Integrative Rheumatology Associates, P.C.
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- Austen Garrett
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1 Integrative Medicine Health History Name: DOB: Today s Date Age: Height: Weight: BMI Name of primary care doctor:. What are your health goals? Concerns? Medical History (specify year diagnosed): Surgical History (specify year of surgery/procedure): Medications (name, dose, frequency, start date): Vitamins/Supplements/Herbs (name, brand, dose, frequency, manufacturer): Drug or food allergies (specific reaction):
2 Family History (immediate family/siblings): Social History: Married/Single/Divorced/Widowed Children? (Names & ages) Occupation/s Hours/day Do you drink alcohol? How many drinks per day/week/month? Do you drink caffeinated beverages? How many per day? Do you smoke? Yes or No? How many cigarettes per day/week? Quit date? Have you tried to quit in the past? What helped or hurt this process? Have you traveled outside of the U.S. recently? Diet: Please describe your daily diet: ):
3 Do you drink soda? (amount, type, frequency) What percentage of your meals are fresh cooked foods vs. pre-packaged? Do you go on diets often? How many servings of fruit and/or vegetables do you eat per day/week? How many servings of fish do you eat per day/week/month? Do you have sensitivities to certain foods? Do you prefer foods that are salty or sweet? Caffeine: How many caffeinated beverages/foods do you drink per day/week? What kinds of caffeinated drinks do you consume? What time in the day do you typically drink/eat caffeinated products? Exercise/Physical Activity: Please describe type, duration and frequency: Do you belong to a gym? How often do you go? Do you have access to a swimming pool? What exercise would you like to try? Any old injuries? Sleep: How many hours do you typically sleep per night? Do you have difficulty falling asleep? Do you wake up in the middle of the night? How many times? Do you feel rested in the morning? Do you take something to fall asleep? Pills? Tea?
4 Do you snore? If yes, do you snore on your side/back/both positions? Do you use a CPAP machine? When did you start? Does your partner snore? Do you sleep in the same room? Do you sleep with children/pets/ a computer in your bedroom? Does stress typically effect your sleep? Stress: How often do you feel stressed? Do you feel that you have control over your stress? Do you take any medications for stress/anxiety? Do you take any herbals/sleep supplements? Is there a family history of anxiety? Depression? Suicide? Have you ever seen a therapist? When? How often? Last time seen? Have you ever tried massage/guided imagery/biofeedback/acupuncture/breathing exercises? Do you tend to eat more when you are stressed, or less?
5 Environment: Do you work with any harsh or toxic chemicals? Do your hobbies involve any chemicals? (painting, gardening etc.) How old is the house that you live in? Do you live near a busy road or highway? How long? Which cosmetics do you wear? Personal care products? Which cleaning products do you use? Do you work with any harsh/toxic cleaning products? Industrial chemicals? Spirituality: Please specify your spiritual beliefs/religious affiliation (optional): Who or what gives you emotional support? When have you been most happy? What makes you happy now?
6 What has been your greatest disappointment/regret in life? What has been your greatest challenge? What has been your greatest source of pride/joy? Anything else you would like to share?
Sleep Questionnaire. If yes, what? If yes, how would you describe it? Please explain? If yes, what times are these?
THE ADRENAL THYROID REVOLUTION Professional Mastermind Aviva Romm MD Sleep Questionnaire Sleep is important for musculoskeletal healing and for healthy immune function, mood, cognitive and brain function,
SLEEP & MEDICAL HISTORY QUESTIONNAIRE
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Denise E. Bruner, M.D. & Associates, P.C.
page 1 of 6 NAME:(LAST) (FIRST) (M.I.) DATE OF BIRTH: / / SEX: M / F AGE: MARITAL STATUS: (please circle ONE) S M W D MEDICATION ALLERGIES Address (street) (city) (state) (zip) Phone numbers home: work:
SLEEP DISORDERS CENTER QUESTIONNAIRE
Carteret Health Care Patient's name DOB Gender: M F Date of Visit _ Referring physicians: Primary care providers: Please complete the following questionnaire by filling in the blanks and placing a check
If you arrive at the office without these forms, your visit may need to be rescheduled.
Dear, Your Appointment for the Welcome to Medicare Visit OR Annual Wellness Visit is scheduled on at There is NO CO-PAY for this visit, so it is free for you. The goal of this visit is to provide time
PATIENT NAME: M.R. #: ACCT #: HOME TEL: WORK TEL: AGE: D.O.B.: OCCUPATION: HEIGHT: WEIGHT: NECK SIZE: GENDER EMERGENCY CONTACT: RELATIONSHIP: TEL:
SLEEP DISORDERS INSTITUTE HOSPITAL: DePaul Building Street Address City, State Zip Tel: (202) 555-1212 Fax: (202) 555-1212 SLEEP QUESTIONNAIRE PATIENT NAME: M.R. #: ACCT #: STREET ADDRESS: CITY: STATE:
General Questionnaire
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HOW DID YOU HEAR ABOUT US?
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Name: Sex: Age: Date: Date of Birth Height Weight Neck size Referring Physician: Primary Care MD: Main Sleep Complaint(s) trouble falling asleep trouble remaining asleep excessive sleepiness during the
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Occupation: Usual Work Hours/Days: Referring Physician: Family Physician (PCP): Marital status: Single Married Divorced Widowed
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Not Sleepy HO Q1 D2 Q3 Q4 ]5 D6 j7 Q8 Q9 Q10 Extremely Sleepy
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www.myvcmf.com 1133 E. Stanley Blvd., Suite 101 Livermore, CA 94550 925 454-4280 5725 W. Las Positas Blvd., Suite 110 Pleasanton, CA 94588 925-416-6767 Sleep Questionnaire Name: Sex: Age: Da te: Da te
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Behavior Health Admission Information Form Name Date What symptoms are you experiencing? Depressed Mood Anxiety Agitation Hopelessness Suicidal Thoughts Worthlessness Guilt Anger Difficulty Concentrating
Please answer each of the questions below. The information you share will help the Registered Dietitian have a better understanding of your needs.
- 1 - Please answer each of the questions below. The information you share will help the Registered Dietitian have a better understanding of your needs. Patient Name: D.O.B: Address: Phone Number: Alternate
On at am/pm for an individual appointment a group appointment at the following location:.
501 New Karner Road, Suite 1A Albany, NY 12205 (518) 452-1337 Option 1 www.capcare.com Hello and Welcome to the CapitalCare Medical Group Nutrition and Diabetes Program. Living with diabetes requires dedicated
Client Intake Form. General Information. Telephone Home: Work: Cell: How would you prefer to be contacted? Emergency Contact: Ph:
General Information Name: Telephone Home: Work: Cell: Mailing Address: Client Intake Form Date: Email: How would you prefer to be contacted? Who referred you? Gender: M F Date of Birth: Primary Doctor: