Waverly Wellness House Donna Florimonte R.N.
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1 Waverly Wellness House Donna Florimonte R.N Lily Lake Road PO Box 255 Waverly, PA Phone: (570) Date: Have you ever been here before? Yes No Date of Birth: Age: Home phone: ( ) Name: Cell phone: ( ) Street Address: City, State, ZIP: Occupation: Business Phone: ( ) Male / Female Height Weight Referred By: Do you have a pacemaker? Yes No Do you have uncontrolled hypertension? Yes No Have you ever had any of the following: Far Infra-Red Sauna treatments Massage Manual / Electro-Lymphatic treatments Colon Hydro Therapy Reflexology Essential Oils Chiropractic Care Muscle Testing Neuro Emotional Technique Colon Hydro Therapy only I,, have been informed and fully understand that Colon Hydro Therapy Colonics has been presented to me as a hygienic method of cleansing the colon. Colonic has NOT been presented to me as a treatment or cure for any illness or specific disease, or with any guarantee to heal any disease. Whether or not I participate in this program is my decision, which I have chosen as a positive action for my personal preventative health care. Everyone should take a good replenishment of acidophilus culture. I recommend taking this culture regardless if you have been on colonic treatments or not. However, it is strongly recommended it to be taken after the colonic treatments. *** WE ARE NOT PRACTICING MEDICINE, BUT WE ARE A SERVICE TO YOUR DOCTOR. *** Signature: Date: Page 1 of 5 Revised 01/11/16
2 Name: Date: IF YOU EXPERIENCE ANY OF THE FOLLOWING, PLEASE CHECK: Arthritis Asthma Colitis Diabetes Diverticulitis Ulcers Kidney Problems Fatigue High Blood Pressure Hemorrhoids Constipation Water Restriction Bad Breath Headaches Indigestion Other Allergies Cancer/type Surgeries/explain DO YOU USE ANY OF THE FOLLOWING: Alcohol drinks / week Tobacco packs/day OTC Medications Prescriptions: Are you under a doctor s care/explain: Doctor s name/phone number TYPICAL DAY FOR FOOD including drinks What do you usually eat for: Breakfast: Lunch: Dinner: Do you experience digestive distress before, during or after you eat a meal?...yes No If so, is this related to a particular type of food?...yes No If so, what type: Do you feel that your current weight is a problem?...yes No Do you feel that you have a problem with food?...yes No Page 2 of 5 Revised 01/11/16
3 Name: Date: DIET AND NUTRITION How often do you use the following? (1-Daily, 2-Weekly, 3-Occasionally, 4-Never) Red Meat Fruits/Veggies Fast Foods Refined Sugar White Flour Fried Foods Dairy Foods Soda Alcohol Snack Foods Salted Foods Nutrasweet Coffee Cups day Tea Cups day Tobacco Amount How much water do you drink per day in ounces? What kind of water do you drink? List any Nutritional Supplements (with amounts) you are now taking: FOOD CHOICES Do you use organic foods whenever possible? Yes No Are you a vegetarian? Yes No Do you eat meat, i.e. beef, chicken, lamb, etc. Yes No Do you buy hormone/antibiotic free meats? Yes No Do you drink milk? Yes No Circle all that apply to your Dairy Consumption: Raw Pasteurized Organic Goat Dairy Circle products that you consume: Soy milk Rice milk Almond milk Hemp milk Other: Do you eat nuts or seeds? Yes No What Type? Do you use spices? Yes No Are they organic? Yes No Circle the type of spices that you consume: Fresh spices Dried Spices Jarred Spices Bulk Spices Organic Spices Do you PREFER to home cook your food or go out to a restaurant? Restaurants Home Do you eat more at restaurants or at home? Restaurants Home When you go to a restaurant, do you prefer menu style or buffet? Menu Buffet Would you like to learn how to prepare foods at low temperatures that are fresh and preserve enzymes? Yes No What types of bread do you eat? What types of pasta do you eat? GENERAL LIFESTYLE How much sleep do you get on average? hours per night Do you feel rested?...yes No How much exercise do you get? Exercise min per day days per week Type(s): Do you experience stress: in your relationships, at work, with finances, in health, with home, in trying to have fun, in being happy, other How often do your bowels eliminate? What is your energy like? Other current health concerns not previously mentioned: Page 3 of 5 Revised 01/11/16
4 Medical History Name: Please circle all that apply. Put a "P" next to the circle if it is a past medical condition. Also, please remember to note any medical condition not mentioned on this sheet under other. Date: Senses Sight Hearing Smell Taste Touch Skin Boils Fungal Infection (Athlete's Foot) Herpes Warts Eczema Hives Moles Psoriasis Respiratory System Bronchitis (490) Sinusitis (J32.9) Asthma (J45.998) Emphysema (J43.9) Allergies (995.3) Endocrine Ovarian Cyst (N83.0) Fibroids PCOS (E28.2) Ovaries Uterus PMS (N94.3) Menopause (Hypo)Thyroid (E03.9) Adrenals (E27.9) Testicles Prostatitis (N41.9) Other Infertility ( N46.9 / N97.9) Diabetes Type 1 (E10.9) Type 2 (E11.9) Hyperglycemia (R73.9) Hypoglycemia (E16.2) Immune Bacterial Viral Colds Flus Lyme's Disease (A69.20) Autoimmune Rheum Arthritis Epstein Barr (B27.90) Chronic Fatigue (R53.82) Musculoskeletal Osteopenia (M85.80) Arthralgia (719.4) Sprain/Strains Osteoporosis (M81.0) Carpal Tunnel (G56.00) Osteoarthritis (715.9) Whiplash (847.0) Herniated Disc (722.2) Neck Pain (M54.2) Low Back Pain (M54.5) Other Pain/Injury Nervous System Multiple Sclerosis Parkinson's Bell's Palsy Stroke Spinal Cord Injury HA 784.0) /Migraine (346) Numbness Tingling Idiopathic pain Digestion Indigestion (K31.9) Constipation (K59.00) Diarrhea (R19.7) Acid reflux (K21.9) Ulcers (K25.9) Hx Appendicitis (v12.79) IBS (K58.94) Ulcer. Colitis (K51.90) Hepatitis (573.3) Gallstones (574) Food Allergies (995.3): Gall Bl removed (051) Gall Bladder Dz (K82.9) Circulatory Blood Clot (I82.91) Anemia (D64.9) Cardiovascular Dz (I25.10) Atherosclerosis (I70.90) High (R03.0)/Low (I95.9) Blood Pressure Vericose Veins (I83.10) Heart Disease (I51.9) Heart Attack (412) Edema (R60.9) High Cholesterol (E78.0) Cancer Breast Ovarian Testicle Thyroid Lung Blood Bone Colon Bladder Stress Chronic Stress (F33.9) Acute Stress Rxn (F43.0) State of Stress & Shock (R45.7) Anxiety (F41.1) Depression 1 (F32.0) Lack of Sleep (G47.9) Phobias (F40.9) Nightmares (F51.5) Viamin / Mineral Deficiency Dehydration (86.0) Hypervitaminosis (T45.2X4A) A (E50.9) B1 Thiamine (E51.9) B2 Riboflavin (E53.0) B3 Niacin (E53.9) B5 Panthenic Acid (E53.9) B6 (E53.1) B9 Folic Acid (E53.9) B11 Biotin (E53.9) B12 (E53.9) C (E54) D (E55.9) E (2E56.0) Fatty Acid Ox. Dis (E63.0) K (E56.1) Unspecified (E63.9) OTHER:
5 Waverly Wellness House Donna Florimonte R.N. 102 Lily Lake Road PO Box 255 Waverly, PA Phone: (570) ATTENDANCE POLICY RETURNED CHECK FEE POLICY Waverly Wellness House (WWH) is in the business of treating clients who require cleansing and detoxification of their bodies. WWH cannot help you or someone else if you do not show for or cancel your appointment without advanced notice. Therefore, by signing below, you agree to provide 24 hours advance notice in the event the appointment(s) have to be canceled or changed. If I, the undersigned, do not show up for the appointment, or provide sufficient notification, I agree to pay the full charge for the service, not just for the inconvenience it has caused, but also the loss of income to our therapist who comes in for your appointment. Appointments cancelled less than 24 hours in advance will be charged 50% of the cost of the service. WWH understands that in certain incidences, this is not possible because of emergencies and therefore the charges may be waived at the discretion of management. Waverly Wellness House accepts cash, credit cards and personal checks for services provided and products purchased. In the event that your personal check is returned by your bank unpaid, you will be assessed a $ returned check fee. Client Date Witness Date Page 5 of 5 Revised 01/11/16
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Today s Date: / / Welcome to Arena Chiropractic! Your Health History is important to us. Please follow the instructions throughout the form and provide us with as much information about yourself as possible.
