I have read and understand this document related to acupuncture and other services to be provided by the employees of TCM Whole Health Inc.
|
|
|
- Gabriella Bennett
- 6 years ago
- Views:
Transcription
1 Colorado Mandatory Disclosure Statement TCM Whole Health, Inc th St. suite B Acupuncture Associates of Castle Rock Castle Rock, CO Education and Experience Rebecca Wilson earned her Master of Science Degree in Traditional Chinese Medicine from Colorado School of Traditional Chinese Medicine in August This intensive 3 year program consists of 2,850 hours total including 795 hours of clinical experience. Rebecca is certi ied as a Diplomate in Acupuncture by the National Certi ication Commission for Acupuncture and Oriental Medicine in fall of This includes certi ication in Clean Needle Technique. She is licensed to practice acupuncture in the state of Colorado. Her license number is: Rebecca also received a Bachelor of Arts degree from Fort Lewis College in 1995.Rebecca is a licensed acupuncturist in the state of Colorado and has always been in good standing. Mei Lie Benink earned her Master of Science Degree in Oriental Medicine from Southwest Acupuncture College in Mei Lie is certi ied as a Diplomate in Oriental Medicine by the National Certi ication Commission for Acupuncture and Oriental Medicine in This includes certi ication in Clean Needle Technique. She is licensed to practice in the state of Colorado. Her license number is: 286. Rebecca s and Mei Lie s training includes adjunctive therapies such as Chinese herbs, moxibustion, tui na, gua sha, cupping, auriculotherapy and dietary and lifestyle recommendations. This clinic complies with the rules and regulations promulgated by the Colorado Department of Health, including the use of single-use, disposable, sterilized needles and the sanitation of acupuncture of ices. Fee Schedule: Initial Consultation and Treatment $150 + cost of herbs Follow-up Treatment $115 + cost of herbs Late Cancelation (24-hour notice required) $50 Tibetan Herbal Foot Soaks $30 Heart Sound Recording Assessment (HSR) $100 Acugraph Energy Assessment $75 Both HSR & Acugraph Assessment $150 Patient s Rights The patient is entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known. The patient may seek a second opinion from another healthcare professional or may terminate therapy at any time. In a professional relationship, sexual intimacy is never appropriate and should be reported to the Director of the Division of Registrations in the Department of Regulatory Agencies. The practice of acupuncture is regulated by the Director of Registrations, Colorado Department of Regulatory Agencies. If you have comments, questions, or complaints, contact the Acupuncturists Registration Of ice, 1560 Broadway, Suite 1350, Denver, Colorado Telephone (303) I have read and understand this document related to acupuncture and other services to be provided by the employees of TCM Whole Health Inc. Patient or Guardian s Signature Date
2 Consent to Receive Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist representing TCM Whole Health, Inc. DBA Acupuncture Associates of Castle Rock. I understand that acupuncturists practicing in the state of Colorado are not primary care providers and that regular primary care by a licensed physician is an important choice that is strongly recommended by this clinic s practitioners. Acupuncture: I understand that acupuncture is performed by the insertion of needles through the skin at certain points on or near the surface of the body in an attempt to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body s physiological functions. I am aware that certain adverse side effects may result. These could include, but are not limited to: local bruising, minor bleeding, fainting, pain or discomfort, and the possible aggravation of symptoms existing prior to acupuncture treatment. I understand that no guarantees concerning its use and effects are given to me and that I am free to stop acupuncture treatment at any time. Chinese Herbs: I understand that substances from the Oriental Materia Medica may be recommended to me to treat bodily dysfunction or diseases, to modify or prevent pain perception, and to normalize the body s physiological functions. I understand that I am not required to take these substances but must follow the directions for administration and dosage if I do decide to take them. I am aware that certain adverse side effect may result from taking these substances. These could include, but are not limited to: changes in bowel movement, abdominal pain or discomfort, and the possible aggravation of symptoms existing prior to herbal treatment. Should I experience any problems, which I associate with these substances, I should suspend taking them and call TCM Whole Health, Inc. as soon as possible. Acupressure/Cupping/Gua Sha/Tui-Na Massage: I understand that I may also be given adjunctive treatments as part of my treatment to modify or prevent pain perception and to normalize the body s physiological functions. I am aware that certain adverse side effects may result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too uncomfortable. Electro-Acupuncture: I understand that I may be asked to have electro-acupuncture administered with the acupuncture. I am aware that certain adverse side effects may result. These may include, but are not limited to: mild electrical shock, pain or discomfort, and the possible aggravation of symptoms existing prior to treatment. I understand that I may refuse this treatment. I understand that there may be other treatment alternatives, including treatment offered by a licensed physician. I have carefully read and understand all of the above information and am fully aware of what I am signing. I understand that I may ask my practitioner for a more detailed explanation. I give my permission and consent to treatment. Signature: Date: Printed Name: Date of Birth: Address: City: State: Zip Code: Phone:
3 TCM Whole Health, Inc. DBA Acupuncture Associates of Castle Rock CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME BIRTHDATE I understand that as part of my healthcare, TCM Whole Health, Inc. originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care of treatment. I understand that this information serves as: A basis for planning my care and treatment. A means of communication among the many healthcare professionals who contribute to my care. A source of information for applying my diagnosis and surgical information to my bill. A means by which a third-party payer can verify that services billed were actually provided. A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals. I understand that I have the right: To object to the use of my health information for directory purposes. To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested. To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereupon. I request the following restrictions to the use of disclosure of my health information: Patient: X Patient Signature or Legal Representative Date Witness Signature Office Use Only: Accepted Denied Signature Title Date
4 Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Emergency Contact Name: Phone #: Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Print all information and indicate areas of confusion with a question mark. Thank you. 1. Who is your primary care physician? 2. Would you recommend them? 3. Other healthcare practitioners on your team (massage, chiro, specialists): 4. Please identify the health concerns that have brought you to TCM Whole Health in order of importance below: Condition A. Past Treatment How does this condition affect you? B. How does this condition affect you? C. How does this condition affect you? D. How does this condition affect you? How committed are you to improving your health? (circle one) a) I m thinking about it c) I have a new routine b) I ve started to make changes d) This is my last resort 1
5 If applicable, please list any foods, drugs, or medications you are hypersensitive or allergic to (please include reaction): 5. Please list any medications (prescribed and over-the-counter), vitamins, and supplements you are currently taking: 5. Do you have any reason to believe you may be pregnant? Y N If so, how far along are you? 6. Do you have any infectious diseases? Y N If yes, please identify: 7. Height: 8. Weight: Currently: 9. Blood Pressure: What is your most recent blood pressure reading? / When was this reading taken? 10. Hospitalizations and Surgeries: Reason When Reason When 11. X-Rays/CAT Scans/MRI s/nmr s/special Studies: Reason When Reason When 12. Emotional (please circle any that you experience now and underline any that you have experienced in the past): Mood Swings Anxiety Stress Depression 13. Energy and Immunity (please circle any that you experience now and underline any that you have experienced in the past): Fatigue Slow Wound Healing Chronic Infections Chronic Fatigue Syndrome 2
6 14. Head, Eye, Ear, Nose, and Throat (please circle any that you experience now and underline any that you have experienced in the past): Impaired Vision Eye Pain/Strain Glaucoma Glasses/Contacts Tearing/Dryness Impaired Hearing Ear Ringing Earaches Headaches Sinus Problems Nose Bleeds Frequent Sore Throats Teeth Grinding TMJ/Jaw Problems Hay Fever 15. Respiratory (please circle any that you experience now and underline any that you have experienced in the past): Pneumonia Frequent Common Colds Difficulty Breathing Emphysema Persistent Cough Pleurisy Asthma Tuberculosis Shortness of Breath Other Respiratory Problems: 16. Cardiovascular (please circle any that you experience now and underline any that you have experienced in the past): Heart Disease Chest Pain Swelling of Ankles High Blood Pressure Palpitations/Fluttering Stroke Heart Murmurs Rheumatic Fever Varicose Veins 17. Gastrointestinal (please circle any that you experience now and underline any that you have experienced in the past): Ulcers Changes in Appetite Nausea/Vomiting Epigastric Pain Passing Gas Heartburn Belching Gall Bladder Disease Liver Disease Hepatitis B or C Hemorrhoids Abdominal Pain 18. Genito-Urinary Tract (please circle any that you experience now and underline any that you have experienced in the past): Kidney Disease Painful Urination Frequent UTI Frequent Urination Heavy Flow Kidney Stones Impaired Urination Blood in Urine Frequent Urination at Night 19. Female Reproductive/Breasts (please circle any that you experience now and underline any that you have experienced in the past): Irregular Cycles Breast Lumps/Tenderness Nipple Discharge Heavy Flow Vaginal Discharge Premenstrual Problems Clotting Bleeding Between Cycles Menopausal Symptoms Difficulty Conceiving Painful Periods 20. Menstrual/Birthing History: 1. Age of First Menses: 4. Birth Control Type: 7. Age of Menopause: 2. # of Days of Menses: 5. # of Miscarriages: 3. Length of Cycle: 6. # of Live Births: 21. Male Reproductive (please circle any that you experience now and underline any that you have experienced in the past): Sexual Difficulties Prostrate Problems Testicular Pain/Swelling Penile Discharge 22. Musculoskeletal (please circle any that you experience now and underline any that you have experienced in the past): Neck/Shoulder Pain Muscle Spasms/Cramps Arm Pain Upper Back Pain Mid Back Pain Low Back Pain Leg Pain Joint Pain (if so, where?): 3
7 23. Neurologic (please circle any that you experience now and underline any that you have experienced in the past): Vertigo/Dizziness Paralysis Numbness/Tingling Loss of Balance Seizures/Epilepsy 24. Endocrine (please circle any that you experience now and underline any that you have experienced in the past): Hypothyroid Hypoglycemia Hyperthyroid Diabetes Night Sweats Feeling Hot or Cold 25. Other (please circle any that you experience now and underline any that you have experienced in the past): Anemia Cancer Rashes Eczema/Hives Cold Hands/Feet Is there anything else we should know? 26. Lifestyle: a. Do you typically eat at least three meals per day? Y N If no, how many? b. Exercise routine: _ c. Spiritual practice: d. How many hours per night do you sleep? Do you wake rested? Y N e. Level of education completed: High School Bachelors Masters Doctorate Other f. Occupation: Employer: Hours/Week: Do you enjoy work? Y/N Why/Why not? g. Nicotine/Alcohol/Caffeine Use: h. Have you experienced any major traumas? Y N Explain: i. How many ounces of water do you drink per day? j. Television habits: Reading habits: k. Interests and hobbies: _ How did you hear about us? address: Would you like to receive our newsletter? 4
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
55 S. Main Street, Driggs, ID (208)
Elements of Health 55 S. Main Street, Driggs, ID 83422 (208) 920-0312 Name: (first) (middle) (last) Date: / / Address: Phone: / street address city zipcode home / cell Date of Birth: / / Age: Gender: M/F
GOLDEN TAMARACK ACUPUNCTURE LLC Patient Health History
GOLDEN TAMARACK ACUPUNCTURE LLC Patient Health History Name: (first) (middle) (last) Today s Date: / / Address: Street City State Zip Home Phone: Cell Phone: Work Phone: Date of Birth: / / Age: Gender:
New Patient Demographics and Health History
New Patient Demographics and Health History Name: (first) (middle) (last) Date: / / Mailing Address: Apt/Unit: City: State: Zip: Home Phone: Cell Phone: Date of Birth: / / Email: May we email you treatment-related
Wisdom Ways Acupuncture
Wisdom Ways Acupuncture 363 W. Drake Suite 1, Fort Collins, CO 80526 Phone (970) 227-3077 Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status:
Ageless Acupuncture Patient Health History
Ageless Acupuncture Patient Health History Name: Date: By what name would you like us to refer to you?: Street Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell Phone: How early/late
WELCOME! Welcome again and thank you for joining us!
WELCOME! We are delighted that you have decided to join us for acupuncture! Here are a few things that we think it will be helpful for you to know: We provide community-style acupuncture. You will receive
Healing Harmony. Acupuncture & Pain Care
Dear New Patient, Welcome! Thank you so much for your interest in acupuncture and Oriental medicine. At Acupuncture & Pain Care I do my best in every way possible to assure that you receive the best quality
Patient Health History Questionnaire
Patient Health History Questionnaire Manitou Springs Acupuncture Randall Johnson, L.Ac., LLC Certified Seitai Shinpo Acupuncturist License Number: Acu-0002072 Phone: (719) 237-4547 Email: 719acupuncture@gmail.com
Patient Health History
Name: (first) (middle) (last) Patient Health History Home Phone: Cell Phone: Work Phone: Date: / / Email address: Please Contact me at: ( ) Home, ( ) Cell, ( ) Work Date of Birth: / / Age: Gender: M/F
Patient Health History. Name: Date: First Middle Last. Street Address: City: State: Zip Code:
STEPHEN D. SAEKS, PhD, LAc 2 Roads Crossing Healthcare, PC 15455 NW Greenbrier Parkway, Suite 240 Beaverton, Oregon 97006 8116 503 617 0450 Patient Health History Name: Date: First Middle Last Street Address:
Kimberly Anne Hoffman, L.Ac. (HIPAA) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME
Kimberly Anne Hoffman, L.Ac. (HIPAA) CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS NAME BIRTHDATE EMAIL PHONE I understand that as part of my
Acupuncture Patient Health History
Acupuncture Patient Health History Name: (first) (middle) (last) Today s Date: / / Date of Birth: / / Age: Gender/Preferred pronoun: Marital status (please circle one): Single Married Domestic Partnership
stoneburner acupuncture
STONEBURNER ACUPUNCTURE, LLC Erin K. Stoneburner, LAc, MAcOM 1135 SE Salmon St, Suite 211 503.784.1660 stoneburner@gmail.com Date: Name: (First) (Middle) (Last) DOB: _ Age: Sex: Address: City/State: ZIP:
Dr. Mark VanOtterloo DAOM - Licensed Acupuncturist
Please keep your healthcare practitioner aware of any changes to your personal information as soon as possible THANK YOU! Patient Info Printed Name: Address: DOB: / / Gender: Marital Status: S M D W Employer:
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
ACUPUNCTURE QUESTIONNAIRE
ACUPUNCTURE QUESTIONNAIRE CHIEF COMPLAINT: PAIN EVALUATION Pain Scale: no pain 0 1 2 3 4 5 6 7 8 9 10 severe pain 1 Mark each area where you are having pain according to the pain scale above. HISTORY HEALTH
Intake Form: Personal History
Intake Form: Personal History Name: Date: Age Birth date Sex Address City State Zip Phone (home) (work)_ (cell) E-mail Occupation Full-time/Part-time Retired Employed by Education In your opinion, what
Average Daily Diet: Morning Afternoon Evening
Average Daily Diet: Morning Afternoon Evening Habits: Cigarettes Coffee Tea Cola Alcohol Drugs Sugar Salt Other Family Medical History: Diabetes Cancer High Blood Pressure Heart Disease Stroke Seizure
Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
Consent for Treatment Form
Consent for Treatment Form By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the Oriental Materia Medica by a licensed acupuncturist at Nourish: Healing
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
Blake Acupuncture & Herbal Medicine 16 Bradlee Road Medford, MA
Please complete this Health History Form. You may email it back to the clinic (LBlakeLac@gmail.com) or print it out and bring it with you to your appointment. Thank You. Name: Date: Address: Phone (day):
Weight Loss Intake Form
Aleksandr Benji FNP 98-71 Queens Blvd, Rego Park NY 11374 646-301-4000 Weight Loss Intake Form Name: Date of Birth ALLERGIES (Please list any food, drug, or medication hypersensitivities or allergies you
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
PEDIATRIC INTAKE. Child s Name: Date: Name of Parent(s)/Legal Guardians: Relationship to child: Address: City: State: Zip Code:
PEDIATRIC INTAKE I appreciate your willingness to fill out this form as completely as possible. It is invaluable information for developing a treatment plan tailored to your child s individual needs. General
New Patient Medical History Intake Form
New Patient Medical History Intake Form Name: Todays Date: / / Date of Birth: / / Age: Gender: M / F Marital Status: S M D W Address: City: State: Zip Code Primary Ph.# (cell, hm, wk) Email Address 2nd
Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212
Initial Intake Form: Berkeley Community Acupuncture 4022 Tennyson St. Denver, Co 80212 ( 3 0 3 ) 3 5 1-1 2 2 8 Name: Phone: Address: City: State: Zip: E-mail: Would you like to be added to our E-Mail newsletter
Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:
Personal &Work Information Date: Patient Name: Age: Birth Date: / / Preferred Name: Gender: Home Phone: Address: Mobile Phone: City: State: Zip: Occupation: Employer: Work Phone: Email: Emergency Contact:
New Patient Intake Form
New Patient Intake Form Name: Address: Date: Birth Date: / / City: State: Zip SS#: - - Male Female Single Married Divorced Widowed I give The Center for Spine, Sport and Physical Medicine permission to
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):
Health Intake Form Name: Prefer Name: Date: Address: Age: City: State: Zip Code: Gender: M F Telephone # (home): (work): (Cell): Email Address: Date of Birth: Marital Status: Married Separated Divorced
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA 98136 206.200.3595 Today s date Name Legal name (if different) Phone (primary) (secondary) Address City State Zip Email
New Patient Intake Form
501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
WELCOME. Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally.
WELCOME Thank you for your interest in acupuncture and Oriental medicine. Our goal is to help you achieve your best health and wellness naturally. Before your Visit: You should eat a light meal or snack
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Personal Information Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female
Patient Health History Form
Thomas S. Burgoon, M.D. West Chester, PA 19382 Patient Health History Form Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient
Acupuncture & Herbal Therapies
Acupuncture & Herbal Therapies 2520 Central Ave. St. Petersburg, FL 33712 (Phone) 727-551-0857 (fax) 727-202-6896 Last Name: First Name: Male/Female: Date of Birth: Address: City: State: Zip: Home Phone#:
Laughing Buddha Community Acupuncture, LLC
Laughing Buddha Community Acupuncture, LLC 970.309.9253 www.laughingbuddha-acupuncture.com Dear New Patient, Welcome! Thank you for your interest in acupuncture and Oriental medicine. At Laughing Buddha
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
PATIENT INFORMATION Please print clearly and complete all blanks
PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX: NAME: LAST FIRST MIDDLE BIRTHDATE: MAILING ADDRESS: CITY STATE ZIP TELEPHONE: CELL PHONE: WORK NUMBER: SS # MARITAL
Good Point Acupuncture Patient Health History
Good Point Acupuncture Patient Health History Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient physically, mentally and
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
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.
Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION
Page1 PERSONAL INFORMATION Last Name First Nickname Middlle Initial Prefix Generation Sex DOB SSN Marital Status Height Weight Address City State Zip Phone (Home) (Work) (Cell) Email Occupation Employer
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
Health History Questionnaire Date: / /.
Health History Questionnaire : / /. Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Cell Phone: Email: of Birth: Place of Birth: Height : Weight: Employer: Relationship Status: Occupation:
TEMPE COMMUNITY ACUPUNCTURE (480)
TEMPE COMMUNITY ACUPUNCTURE (480)269 0415 WWW.TEMPEACU.COM HEIDI@TEMPEACU.COM Welcome to Tempe Community Acupuncture! TCA is one of many community acupuncture clinics established in the country who are
SOUTHSIDE COMMUNITY ACUPUNCTURE, LLC. Financial Policies
Disclosure of Information - Please Read the Following Carefully How to Prepare for Your First Visit : Plan on showing up a 15 minutes early to your first appointment and please wear, or bring with you
New Patient Information
Kairos Acupuncture, Chinese Herbs, & Bodywork LLC 262-323-9022 kairosacupuncture@hotmail.com acupuncturewestbend.com New Patient Information Name Today s Date Street Address Apt. City State Zip Preferred
Rockwood Natural Medicine Clinic
Rockwood Natural Medicine Clinic 9755 N. 90 th St., Suite A-210 Scottsdale, Arizona 85258 480-767-7119 Date: Name: Age: Sex: M F Are you: Married Separated Divorced Widowed Single How did you hear about
Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT
Patient Information Name Date Home Address City State Zip Phone E-mail Address Cell Phone: Business Address City State Zip Phone Occupation Place of Birth Date of Birth Age Height Weight Soc. Sec. # Sex
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
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
Chinese Medicine Adult Intake Form. Name (Last, First): Home address: Phone: Emergency contact name & phone number: Relationship Status:
Chinese Medicine Adult Intake Form Name (Last, First): Date of Birth: Occupation: Hours per week: Home address: Phone: Email: Preferred contact method (circle one): Phone / Email Emergency contact name
Laser Vein Center Thomas Wright MD Page 1 of 4
Demographics Laser Vein Center Thomas Wright MD Page 1 of 4 Patient Name: Address: City, St, Zip Primary Phone: Alternate: DOB: Social Security #: Insurance Information Primary Insurance ID# Group# Subscriber
PATIENT INFORMATION. Emergency Contact Name Relationship. Kalin Davidov, L. Ac., M.S.TCM. Marital Status Phone (cell) Address City State Zip
Kalin Davidov, L. Ac., M.S.TCM PATIENT INFORMATION Patient Name Date of Birth / / SSN Male Female Height Weight Marital Status Phone (cell) Address City State Zip E-mail Phone (home) Occupation Phone (work)
Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.-
Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.- INFORMED CONSENT Acupuncture involves the insertion of special needles into particular
Chiropractic Patient Admittance Form
Chiropractic Patient Admittance Form PERSONAL INFORMATION Last Name: Given Name: Initial: Address: City/Province: Postal Code: Home Phone: Work Phone: Cell: E-mail Address: Date of Birth (D/MM/YYYY): Male
Avery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below.
CHIEF COMPLAINT(S) Please mark area(s) of injury or discomfort on the diagrams below. Please describe your current primary complaint? Difficulty in: Standing, Sitting, Bending, Walking, Reaching Cannot
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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:
Naturopathic New Patient Form
611 Main St., Suite A Edmonds, WA 98020 Naturopathic New Patient Form Patient Name: Date of Birth: / / Age: Gender: Address: City: State: Zip: Primary Phone -! Email: Marital Status: Emergency Contact:!!!!
Acupuncture Intake Form
Acupuncture Intake Form Name Age Birth Address City Postal Code Phone (home) (cell) OK to leave a message? Y/N Email address Occupation Employer Marital Status: Single / Married / Com Law / Divorced /
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
New Patient Intake Form
New Patient Intake Form Thank you for your interest pursuing health at the Riordan Clinic. As Co-learners you will work with the doctors and staff to understand your whole health picture; therefore, we
Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
New Patient Intake Bridges Family Wellness Intake Form Full Name: * What is your birthdate? MM/DD/YYYY * What is your gender identity? * Home address: * Cell Phone * Other Phone number(s): Emergency Contact
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK
HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Address: City: Contact: State: Zip: Home Phone: Email: Work: Cell: Date of Birth: SSN#: Age: Gender: I am: q Married q In a Partnership q Separated q Divorced q Widowed q Single
New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )
New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
New You Acupuncture Wellness Center Oriental Medicine - Acupuncture - Herbs - Homeopathy
Patient Contact Information Form Your privacy is being protected per HIPPA guidelines. No information will be given out without your expressed consent. Please indicate any of the following methods of communication
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM Full Name: Date of Birth: Marital Status: Gender (circle one): Female Male Home Address: City: State: Zip: Email Address: May we send you promotions to the above e-mail address?
WELCOME TO THE MILLER CHIROPRACTIC CLINIC
WELCOME TO THE MILLER CHIROPRACTIC CLINIC We are pleased that you have chosen to consult us regarding your health. In order to help us evaluate your condition thoroughly, please complete the following
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
Dr Chu Acupuncture Clinic 1615 Maxwell Dr. Suite D. Hudson, WI Patient Notes
Dr Chu Acupuncture Clinic 1615 Maxwell Dr. Suite D. Hudson, WI 54016 Patient Notes Patient Gender F M DOB Name Address Phone Work: Home: Cell: Email Chief Complaint How long has it been: Secondary complaint
Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F
Patient Information Camas Acupuncture & Nutrition General Information Name: Date: Address: City: State: Zip Code: Phone (H): (W): Cell: Email: Appt reminders via text? Y N via email? Y N Date of Birth:
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:
Health History Questionnaire
Health History Questionnaire Name: Gender: M F Age: Address: City: State: Zip Code: Home Phone: Mobile Phone: Email: Date of Birth: Place of Birth: Height: Weight: Relationship Status: Employer: Single
Name Today s Date Birth Date. Age Gender M / F Address City. Zip Cell/Home Phone:
Name _Today s Date Birth Date Age Gender M / F Address City State Zip Email: Cell/Home Phone: Work Phone: Can we leave detailed message: Cell: yes / no Email: yes /no Work: yes /no Place of Employment
AHI - New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
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
1. Have you ever had or now have: 2. Have you ever had or now have:
1. Have you ever had or now have: 2. Have you ever had or now have: Yes No Please Check each item no blanks CARDIOVASCULAR Yes No Often Seldom 1. Chronic or frequent colds 1. Shortness of breath with normal
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -
ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security : - - Home Address: City, State, Zip: Home Phone: ( ) Work Phone:
DEAN S CHIROPRACTIC CENTER
PATIENT INFORMATION Welcome to Our Office Patient Name of Birth SS# Address City ST Zip Home Phone Cell Work Phone Male Female Email Address Single Married Divorced Widowed Employer Name Occupation Spouse
White Lily Acupuncture th St W Lakeville, MN (952)
White Lily Acupuncture 10591 165 th St W Lakeville, MN 55044 (952) 892-5511 Notice of Privacy Policy White Lily Acupuncture is committed to providing exceptional care including the protection of your privacy
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY
CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY REGISTRATION PAGE Date: Name: Tel: 510-526-5256 (Albany) 415-334-1010 (San Francisco) Fax: 510-526-5547 christopherbrowndo@gmail.com DOB: Age: Sex: Address:
Greg Garcia ND, LAc S.W. Watson Ave., Beaverton OR ~ Office: ~ Office Fax: ~
Greg Garcia ND, LAc 4720 S.W. Watson Ave., Beaverton OR 97005 ~ Office: 503.526.0397 ~ Office Fax: 503.643.4633 ~ www.drgreggarcia.com Patient Intake Form Name: Date Address: City: State: Zip Code: Phone
New Patient Information
Personal Information Last Name First Name Middle Initial Address: Street Unit # City Province Postal Code Date of Birth (Day/Month/Year) Home Phone # Work Phone # Cell Phone # May the clinic leave you
Healthworks Nutrition Centre. Naturopathic Medical Questionnaire. Name Date of First Visit. Address. Province Postal Code. Telephone # (home) (work)
Healthworks Nutrition Centre Naturopathic Medical Questionnaire PERSONAL INFORMATION Name Date of First Visit Blood type # of Children Address City Province Postal Code Telephone # (home) (work) E-mail
KEY TO LIFE CHIROPRACTIC
KEY TO LIFE CHIROPRACTIC REGISTRATION FORM Date Home Phone Cell Phone Email Last Name First Name Middle Initial Street Address City State Zip Sex M F Birth Date Occupation How did you hear about this office?
HEALTH INFORMATION FORM
#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
www.monctonnaturopathic.com 12 Fifth Street, Moncton, NB, E1E 3G9 Ph: 506-382-1329 Fax: 506-382-1828 Pediatric Intake Form (6-12 years) Name: Date: Age: Date of Birth: / / Gender (circle one): female or
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): address: Occupation: Who referred you/how did you hear about us?
Name: Date of birth: Address: City: State: Zip: Phone: (day) (evening): (cell): Email address: Occupation: Who referred you/how did you hear about us? Your primary health care provider: Phone: Emergency
CHIROPRACTIC INTAKE FORM
3885 Duke of York Blvd., Suite C211, Mississauga, ON L5B0E4 T: (905)276-6800 F: (905)276-6802 www.naturawellnessclinic.com CHIROPRACTIC INTAKE FORM DATE: PATIENT INFORMATION Name Sex: M/F Age Date of Birth
ND DSOM LAc CNS PREFERRD NAME: LEGAL NAME: PRONOUNS: GENDER: GENDER DESIGNATED AT BIRTH: DATE OF BIRTH:
PREFERRD NAME: LEGAL NAME: PRONOUNS: GENDER: GENDER DESIGNATED AT BIRTH: DATE OF BIRTH: ADDRESS: CITY, STATE, ZIP: PHONE NUMBER: PERMISSION TO LEAVE MESSAGE ON VOICEMAIL: Y N EMAIL: PERMISSION TO COMMUNICATE
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Naturopathic & Acupuncture Intake Form (Age 14+)
Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair, B.Sc., ND 86 Norfolk St., Guelph 519-827-0040 Contact Information Naturopathic & Acupuncture Intake Form (Age 14+) Name: Gender: Age: Birth Date (dd/mm/yy):