Shirley Gutkowski, RDH, BSDH. Primary OMT Practitioner and Breathing Re-training Instructor 1266 W. Main Street Sun Prairie, WI
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- Sybil Eaton
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1 , RDH, BSDH Primary OMT Practitioner and Breathing Re-training Instructor Street Name Date of Birth Guardian Address Phone Home Referred by Insurance Carrier Patient SS number Insurance garniture SS Member ID Group # Office Only
2 Authorization for Release of Information: This authorization or photocopy hereof, will authorize Shirley Gutkowski to obtain and furnish pertinent information regarding the condition of while under her observation or treatment. This information may be obtained from and/or released to: Dentist Address Orthodontist Address Chiropractor Address Physical Therapist Address Signature Date
3 Client s Full Name Sex M F If patient is a minor, 1st attending Parent/Guardian Name 2nd attending Parent/Guardian Name Age Occupation Contact (please, provide at least one) Phone (H) Phone (W) Phone (M) Med practitioner s name Med practitioner s phone Name/location of the clinic How did you hear about Primal Air? Internet search Books (specify) Friend / word of mouth Media (specify) Health Care provider Advertisement (specify) Primary reason for attending Asthma Other (specify) Approximately, for how long you are having this condition? Have you ever had the following: Heart disease Epilepsy High blood pressure Schizophrenia Low blood pressure Depression Diabetes Blood clots (thrombosis) Kidney disease Hypoglycemia Sickle cell anemia Over Active Thyroid Brain tumor Arterial aneurysm
4 Do you experience any of the following Breathlessness at rest Frequent colds /viral infections Heart region chest pain Rhinitis, blocked nose Irregular heartbeat, palpitations Tingling, numbing of the limbs Dizziness Muscle pain Frequent headaches Dry mouth Digestive problems PMS / Irregular periods Irritability, mood swings Frequent yawning, sighing Panic attacks taking deep breaths Food allergies Need to breathe through the mouth Respiratory allergies Skin allergies, rashes Insomnia Weight gain Fatigue Poor concentration, mental fatigue Vision deterioration ADD / ADHD Snoring Sleep apnea If female, are you currently pregnant? Y / N Do you smoke? Y / N How many hours a week do you exercise? Less than 1 hour 1-3 hours 3-5 hours 5-7 hours 7 or more hours regularly involved in athletics / sports
5 If Asthma is your primary reason for attending, please fill out this page Approximate age of asthma diagnosis What best describes your asthma Asthma symptoms you are having Mild, exercise induced Coughing Mild, allergic Wheezing Mild, continuous Breathlessness Moderate continuous Chest tightness Severe continuous Frequent cold/chest infections Number of hospitalizations during past 3 years What triggers your asthma symptoms or do you symptoms get worse after Exercise Sleeping Cold weather Big meals Pollen Laughing Dust mites Excessive talking Animal dander Stress Dairy food intake Cold/Chest infections Weather Airborne irritants (chemicals, pollutants, smoke etc ) Please, list asthma medication(s) and indicate dose you are currently taking
6 RELEASE OF CLAIMS Primal Air, LLC OMT and Breathing Retraining The course offered by Primal Air, LLC OMT and Breathing Retaining teaches the Buteyko Breathing Method through a program of lectures and training sessions. No part of this course constitutes medical treatment. Do not modify your current medical treatment or course of prescribed medications in any manner, or undertake this course with Primal Air, LLC OMT and Breathing Retaining before consulting with your health care provider. Acknowledgements and Representations. 1. I understand and acknowledge that the instructor teaching this course is teaching a particular method, and is not in any way diagnosing or treating any known condition that I may have. 2. I understand and acknowledge that the instructor teaching this course is not a medical practitioner or knowledgeable in prescribing medication. 3. I understand and acknowledge that this course is not medical treatment, nor is it a substitute for medical treatment or advice. 4. I understand and acknowledge that I should consult my health care provider before undertaking this course or practicing any part of the Buteyko Breathing Method. 5. I understand and acknowledge that I should consult my health care provider before modifying any current medical treatment or course of medication that may be prescribed to me before I undertake this course. If I modify my medication or treatment in any manner during or after this course without first consulting my health care provider I take full responsibility for that decision. 6. If, at any time during this course, I have any concerns about my health or well being, I agree to notify my course instructor immediately. I understand that I am free to leave the course at any time for any reason. If, during this course, or at any time after this course, I feel the need for any assistance, medical or otherwise, I take full responsibility for communicating this, as well as for seeking appropriate care, including leaving this course and obtaining such appropriate care. 7. I understand and acknowledge that Buteyko Clinic USA, LLC makes no guarantees or warranties as to any results of this course that I may experience.
7 Release In partial consideration for the knowledge provided by Primal Air, LLC OMT and Breathing Retaining in its course, I hereby voluntarily agree to release Buteyko Clinic USA, LLC and all instructors teaching the course offered by Primal Air, LLC OMT and Breathing Retaining from any and all claims that might arise by reason of illness, injury, or death resulting from my participation in the course offered by Primal Air, LLC OMT and Breathing Retaining so long as such illness, injury, or death is not caused by an intentional, willful, or wanton act. I assume full responsibility for the risk of illness, injury or death and hold Primal Air, LLC OMT and Breathing Retaining and all of its instructions harmless from any liability thereof. Moreover, if I have requested or registered my minor child to participate in any courses, then the provisions of this Release shall apply with equal force to such child. Dispute Resolution If I should have any claims against Primal Air, LLC OMT and Breathing Retaining in connection with the terms of this Release or otherwise, then I agree that Minnesota law shall govern and that the District Court for Hennepin County, Minnesota, shall have jurisdiction of the parties and the controversy. I also agree, should Primal Air, LLC OMT and Breathing Retaining so submit, to the submission of any such claims to binding arbitration in Dane County, WI under the rules of the American Arbitration Association, and agree that the award of the arbitrator in such case shall be binding any may be enforced by any court. Similarly, I agree that any claim I file in a court of law may be removed by Primal Air, LLC OMT and Breathing Retaining to arbitration and I shall not contest such removal. X Client Printed Name X Client Signature and Date X Shirley Gutkowski, RDH, BSDH, Breathing Reeduc...
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FEMALE SYMPTOM QUESTIONNAIRE CLIENT NAME: DATE: Please circle the appropriate number to indicate the frequency of the listed symptoms. Descriptions of terms are found on the back of this page. SYMPTOM
WOODLANDS FAMILY CHIROPRACTIC
We appreciate you choosing our office. Is there anyone we can thank for referring you? Please indicate the main reason you are seeing us today: IF you are seeing us for a PAIN related issue, USE THE SYMBOLS
LECOM Health Ophthalmology
Patient Name: Date of Birth: New Patient Questionnaire Your answers will be used by your healthcare provider get an accurate history of your medical conditions and ocular concerns. If you are uncomfortable
Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP
Shiatsu Intake Form DATE PURCHASED PRODUCT/SERVICE FIRST NAME LAST NAME Date of Birth Age Height Weight Home Address City State ZIP Home Phone Cell Phone Email Name of Emergency Contact Would you like
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
Initial Patient Intake Form
Initial Patient Intake Form Patient Registration Today s Date Patient Name (last) (first) (middle) Address (city) (state) (zip) Date of birth (mm/dd/yyyy) SSN # Current Gender Identity: Male Female Transgender
EYE ASSOCIATES OF MONMOUTH, LLC
EYE ASSOCIATES OF MONMOUTH, LLC In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible. This is very important information. Please
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's