Comprehensive Care. Dear Patient,
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1 Comprehensive Care Rheumatology Paul F. Howard, MD, FACP, FACR Nisha Manek, MD, MRCP Amanda Herron, PA-C Naturopathy & Acupuncture Leslie Axelrod, NMD, L.Ac. Keith Wilkinson, NMD Yoga Therapy Ginnie Livingston, RN, MSN, CYT Ellen Martinoni, CYI, RYT Kimberly Howard, CYT Sherry Petersen, CYT Dear Patient, Thank you for your interest in naturopathic care, prolotherapy, and the opportunity to work with you. Naturopathic medicine is an approach to care that provides an array of treatment options. However, more importantly, I believe naturopathic medicine offers a distinctly different way to thinking about health. Prolotherapy is one of these treatment options. The following pages are the start of our comprehensive discussion to learn about your musculo-skeletal condition. I appreciate your time to thoughtfully answer these questions. During the first visit we will review the history and complete a physical exam specific to your condition to determine if prolotherapy is appropriate for you. In order for me to prepare for this visit, I kindly request that this form and relevant radiology reports be mailed or faxed to Arthritis Health at least 3 days prior to your appointment. Additionally, if you have recent imaging (X-rays, MRI), please bring these to the visit. Thank you again for your interest in working with me. I look forward to meeting you. Sincerely, C. Keith Wilkinson, NMD Naturopathic Physician 9097 East Desert Cove, Suite 100 Scottsdale, Arizona Phone: Fax:
2 New Patient Form Prolotherapy Date: Patient Information Name: Address: City: State: Zip Code: Telephone # Home: Cell: Work: address: Age: DOB: Gender: M F Married Separated Divorced Widowed Single Partner Live With: Spouse Partner Parents Children Friends Alone Occupation: Hours per week: Retired/Not Working Employer: Additional Information Primary Care Physician: Phone #: Address: City: State: Zip: Emergency Contact: Relationship to You: Contact #: Referral Information How did you hear about Dr. Wilkinson? Were You Referred by a Physician? Y N If yes, could you provide us with information for the referring physician? Referring Physician s Name: Address: City: State: Zip: Telephone Number: Page 1 of 4
3 The following questions will help me understand your expectations. 1. Why did you choose to come to Arthritis Health? 2. What do you know about Prolotherapy? 3. What lifestyle habits do you currently engage in that you believe support your health? 4. What lifestyle habits do you currently engage in that you believe harm your health? Your Current Health Are you currently receiving medical care? Y If yes, where and from whom: N If no, when and where did you last receive medical care? What was the reason? What are your most important health problems? List in order of importance Do you have any known contagious diseases at this time? Y N If yes, what? Page 2 of 4
4 Musculo-Skeletal Conditions Describe your M/SK history with relevant details of injuries, duration, and treatments: Problem #1: Problem #2: Problem #3: Do You Have any of the Following? Headache Y N P Migraine Y N P Neck Pain Y N P TMJ Pain Y N P Hip Pain Y N P Sciatica Y N P Shoulder Pain Y N P Elbow Pain Y N P W rist Pain Y N P Thumb Pain Y N P Finger Pain Y N P Muscle Spasms Y N P Knee Pain Y N P Ankle Pain Y N P Foot Pain Y N P W eakness Y N P Stiffness Y N P Numbness Y N P Arthritis Y N P Leg Cramps Y N P Tremors Y N P Upper Back Pain Y N P Mid Back Pain Y N P Low Back Pain Y N P note - Y = Yes you have now N = Never had P = Past problem (significant) Circle any problem areas below. Page 3 of 4
5 Are you hypersensitive or allergic to: Any drugs? Any foods? Any substances in the environment or chemicals? Allergies Current Medications / Supplements Prescription Medications OTC Medications (i.e., Ibuprofen, antacids) Supplements Other/Additional Space General Current Height: / Weight: Weight 1 year ago: Maximum Weight: When: Ideal Weight: When: Do you have sufficient energy throughout day? Y N If not, when is energy best? Worst? Habits/Lifestyle Main interests and hobbies? Do you exercise? Y N, If yes, what kind/how often? Hours of sleep each night? Enjoy your work? Y N Sleep well? Y N Spend time outside? Y N Awake rested? Y N How many hours of TV per day? Do you need naps during day? Y N Do you drink coffee? Y N P If nap, how long/often? Do you drink sodas? Y N Been treated for drug dependence? Y N P If yes, quantity per day or week. Use alcoholic beverages? Y N P Do you have a sweet tooth? Y N P Treated for alcoholism? Y N P Do you use tobacco? Y N P How many years and packs/day? Thank you for completing this form. See you at Arthritis Health. Page 4 of 4
Comprehensive Care. Dear Patient,
Comprehensive Care Rheumatology Paul F. Howard, MD, FACP, FACR Nisha Manek, MD MRCP Amanda Herron, PA-C Naturopathy & Acupuncture Leslie Axelrod, NMD, L.Ac. Keith Wilkinson, NMD Yoga Therapy Ginnie Livingston,
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Welcome To Parkside Health & Wellness Center Contact Information Date:
Welcome To Parkside Health & Wellness Center Contact Information Date: First Name: Sex: M F Middle Init: Marital: Married Single Divorced Separated Last Name: Partnered Widowed Minor Address: Birth Date:
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Have you had labs (lipid profile & basic metabolic panel) done within 6-12 months? I don t know
What is the date of the information session you attended? Which Transformations location do you plan on attending? Savoy Monticello Have you had labs (lipid profile & basic metabolic panel) done within
APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC
Today s Date: APPLICATION FOR CARE AT OPTIMAL HEALTH CHIROPRACTIC PATIENT DEMOGRAPHICS Name: Birth Date: / / Age: Male Female Address: City: State: Zip: E-mail Address: Home Phone: Cell Phone: Martial
Patient Information. Name: Last First MI. Address: Street City State Zip
Date: WELCOME TO: Name: Address: Patient Information Last First MI Street City State Zip Phone # : (Mobile) (Home) (Work) Can we leave a voicemail or text message? Yes No Email: Date of Birth: Gender:
STANTON SCHIFFER, M.D. PATIENT INFORMATION. Patient s Name: Last First Middle Home Address: City : State : Zip: Home Phone : Cell Phone :
STANTON SCHIFFER, M.D. PATIENT INFORMATION Patient s Name: Last First Middle Home Address: City : State : Zip: Home Phone : Cell Phone : Work Phone # Fax # Date of Birth : Age: Sex: M F SS# Married : Single:
Dawn Smallwood, DC, NTP PATIENT INFORMATION
Dawn Smallwood, DC, NTP 120 East 1st Street Cle Elum, WA 98922 509.674.4448 CleElumchiropractic.com PATIENT INFORMATION Name: Date: (Last) (M.I.) (First) Sex: M F Marital status: (circle) single married
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Who? When? Results? Please Mark P For In The Past OR Mark C For Currently Have:
T, CD, E, C New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Email Address Occupation Employer s Name Single / Married / Divorced / Widowed
Dr. Janet L. Yarger 510 Baxter Road, Suite 8, Chesterfield, MO
Registration Form Date: / / Name: Social Security #: - - Address: City: State: Zip Code: Home Phone #: ( ) - Age: Date of Birth / / Cell Phone #: ( ) - Best Phone to call you at: HOME/CELL/WORK Email Address: