Legal Name Preferred Name (if different) Date of Birth. What are your long term personal goals for our work together?
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- Bridget Fitzgerald
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1 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 n e a d d r e s s t h e w h o l e p e r s o n o n a p h y s i c a l, e m o t i o n a l a n d m e n t a l l e v e l. Y o u r t i m e, t h o u g h t f u l n e s s a n d h o n e s t y w i l l g r e a t l y a i d us i n a s s i s t i n g y o u r h e a l t h n e e d s. T h a n k y o u f o r y o u r t r u s t a n d p a t i e n c e Legal Name Preferred Name (if different) Date of Birth Preferred Phone Alternate Phone Address City, State: Zip Emergency Contact and Phone Parents name if under 18yo Insurance Company How did you hear about us? What are your long term personal goals for our work together? Concern Headaches Ongoing Concerns (in order of importance) Started when? How often? June per week How severe? mild/mod/severe You may list more later on the Health Systems Check-list
2 Context of Your Concerns Is there an event, illness, stress where your health has never been the same since? What behaviors do you engage in that you feel are very supportive to your health goals? What behaviors do you engage in that you feel are not supportive to your health goals? Are there things that you feel you should be doing for your health, but aren t? Why? How committed are you to making the lifestyle changes necessary to meet your goals? 0% % Tell us about your prior medical history Hospitalizations or Surgeries and Dates Allergies (food, environ, meds) Type of Reaction Illness Past Now Family Who? Other Important Information? Asthma Autoimmune Cancer Diabetes Digestive Concerns Heart Disease Hepatitis High Blood Pressure Lung Disease Thyroid Condition Neurological
3 What medications are you currently taking? (Both prescriptions and OTC) Medication and Dose Zantac 20mg 2x/day Reason Stomach upset Started? 11/2008 Prescribed By Alan James, MD If you would like, we can provide you with a longer medication and supplement form Supplement, Brand and Dose Super Vitamin C (Thorne) 500mg / day Reason Immune Support Started? 11/2008 Recommended By Self Other Healthcare Providers? Additional Prior Medical History that you would like to share:
4 Tell us about how you eat Sodas, oz/day Food Sensitivity Caffeine, oz/day Food Restrictions Water, oz/day Food Ethics Vegetarian Vegan Paleo Other: Alcohol #/day In the car Watching TV Standing Do you eat? With others On the go In a hurry Food Cravings After 11pm In your sleep On waking Snack Foods Typical Breakfast How often do you eat out? Where? Typical Lunch Tobacco Use? Never Age to. packs per day Typical Dinner Bowel movements per day Constipated? Any Bowel Concerns? Diet Chart Create a pie chart below that roughly describes the distribution of the food groups that you eat a typical daily meal Vegetable Protein (VP) Animal Protein (AP) Dairy (Da) Grains (Gr) Oils and Fats (Oi) Vegetables (Ve) Fruits (Fr) For example, your chart may look like this:
5 What is your occupation? Do you enjoy it? Tell us about your life What stresses you out in your life? Do you have supportive relationships? How is your sleep? Typical bedtime and wake time? Do you wake Rested? Do you Snore? What do you do to relax? What are your hobbies? What types of physical activity do you do? How often? When during the day is your energy the best? Worst? Height Weight Weight 1 yr ago Max weight (and year)
6 Initial Health Systems Check-list As a New Patient, please check any items that have concerned you in the last YEAR. If it was in the distant past, put P next to the item. We will use this sheet to track progress over future visits. GENERAL: FATIGUE WEIGHT LOSS MOOD CHANGES HARDER TIME EXERCISING HISTORY OF ABUSE STRESS WEIGHT GAIN INSOMNIA CHANGES IN STRENGTH OTHER: ABDOMEN/DIGESTION: ABDOMINAL PAIN CONSTIPATION DIARRHEA HEART BURN - REFLUX GAS OR BLOATING NAUSEA/VOMITING APPETITE CHANGES BLOOD IN STOOL FOUL ODOR OTHER: HORMONES: FATIGUE TIRED-BUT-WIRED AFTERNOON CRASH SALT CRAVING DIABETES HYPOTHYROID HYPERTHYROID EXCESSIVE THIRST COLD INTOLERANCE 3AM WAKING DIZZY ON STANDING EXCESSIVE HUNGER HYPOGLYCEMIA OTHER: NEUROLOGICAL: CHANGE IN SLEEP BRAIN FOG SEIZURES-TREMORS LOSS OF COORDINATION FOCUS ANXIETY DEPRESSION MEMORY CHANGES COGNITIVE IMPAIRMENT OTHER: MENS HEALTH: LOW LIBIDO ERECTILE ISSUES LOSS OF STRENGTH TESTICLE CONCERNS APATHY/BOREDOM SWELLING ACHES/PAIN PROSTATE/URINARY OTHER: WOMENS HEALTH: FIRST MENSES AGE PERIOD CRAMPS PELVIC PAIN DIFFICULTY CONCEIVING NIGHT SWEATS CYCLE LENGTH (28d?) SPOTTING CRAMPING VAGINAL DISCHARGE HOT FLASHES PERIOD LENGTH MENSES CHANGE BIRTH CONTROL? PMS OTHER: HEAD/EAR: FREQUENT COLDS DIZZINESS HEAD TRAUMA CHANGES IN HEARING MENTAL FOG HEADACHES RINGING IN EARS SINUS CONGESTION OTHER: EYES: VISION CHANGES DOUBLE VISION EYE PAIN BLURING OF VISION EXCESSIVE TEARS BLIND SPOTS CORRECTIVE LENSES OTHER: NOSE/MOUTH: CONGESTION BLEED OFTEN BLEEDING GUMSN COLD/CANCRE SORES TOOTH PAIN NASAL DISCHARGE NOSE OBSTRUCTION USE OF DENTURES BAD BREATH OTHER: NECK/THROAT: SORE THROAT NECK PAIN LUMPS/BUMPS DIFFICULTY SWALLOWING SWOLLEN LYMPH NODES NECK STIFFNESS NECK TENDERNESS POST-NASAL DRIP PHLEGM OTHER: CHEST/LUNG: COUGH ASTHMA SPITTING UP BLOOD PAIN WITH BREATING WHEEZING SHORT OF BREATH MANY INFECTIONS OTHER: CARDIOVASCULAR: CHEST PAIN HIGH CHOLESTEROL LEG SWELLING HIGH BLOOD PRESSURE LIGHTHEADEDNESS IRREGULAR BEAT COLD HANDS/FEET ANEMIA OTHER: URINATION: FREQUENCY URGENCY MANY INFECTIONS INCOMPLETE EMPTYING PAIN INCONTINENCE DRIBBLING OTHER: MUSCULOSKELETAL: MUSCLE CRAMPS MUSCLE SORENESS MUSCLE TENSION NUMBNESS/TINGLING MUSCLES WEAK JOINT PAIN LIMITED MOBILITY SHAKINESS/TREMBLING OTHER: SKIN/HAIR: THINNING HAIR EASY BRUISING RASH/HIVES TEXTURE CHANGES DRYNESS ECZEMA/PSORIASIS COLOR CHANGES CHANGES IN NAILS OTHER:
7 Please INITIAL and SIGN to indicate that you have read and understand each statement below. Packet available at Informed Consent for Treatment I have fully read, or have had read to me, the CONSENT FOR TREATMENT section of the Informed Consent Packet and I fully understand the agreements and authorizations. I voluntarily consent to services rendered by the Doctors realizing that no guarantees have been given to me. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment. If Pregnant, name of OB/GYN and next appointment date Financial Policies Acknowledgement I acknowledge that I have read or have had read to me the FINANCIAL POLICIES for the Clinic and agree to the to these policies and will comply with them in all respects. I understand the cancellation policy and that full payment is due at the time of service for all fees. Notice of Privacy Practices I acknowledge that I have read, or have had read to me, the NOTICE OF OUR PRIVACY PRACTICES section of the Informed Consent Packet and I fully understand and agree to the stipulations therein. I have been offered a copy of these policies and, if accepted, received a copy. Consent to communicate via I acknowledge that I have read, or have had read to me, and agree to the CONSENT TO COMMUNICATE VIA in the Informed Consent Packet. Consent for Intravenous Therapy I acknowledge that I have read, or have had read to me, and agree to the INFORMED CONSENT FOR INTRAVENOUS (IV) THERAPY in the Informed Consent Packet and that I agree with all stipulations therein. By my signature, I affirm that I agree to all aspects of the initialed sections above, and their relevant sections in the Informed Consent Packet. Patient (or guardian) Signature Date Patient (or guardian) Name (PRINT) Guardian Relationship to Patient
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Health History Questionnaire. Age Date of Birth Gender. Married Single Separated Divorced Widowed Partnership
Health History Questionnaire Name Date Age Date of Birth Gender Married Single Separated Divorced Widowed Partnership Live with: Spouse Partner Parents Children Friends Alone Please complete these next
Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
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
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
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Weill Cornell Vascular
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Female Patient Intake Form
Basic Information STREET ADDRESS CITY, STATE, ZIP HOME PHONE ALTERNATE PHONE EMAIL ADDRESS HOW DO YOU PREFER TO BE CONTACTED? EMAIL PHONE BIRTH MARITAL STATUS SINGLE MARRIED WIDOWED DIVORCED REFERRED BY
NEW PATIENT HEALTH HISTORY
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EMORY SLEEP CENTER Sleep and Health Questionnaire
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Eastern Body Therapy
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Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Address: Sex: M F Age: Birth date: Height: Weight: Occupation: Hobby:
Name: Date: Street Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Sex: M F Age: Birth date: Height: Weight: Marital Status: Single Married Widowed Separated Divorced Occupation: Hobby:
PATIENT INTAKE AND HISTORY FORM
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New Patient Medical History and Intake Form Medical Marijuana ( MMJ ) Certification
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WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
Office Policy for New Patients
Office Policy for New Patients Thank you for contacting us for your medical needs. We are glad you have entrusted us to be your medical provider. We are enclosing a few guidelines to help you transition
New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )
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Parkinson Disease and Movement Disorder Institute
428 East 72 nd Street (Between 1st Avenue & York Avenue), Suite 400 (Ground Floor), NY, NY 10021 Telephone: 212-746-2584 Fax: 646-962-0517 156 William Street, 11 th Floor (Between Ann Street and Beekman
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:
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