Naturopathic New Patient Form
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- Jodie Reeves
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1 611 Main St., Suite A Edmonds, WA Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Marital Status: Emergency Contact:!!!! Name!!! Phone!!! Relationship Are you currently receiving healthcare? yes no Physician & Office Name!!!!!!! Phone! Context of Care: Please list your most important health problems (in order of importance) Have you received treatment for these concerning problems? yes no If yes, what modalities? What three specific expectations do you have for your visit today? Please describe your goals for treatment. Please describe your current state of health.
2 What is your level of commitment to address the underlying causes of any of your symptoms that relate to your lifestyle. Rate from 0-10, 10 being most fully committed General Height: Weight: One year ago? Ideal Weight? Do you have an exercise routine? yes no What type of exercise do you do? How often? History of trauma? yes no History of abuse? yes no Occupation: City: Do you enjoy your work? yes no why/why not? Hrs of sleep per night: Bed time: Do you wake refreshed? yes no Diet, Lifestyle, Habits What is the current level of stress in your life? Rate from 0-10, 10 being severe stress What things have you found to help in the relieving of your stress? Spiritual Practice? yes no!! what? Do you eat three meals per day? yes no If no, how many? Please describe your typical daily meals. Breakfast Lunch Dinner Snacks
3 Do you use any of the following? (please check) Alcohol Tobacco Coffee Caffeine Recreational drugs Soda Do you have any cravings? Please specify and describe frequency. Do you have any allergies to the following? (please check) Medications Foods Seasonal Animals Environmental/Chemical If you checked any, please explain. Current Medications: Please list all current prescription medications, over-the-counter medications, vitamins, herbs and nutritional supplements. Include frequency and dosages. Attach a separate sheet if necessary. Prescription & Over-the-counter medications: Vitamins & Nutritional Supplements: Patient Medical History: Please check all that apply:! Broken or Fractured Bones Major Illnesses Operations & Hospitalizations If checked, please provide the date, diagnosis, location of injury and/or surgery.
4 Personal & Family History Check any conditions listed below that you currently have or have had in the past. If there is a family history of any of the conditions listed, please underline and specify.! Appendicitis! Cancer (type)! Hepatitis type)! Asthma!! Autoimmune Disorder! Blood Clots! Bronchitis! Diabetes! Migraines! Emphysema! Digestive problems! HIV/AIDS! Pneumonia! Addiction! Paralysis! Tuberculosis! Epilepsy! Colitis/Enteritis! Heart Disease! Multiple Sclerosis! Thyroid Problems! High Cholesterol! Mumps! Blood Clots! Hypertension! Scarlet Fever! Syphilis! Stroke! High Fever! Polio! Pace Maker! Bleeding Disorder! Mental Illness! Arteriosclerosis! Intestinal Parasites! Allergies Immunizations: yes no! which? Other relevant history. Patient Signature (or Guardian, if under age 18) Date
5 Review of Systems Please Check the Following Symptoms If Present: Endocrine! Cold Hands/Fingers! Cold Feet/Toes! Sweaty Hands! Sweaty Feet! Cold Intolerance! Heat Intolerance! Night Sweats! Hot flashes! Excessive Thirst! Excessive Hunger! Easily Perspire! Lack of Perspiration Respiratory/Cardiovascular! Shortness of Breath! Difficulty Inhalation! Difficulty Exhalation! Cough! Asthma! Chest Pain! Heart Disease! High Blood Pressure! Low Blood Pressure! Blood Clots Gastrointestinal! Nausea! Vomiting! Gas! Bloating! Diarrhea! Constipation! Abdominal Pain! Blood in Stool! Food in Stool! Number of bowel movements per day? General! Anxiety! Depression! Restlessness! Fatigue! Tension/Stress Neurological! Tingling! Numbness! Dizziness! Headaches! Memory Loss! Tremors! Fainting! Seizures EENT! Vision Changes! Double Vision! Painful Vision! Blurry Vision! Light Sensitivity! Ear Pain! Ear Discharge! Ringing in the Ears! Hearing Loss! Nasal Congestion! Sinus Congestion! Allergies! Sore Throat! Swollen Lymph Nodes! Mouth Sores/Ulcers Musculoskeletal! Joint Pain! Muscle Spasms! Muscle Twitches! Muscle Weakness Skin! Dryness! Rash! Eczema! Hives! Color Changes! Suspicious Lesions Genitourinary! Painful Urination! Urgency! Frequency! Blood in Urine Libido! Normal! High! Low Reproductive MEN -! Swollen Testes! Testicular Pain! Impotence! Premature Ejaculation! Erectile Difficulties! Hernia WOMEN -! Mood Swings! Food Cravings! Water Retention! Breast Swelling! Breast Tenderness! Frequent Headaches! Migraines! Depression! Irritability! Anxiety! Pain with Intercourse! Irregular Discharge Age of first menses Average # days in flow Average # days in entire cycle # of children # pregnancies Age of menopause yes no Regular menses cycles? yes no Bleeding between periods? yes no Are you pregnant? Date of last menses? yes no Birth control use? What type? yes no Hx of STIs? What type?
6 HIPPA Notice of Privacy Practices Please review the following information carefully. It discusses how your medical information may be used and disclosed and how you can gain access to this information. This HIPPA Notice of Privacy Practices explains how we may use and disclose your Protected Health Information (PHI) to carry out treatment, for payment of healthcare operations, and for other purposes that are permitted or required by law. Uses and Disclosures of Protected Health Information Treatment: We may use and disclose your PHI in order to provide, coordinate or manage your healthcare and any related services. This includes the coordination or management of your healthcare with a third party to whom has already obtained your permission to have access to your PHI. For example, we would disclose your PHI to another practitioner with whom you have begun treatment, if requested. This would be done in order to ensure that the practitioner has the necessary information to manage your care accordingly. Payment: Your PHI will be used as needed to obtain payment for your healthcare related services. This may include certain activities that your health insurance plan may undertake before it approves or pays for healthcare services provided. Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the activities of your healthcare providers practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical students that see patients at our office. In addition, we may use a sign-in sheet at registration desk where you will be asked to sign in and indicate your healthcare provider. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. Required by Law: We may use or disclose your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. Public health issues such as communicable diseases, legal proceeding, law enforcement, coroners, funeral directors, organ donation, criminal activity, national security, workers compensation, abuse or neglect may require the use of your PHI. You will be notified, as required by the law, of any such uses or disclosures. You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purpose of treatment, payment or healthcare operations. You may also request that any part of your PHI information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. You may revoke this authorization at any time, in writing, except to the extent that your healthcare provider or the practice has taken action in reliance on the use or disclosure indicated in the authorization. Patient or Guardian signature!!!!! Date
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Name Date These questions that you are about to answer are very important for the Doctor. They will enable the doctor make a complete and diagnosis, and provide medical documentation (if needed)to your
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Legal Name Preferred Name (if different) Date of Birth. What are your long term personal goals for our work together?
Personal Health Questionnaire A l l i n f o r m a t i o n w i l l r e m a i n s t r i c t l y c o n f i d e n t i a l. S u c c e s s f u l h e a l t h c a r e a n d p r e v e n t a t i v e m e d i c i
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:
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
NEW PATIENT FORM GUARANTOR INFORMATION - IF DIFFERENT FROM ABOVE
NEW PATIENT FORM Patient Name: DOB: Gender: Address: City & State: Zip: Home phone #: Cell Phone#: E-MAIL: Pharmacy Name: Phone #: Social Security #: Drivers License #: State: Employer: Phone #: Emergency
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 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:
PLEASE DESCRIBE YOUR PRIMARY HEALTH CONCERNS
Dr. Kenzie Maloy, DC, DABCI, DACCP, DACBN 505 E. Main St. Suite B Hermiston, OR 97838 Phone:541-371-3700 Fax:541-515-7022 PERSONAL INFORMATION: First Name: Last Name: Middle Initial: Email for doctor communications:
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Northeast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
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
New You Acupuncture Wellness Center Oriental Medicine - Acupuncture - Herbs - Homeopathy
Patient Contact Information Form Your privacy is being protected per HIPPA guidelines. No information will be given out without your expressed consent. Please indicate any of the following methods of communication