practitioner (eg. family doctor, counselor,
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
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
EMORY SLEEP CENTER Sleep and Health Questionnaire
EMORY SLEEP CENTER Sleep and Health Questionnaire Demographics Today s Date: / / Name: Date of Birth: / / Address: Sex: Male Female City/State/Zip: Preferred Contact Number: Work Home Cell Occupation:
5210 E Farness Drive P: (520) Tucson, AZ F: (520) E:
Personalized HealthC are Patient Registration 5210 E Farness Drive P: (520) 795-4100 Tucson, AZ 85712 F: (520) 795-4224 E: www.phcoftucson.com First Name Middle Last Name DOB Age Sex SSN Race Ethnicity
New Client Health & Wellness Paper Work
Nutritionally Yours Health Solutions 604 Macy Drive, Roswell GA 30076 678-372-2913 / alanepnd@gmail.com New Client Health & Wellness Paper Work Today's Date Patient Name: _ Parents Name (if patient is
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:
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
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE
WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE Name: Date: This is not a test, or a quiz, and there are NO right or wrong answers here. This health assessment questionnaire is about YOU, and will
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
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:
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
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
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
Personal Health Evaluation
Personal Health Evaluation Note: Information provided on this forms will be held in strict confidence. I. Personal Information Name Age Sex Height Weight Eye Color Phone Number or Skype Number you wish
MEDICAL DATA SHEET For Patients 18 years of age and older
MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
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
Patient Health History
Patient Health History Name: Date: Address: City, State, Zip code Phones: Home Work: Cell: Email address: Date of Birth: Age: Occupation: Emergency contact: Referred by: Current Medications: Are you/might
HORMONE QUIZ Time to get clear about your symptoms
HORMONE QUIZ Time to get clear about your symptoms WHAT SYMPTOMS ARE YOU EXPERIENCING? Follow the instructions in each of the 4 categories, count your scores, discover how to interpret your symptoms and
PATIENT INFORMATION. Name Today s Date. Address. City State Zip. Primary Phone # (h, w, c) Secondary Phone # (h, w, c)
PATIENT INFORMATION THANK YOU FOR CHOOSING BEAUTIFUL AMA! We are excited to work with you to balance your body and emotions naturally. These questions will help us develop an individualized diagnosis and
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)
Medical History. Yes or No
Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have