Primary (First) Complaint and Location
Name: : File #: Case Type: Sex: Birth : Age: Social Security #: Address: Residence and Mailing City State Zip Code Home Phone: Mobile Phone: Email: Occupation: Employer: Work Phone: Marital Status: S M
ABOUT YOU CHIROPRACTIC EXPERIENCE REASON FOR THIS VISIT ABOUT YOUR SPOUSE HEALTH HABITS
NAME: ABOUT YOU WHO REFERRED YOU TO OUR OFFICE? CHIROPRACTIC EXPERIENCE ADDRESS: CITY: HOME PHONE: STATE/ZIP CODE: CELL PHONE: How did you hear about our office? NEWSPAPER SIGN YELLOW PAGES COMMUNITY EVENT
HEALTH HISTORY/INTAKE
HEALTH HISTORY/INTAKE Name: Birthdate: Date: / / Address City, State, Zip Email: Phone (day): (evening): Billing address, if different: Best time to call: Preferred form of communication: Weight: Height:
PATIENT REGISTRATION
PATIENT REGISTRATION Last Name First Name MI Street Address City State Zip Code Social Security # - - Email Address Home Phone( ) Cell Phone( ) Sex Male Female of Birth Age Marital Status Married Single
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
ABA Chiropractic Holistic Health Center Nutritional Assessment
ABA Chiropractic Holistic Health Center Nutritional Assessment Name: DOB: Age: Social Security # Marital Status: M D S W Employer Occupation: Address: City: Zip: Phone: Alternate phone: Today s date: Emergency
JOHN MICHAEL ROACH, MD
GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy:
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
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy
Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy Patient Number: Date of First Visit: Last Name: First Name: MI: Address: City: State: Zip Code: Email address: Phone: H
Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL:
Patient Intake Form LEGAL NAME: LAST FIRST MI I PREFER TO BE ADDRESSED AS BIRTHDATE: AGE: SEX: F M ALLERGIES TO MEDICATIONS: ADDRESS: CITY: STATE: ZIP: HOME PHONE: WORK: CELL: MAY WE LEAVE A MESSAGE? YES
INSURANCE AND MANAGED CARE APPOINTMENT CANCELING POLICY
The physicians and staff of New England Dermatology & Laser Center value and appreciate your selection of our office for your skin care. We are committed to providing you with the best possible service.
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY Tel # PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A
Raymond G. Cavaliere, DPM 201 East 28 th St., Suite 1A New York, NY 10016 Tel # 212-481-0064 PLEASE FILL FORM OUT COMPLETELY, IF NEEDED USE N/A Last Name First Name Age Date Of Birth Sex Marital Status
Adult Health History Summary
Adult Health History Summary Name Age Date of Birth Address City Province Postal Code Phone (home) (cell) Occupation Email May we contact you via email? YES NO Emergency Contact Phone # How did you hear
Ea Medical Weight Loss Services Solutions for permanent weight loss PATIENT HISTORY. When did you first become overweight? (Your age then) or Year
PATIENT HISTORY Name: Age: Date: When did you first become overweight? (Your age then) or Year How did your weight gain start? Describe any circumstances: What do you think is the cause of your weight