.'jolufions, LLC Giiiti A. Di Ioru.1, Ouner Clinsci^l Nurvuionist 26 AnJi.ivci Ct. Bordemown, Nj 085C5
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1 Oils tic Nu5:r if," I I.'jolufions, LLC Giiiti A. Di Ioru.1, Ouner Clinsci^l Nurvuionist 26 AnJi.ivci Ct. Bordemown, Nj 085C5 PRIVATE LICENSE, INFORMED CONSENT AND RELEASE Nutrition and Holistic Health Practitioner The undersigned hereby grants a Private License to Gina A. Di lorio of Holistic Nutritious Solutions, LLC (Nutrition and Holistic Health Practitioner) to engage in nutritional and holistic health modalities v^th the undersigned. The undersigned acknowledges that the practitioner is not a medical doctor and does not diagnose or prescribe for medical or psychological conditions, nor claim to prevent, mitigate or cure such conditions. The Practitioner does not provide diagnosis, care, treatment or rehabiutation of individuals, nor does the Practitioner apply medical, mental health or human development principles. The Practitioner helps clients achieve good health and peak performance by nutrition and holistic means, without the use of any drug material remedy or other medical means. The undersigned gives Informed Consent to the services that will be provided. The undersigned hereby releases the Practitioner (Holistic Nutritious Solutions, LLC) from all claims and liabilities arising from the use or misuse of nutritional or holistic modalities, indemnifying and holding the Practitioner harmless from all claims and liabilities there from, whatsoever. The Practitioner reserves all rights. 4l Name (please print): Date; Signature: Parent or Guardian Signature: (If under the age of 18 years old Parent or Guardian signature required).
2 I 4 Holistic Nutntious Solutions. LLC ^ Gina A. Di Itvrio, Ou ncr Clinical NJiitritionisf 26 AudoverC:!. Bordentcvm. HJ 0;-i o56'374l Ho!isucNoo!uiiL'Us('r?u!fii!.coi)i w.«.) I.->liVticN:N.:li=ik>w*.coro Clinical Health Information 1. Print Name: 2. Address: 3. Sex: ForM 4. Occupation: 5. Are you presently under a Physician's Care? Yes or No 6. For what condition? 7. List any medications including vitamins/supplements you are taking including how many times/day. For what? a. b. c. d. e. f 8. Physician's Name: Address: Phone: 9. Are you allergic to any medications? Yes or No If Check answered if you yes, eat, what drink medications or use the following are you allergic and how to? much daily: Cigarettes Alcohol Coffee Fast Foods Candy Soft Driiiks_ Table Salt Sugar Margarine_ Lunch (Deli) Meat Saccharine Distilled Water 1
3 12. How many glasses of water do you consume daily? 13. Do you eat dairy products? Yes or No 14. Do you feel tired after eating? Yes or No 15. Do you shake, get lighted-headed or feel anxious after eating? Yes or No 16. Do you wake up in the middles of the night in a cold sweat or feeling hungry? Yes or No 17. Circle the foods you eat on a daily basis: Starchy vegetables Rice Meat Fish Eggs Green Vegetables White Flour Fruits Nuts Butter Beans/Legumes Whole Grains Seeds Fowl Veg. Oil 18. Are you allergic to any foods? Yes or No If yes, hstthe foods: 19. Have you been recently under great stress due to work-related employment/unemployment, moving, marriage, divorce, school, death in the past 3 months? Yes or No If yes, list from the criteria above or other and briefly explain: 20. Do you practice any stress reduction techniques? If yes, explain. 21. How many meals do you eat per day? 22. How often do you have a bowel movement per day? 23. What is the usual color of your stool? Circle one: Dark Brown Medium Brown Green Beige 24. What is the consistency of your stool? Circle one: Hard and Dry Firm and Moist Loose (ex. like pudding) Watery 25. Is your energy level: Poor Fair Good Very Good 26. Is your sex drive: Poor Fair Good Very good 27. Is your appetite: Poor Fair Good Very good 28. Is your sleep pattern: Poor Fair Good Very Good 2
4 29. Have you been diagnosed with the following: Atherosclerosis Arteriosclerosis Angina 30. What are your most recent blood levels of: Cholesterol HDL LDL Triglycerides 31. Have you taken a course of antibiotics in the past five years? Yes or No 32. Have you taken a course of steroids in the past 5 years? Yes or No 33. Do you use estrogen? Yes or No 34. Do you have: Dandruff Thinning Hair Dry Hair? 35. Do you have patches of rough or dry skin? Yes or No 36. Do you have excess ear wax? Yes or No 37. Do you get nose bleeds? Yes or No 38. Do you have cracks behind the ears or knees? Yes or No 39. Do you have a diminished taste of smell? Yes or No 40. Do you have a diminished sense of taste? Yes or No 41. Do you heal slowly from cuts, scrapes or sores? Yes or No_ 42. Do you have white spots on your finger nails? Yes or No 43. Are you finger nails brittle or dry? Yes or No 44. Is your night vision: Poor Fair Good Very Good 45. Does sun light hurt your eyes? Yes or No 46. Do your gums bleed when you brush your teeth? Yes or No 47. Are your eyes often red, dry, gritty or burning? Yes or No_ 48. Is your tongue sore? Yes or No 49. Do you hands often tingle? Yes or No 50. Do your feet often bum? Yes or No 51. Do you often get leg cramps? Yes or No 52. Are your hands and feet usually cold? Yes or No 53. Do you often feel cold when others feel warm? Yes or No_ 3
5 54.Have you ever had or following: Abdominal Pain Acne/Boils AIDS Alzheimer's Anemia Anxiety Arthritis Asthma BackPain Bad Breath_ Bedwetting_ Circulation, Colds/Flu Colitis Constipation_ Cough Cystitis Depression Cysts Diabetes Typel. Diarrhea Digestion Diphtheria. Dizziness Baiaches R ^- Eczema Edema Epilepsy Eyes R_^L Fainting Fatigue been diagnosed as having problems with Type2. Blood Transfusion Blood Pressure Bladder R L Blood in Urine Blurred Bowl Movements Vision Bruising Cancer Candida Chest Pains Chicken Pox_ KidneylnfectionsR.L_ Kidney Stones Liver Low Blood Pressure Lungs Measles Memory Loss Migraines Muscle Cramps Muscle Tension Nervousness Obesity Osteoporosis Pancreas Pancreatitis Parasites Prostate Tuberculosis. (enlarged) Phobias Polio Thyroid
6 Gallbladder Gas Hay Fever Heart Attack Hemorrhoids Hepatitis Type.l 2 High blood Pressure_ Hypoglycemia Impotence Jaundice Joint Pain Ulcers Urinary Tract Infections Whooping cough Yeast Infections Personality Traits: Which of these traits describe your personality the best? Angry Happy Peaceful Anxious Joyful Sad Depressed Nervous Stress Fear Panic Worry_ Are you under stress? Where are you most under stress? Home? Work? Social Engagements? What do you do when you are under stress? Bed Time Habits: Do you sleep well at night? Y N How many hours do you get a full night sleep? 5
7 Do you wake up in the middles of the night? Y If yes, explain N What is your routine I hour prior to going to bed for the night? FamilY HistorY: Mark where appropriate: L= Living D= Dead Mother: Father: Brother(s): Sister(s): Check if there is a history of any of the following in your family: Asthma Gout Mental Illness_ Blood disorders Heart Disease Obesity Cancer Hypertension Thyroid Issues Diabetes Type Kidney Disease Tuberculosis Epilepsy Lupus Other: 6
8 Exercise Routine: Do you exercise? Y N Describe your daily/weekly workout regimen. Frequency? How often? In general how to you feel about yourself? In general how do you feel about life? What do you do when you celebrate? How did you learn about this service? 7
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Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s
*All information provided is kept in strict confidence Child s Name: Date: Date of Birth: Age: Sex: male female Weight: Height: Girls: Age at first period: Address: Parents: Mother s Phone: (home) (cell)
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
NEW PATIENT INTAKE FORM
NEW PATIENT INTAKE FORM Acupuncture * Herbs * Nutrition Located inside of Yoga 360 91 Bankview Drive Frankfort, IL 60423 815-806-0360/www.yoga-360.com lkacupuncture.com lizkelchak@gmail.com How To Prepare
Avicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s email address: Date of Birth: Gender: How did you hear about this clinic?
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
!!!! Traditional & Contemporary Acupuncture! 19 Golden Ave, Toronto ON! ! Gregory Cockerill, R.
Traditional & Contemporary Acupuncture 19 Golden Ave, Toronto ON info@livehandacupuncture.com 416-899-3364 Gregory Cockerill, R.Ac First Name: Last Name: Birthdate: Gender: Female Male Address: Email:
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
2. Have your symptoms affected your ability to carry out your daily activities? YES NO
QUESTIONNAIRE Page 1 of 5 Date: Referring MD (Name, Address, Phone Number): Primary Care Physician (Name and Address, Phone Number): Reason for visit: 1. How long have you had symptoms? Describe your symptoms?
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:
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.
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:
Headache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
Inflammatory Bowel Disease Medical Exam Questionnaire
Patient Name: MR: Date: Name DOB / / Age Marital Status Race Gender M / F Height Present Weight Usual Weight Insurance Managed Care Self referral Yes No Yes No Yes No Primary Care Physician Referring Physician
CHEMOTHERAPY. What should I expect?
CHEMOTHERAPY What should I expect? WHAT IS CHEMOTHERAPY? Chemotherapy is treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy