PDX Acupuncture Inc. Patient Health History Form
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1 PDX Acupuncture Inc. Patient Health History Form Please fill this form out to the best of your ability and bring it with you to your first office visit. If you have any questions, please feel free to ask. Thank You! Name Date Address City State Zip Phone (H) (W) (C) Insurance Information: Carrier ID# Group # Date of Birth Age Sex Marital Status Social Security Number Employer Occupation Emergency Contact Phone How did you hear about us? Friend/Co-worker Our Website Google Acufinder Yelp Insurance carrier I will call patients at times, and wish to ensure your privacy regarding treatment at this clinic. In the event that we are unable to reach you by phone please indicate where it is appropriate to leave messages for you: Home message machine With family member At work Never leave message What are you primary health concerns? List as many as you can, in the order of their importance to you What are your expectations you have for your visit today? We strive to give you a range of treatment options so you can find what works for you. Please circle each modality that is of interest to you or that you are willing to try. Star anything you would like to know more about or are excited to try. Herbal treatment: Pill/capsule, tincture, tea, granule, bulk herbs. External treatment: Salves, liniments, massage. Stretching exercises. Informative handouts. Home care: Dry brushing, netti pots, hydrotherapy. Diet and nutrition: Recipes, books, suggestions, detoxes, elimination diet, food journal. 1
2 General Information: Height Weight Weight 1 yr ago Max weight Typical Diet: Breakfast Lunch Dinner Snacks Foods you crave Caffeine/Alcohol/Sugar intake: Primary Interests & Hobbies Primary form of exercise, if any and how often Family History: Do you have a family history of any of the following diseases or conditions? Please include your parents, brothers/sisters, and grandparents, if known. Check all that apply. Anemia Cancer Heart Disease Mental Illness Alzheimer s Arthritis Diabetes Hypertension Multiple Sclerosis Stroke Asthma Epilepsy Kidney Disease Parkinson s Other Please list other significant family medical history not listed above Are you currently receiving healthcare? If so, where and from whom? Please provide contact information (phone and address) if available. If not, when was the last time you received medical care and why? If you have a practitioner that you think I should speak with to coordinate your care, please list their name and contact info. Which of the following childhood illness have you had? Diphtheria Measles Scarlet Fever German measles Mumps Rheumatic Fever Chickenpox Other Which immunizations have you had? 2
3 Diphtheria Measles/Mumps/Rubella Meningitis Polio Tetanus Chickenpox Hepatitis A/B/C Pertussis Flu Other Which diagnostic studies have you had and briefly describe why? EKG X-Ray Bone Density Scan CT Scan EEG Mammogram MRI Other Do have any allergies? Please any medications, either by prescription or over-the-counter and all vitamins/supplements/herbs, you are regularly taking or have taken in the past 6 months. Prescription Drugs:(If you brought this with you on a separate paper just attach) 5. Reason for taking Dosage Side effects Effective 6. Reason for taking Dosage Side effects Effective (Effective meaning are you getting the drugs desired effects? Yes or no) Over the counter Drugs: Vitamins/Supplements: Herbs: Assessing the Areas of Your Life 3
4 In assessing your health, it is helpful to have some sense of the degree of satisfaction you feel in various areas of your life. Using the scales below please rate yourself in terms of satisfaction and dissatisfaction. Number 0 means you are very dissatisfied or stressed. Number 10 means you are very satisfied or comfortable. Friends & Family Physical Environment Health Career Intimate Relationships Recreation Money Personal Growth/Spirituality Review of Systems: Please fill in the circle if you have the symptom currently, or check it if you have experienced it in the past 6 months. Mental/Emotional: Depression Mood Swings Poor concentration Anxiety Tension/Stress Memory problems Mental Fogginess Mental/physical restlessness Endocrine: Hair Loss Brittle Nails Excessive Thirst General Fatigue Fatigue after meals Heat Intolerance Cold Intolerance Excessive Hunger Seasonal Depression Night Sweats Head: Headaches Migraines Head Injury Jaw pain/tmj Immune: Chronic Fatigue Syndrome Swollen Glands Recurrent Infections Slow Wound Healing Frequent colds/flus 4
5 Neurological: Seizures Muscle Weakness Loss of memory Vertigo/dizziness Paralysis Numbness/Tingling Easily stressed Shaking/Trembling Limbs Ears: Impaired hearing Earaches Ringing Itching Popping Nose/Sinuses: Frequent colds Stuffiness Sinus Pain Nose Bleeds Hay Fever Loss of Smell Eyes: Floaters/spots Blurriness Color Blindness Double Vision Twitching Cataracts Eye Pain/Strain Excessive tearing/dryness Glaucoma Neck: Lumps Goiter/enlargement of throat Pain/Stiffness Skin: Rashes Acne Color Changes Lumps Eczema Hives Itching Boils Urinary: Pain Frequency Frequent Infections Incontinence Kidney Stones Nighttime urination (waking up to urinate) Respiratory: Cough Cough w/ Blood Asthma Pneumonia Emphysema Painful Breath Shortness of Breath Congestion Wheezing Bronchitis Pleurisy Difficulty Breathing Cardiovascular: Heart Disease High Blood Pressure Low Blood Pressure Blood Clots Phlebitis Rheumatic Fever Ankle Swelling Angina/Chest Pain Heart palpitations/fluttering Intestinal: Trouble Swallowing Change in Appetite Nausea/Vomiting Burning Pain in Stomach Jaundice Gallbladder Disease Liver Disease Hemorrhoids Heartburn Abdominal Pain Excess Gas Constipation Diarrhea Black Stools Blood in the Stools Excessive hunger Fatigue after meals Musculoskeletal: Joint Pain/Stiffness Broken Bones Spasms/Cramps Arthritis Weakness Sciatica Osteoarthritis Herniated discs Clicking/popping Blood/Peripheral Vascular: Easily Bruise/Bleed Deep Leg Pain Varicose Veins Anemia Cold hands/feet 5
6 Male Reproductive (applies to lifetime): Hernias Prostate Disease STD s Impotence Premature Ejaculation Testicular masses/pain Discharge/sores of Penis Erectile disfunction Female Reproductive (applies to lifetime): Age of first menses (period) Age of last menses How many days between menses? How many days do you menstruate (bleed) for? Are you currently taking birth control? What is your history of birth control? Irregular cycles Painful menses Heavy flow Light flow Bleeding/spotting between periods Clotting Discharge PMS. If yes, what do you experience? Menopausal Symptoms If yes, what do you experience? Endometriosis Ovarian cysts Cancer Date of last annual exam/pap/results: Sexually active Pain during intercourse Difficulty conceiving. If so, for how long? Cervical dysplasia Sexual difficulties STD Breast Pain/Tenderness Breast lumps Pregnancies Births Complications Please list any habits you would like me to know about (smoking, extreme diets, sleep habits, mental or emotional struggles etc.): Is their any additional comments or information I should know to further your treatment? Are there any other health concerns that you have which have not been covered in this questionnaire? Thank you for taking the time to complete this form, it is very helpful for us! Signature Date Print name 6
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PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
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
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
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
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
Patient Name: 3866 Johns St Madison, WI DATE: Acupuncture Patient Health History
Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender: Marital status (please circle one): Single Married Domestic Partnership Divorced Widowed
Dr. Jeannie Doig, HBSc, ND Naturopathic Physician Port Alberni (250)
Child Intake Form Child s name Age Date of Birth Date Sex M F Who is filling out this form (name and relation)? Contacts (in order of preference): Name Phone h Address w other Relationship to Child Name
Client Intake and Health History
Providence Wholistic Healthcare Sheila M. Frodermann, MS, ND, DHANP, CCH Carol L. Seng, MAOM, DA, LAc 144 Waterman Street, Suite #3 Providence, RI 02906 www.providencewholistic.com (401) 455-0546 Client
Laser Vein Center Thomas Wright MD RVT Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD RVT Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Marital Status: Married Single Other Emergency Contact:
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?
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.
Please Print Patient Information
Please Print Patient Information Name Date Date of Birth E-Mail Address Street Address City State Zip Home Phone Cell Phone Occupation Employer Business Phone Sex: Male Female Height Weight Are you: Married
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
Patient Registration Form
Patient Registration Form Name: Today s Date: FIRST MIDDLE LAST Home Address: City: State: Zip: Telephone: ( ) Birthdate: Age: Occupation: SSN: Employer: Years There: Employer s Address: City: State: Zip: