Welcome to Vibrant Living Wellness Center Where You Begin Healing With a Nourishing Lifestyle
|
|
|
- Trevor Wilkinson
- 5 years ago
- Views:
Transcription
1 Welcome to Center Where You Begin Healing With a Nourishing Lifestyle Holistic nutrition evaluates health concerns by considering your body as a total system, unique to you. I, Leona Harter am here to assess all of your body systems, discover the origins of your health concerns, make recommendations, educate you, and guide you through your healing journey. Although I am here to help you, ultimately, the power of healing resides in you. By assessing your family history, nutritional status, lifestyle, digestive function, food and environmental allergies, amino acid balance, metabolic function, and hormone levels, we can start to see patterns unique to your biochemical individuality and work to alleviate symptoms, balance body systems, and rejuvenate your health. I will evaluate the information you provide and make dietary and lifestyle suggestions that will help you feel better. It is up to you to follow the recommendations and be aware of the effects these changes have on your body and your mind. You may begin to feel relief within a couple of days, but more substantial changes will occur over time. Please remember to be patient and stay positive: it may have taken you years to develop your health concerns so expecting immediate results is impractical. I am here to provide nutritional support and lifestyle management. To provide the best support, I need to know about your symptoms, health concerns, digestive wellness, and family history. Please complete the following questionnaires, being as honest and as detailed as possible. In regards to the food intake journals, keep a detailed record of your food and liquid consumption for three days. Include preparation method (boiled, fried, sautéed, grilled) and portions. Please be detailed and specific. If a food you eat is not a part of your normal diet, note that as well. Note the fluctuations in your energy levels and mood throughout the day. observations you may have and supplements or medications you take. Record any other Note that the information and recommendations I propose for you are not intended to diagnose, treat, or cure disease. info@leonaharter.com ((912)
2 New Client Intake Form Date Last name FirstMiddle_ Date of Birth Age Gender Height Weight_ Desired Weight_Blood Type: Address City State Zip Home phone # Cell # Work # Please denote how you prefer to be reached: (home/ cell/ work/ ) Primary Care Physician Phone Other health care professionals with whom you are working: Name Phone Name Phone Name Phone Referred by/how did you hear about me?: What are your health concerns? Please include history of symptoms, severity, frequency, blood tests, duration of medication, and previous types of care. What are your health-related goals? On a scale of 1-10, how motivated are you to change? What are your current medications (please provide dosage and length of time you ve been taking each medication)? What supplements, vitamins, or herbs do you take (please provide brand, dosage, and duration)? What is your relationship status? Do you have children and/or pets?
3 Do you have a history of serious surgeries or hospitalizations? If yes please explain, especially if it is related to your health concerns. How often do you take over the counter pain medication (Aspirin, Advil, Tylenol)? Do you have any known allergies (food, medication, environmental)? What is your occupation? How would you describe your work environment? On a scale of 1-10, how stressful is your job? How well do you sleep at night? How long? Do you have trouble falling asleep? Staying asleep? How is your energy level when you wake up? During the day? How often do you eat at home? How often do you eat out? In the past 6 months, have you had any diet or lifestyle changes, including weight gain or loss? Please describe your current exercise routine: Do you smoke cigarettes? If yes, how frequently? FOR WOMEN: Do you have regular periods? How many days do they last? How often? Are your periods painful or symptomatic? Please explain, including what you find alleviates or aggravates your symptoms. Are you taking birth control pills? If yes, for how long? Do you experience frequent yeast infections or urinary tract infections? If yes, please explain.
4 1 = past; 2 = current; 3 = both Your Health History Abscesses Bad breath Goiter PMS (halitosis) Acne Benign tumors Herpes/cold Pneumonia sores Alopecia/hair loss Bipolar disorder Hot Flashes Seizures Amenorrhea Bronchitis Heavy metal toxicity Pain during sex/ impotence Anemia Teeth grinding Insomnia Shingles Appetite Dry skin Lactose Sinusitis (excess/reduced) Intolerance Arrhythmia Endometriosis Low blood Tendonitis pressure Autism Epstein-Barr Virus Lyme disease Other Back Fainting/dizzy Nervousness Other Problems/Sciatica spells Bacterial Infection Fibrocystic breast disease Night blindness Other Family History Mark 1 for you, and 2 for a family member): AIDS Candida Heart Failure Metabolic Syndrome ADD/ADHD Chronic Heart Murmur Migraines Fatigue Alcoholism Depression Hypertension Obesity Allergies Diabetes Immune Osteoporosis Type 1 or 2 Disease Alzheimer s Eczema Kidney Disease Prostate Disease Anxiety Epilepsy Kidney Stones Stroke Arthritis (Rheumatoid or Osteo) Fibromyalgia Lactose Intolerance Hypo/ Hyperthyroidism Asthma Gallbladder Liver Disease Tuberculosis Issues Bowel Problems Glaucoma Lung Disease Ulcer Bronchitis Gout Lupus Other Cancer Heart Attack Menopause Problems Other
5 Health Appraisal Questionnaire In this section, you will complete a series of surveys that will address your gastrointestinal system, detoxification processes, metabolism, adrenal health, and your musculoskeletal system. Please answer all questions in terms of how you are feeling now, not how you used to be or how you think you should be. Some questions are asked multiple times as one symptom can have several different origins. Please be thoughtful and honest when answering the questions in order for the results to accurately reflect your health. These tests can be repeated after making dietary and lifestyle changes as a means of tracking progress and identifying areas of the body that need support. The questions are designed to be answered on a scale of 0 to 3: 0: I do not experience this symptom 1: Mild (twice a week or less) 2: Moderate (three to 6 times a week) 3: Severe (daily, or several times a day) Hyperacidity of the Stomach Stomach pains Dependency on antacids for heartburn/acid reflux relief Chronic abdominal pain Butterfly sensations in stomach Burping or bloating Stomach pains when emotionally upset Sudden, acute indigestion Relief by drinking a carbonated drink Relief of pain by drinking milk History or family history of ulcer or gastritis Current ulcer Black stool (not from iron supplement) Use or previous use of pain medications (aspirin, advil) Hypoacidity of the Stomach Rectal itch Weak, pealing, cracked fingernails Dilated blood vessels in cheeks and nose Acne Iron deficiency Undigested food in stool Chronic candida infections Difficulty swallowing Partial loss of taste or smell Yes or No? (these questions only) Have you ever had a diagnosis of: Asthma Eczema Hepatitis Chronic hives Osteoporosis Psoriasis Rheumatoid arthritis Rosacea Vitiligo Small Intestines/Pancreas Bloating, burping, gas immediately after eating Indigestion, diarrhea, constipation Abdominal cramps Sense of fullness during meals Indigestion and fullness 1-3 hours after Known food allergies eating Nausea after taking supplements Fatigue after eating
6 Lower bowel gas Alternating constipation and diarrhea Specific foods aggravate indigestion Diarrhea Constipation Mucus in stools Stool poorly formed Shiny stools 3 or more large bowel movements daily Dry flaky skin/hair Pain in left side under rib cage Chronic stomach pain Acne Food allergies Difficulty gaining weight Gallstones/history of gallbladder disease Undigested food in stool Nausea Acid reflux/heartburn Connective tissue disease: lupus, rheumatoid arthritis, Sjogrens Alcoholism, diabetes, osteoporosis Colon/Large Intestine Family history of IBD Liver/Gallbladder Intolerance to greasy foods (indigestion) Headaches after eating Burping, heart burn, gas after meal Light-colored stool Foul-smelling stool Less than one bowel movement per day Hard stools Sour taste in mouth Gray-colored skin Yellow in whites of eyes Bad breath Body odor Fatigue and sleepiness after eating Pain in right side under rib cage Abdominal pain worsens with deep breathing Painful to pass stool Water retention Feel restless and agitated, fatigue, weak, irritable Big toe painful Pain radiates along outside of leg Dry or red skin /hair Red blood in stool Jaundice or hepatitis High blood cholesterol and low HDL Cholesterol above 200 Triglyceride level above 115 Seasonal or recurring diarrhea Frequent and recurring illness Bladder and kidney infections Vaginal yeast infections Abdominal cramps Ab pain relieved by bowel movement or gas Toe and fingernail fungus Alternating diarrhea and constipation Constipation More than 3 bowel movements daily Intestinal Integrity/Dysbiosis Narrow stools History of antibiotic use Constipation and/or diarrhea Meat eater Abdominal pain or bloating Rapidly failing vision Mucus or blood in stool Recurrent stomach pain Joint pain, arthritis or swelling Blood or pus (mucus) in stool Chronic fatigue or frequent tiredness Rectal itching Food allergies, sensitivities, intolerances
7 Sinus or nasal congestion Chronic or frequent inflammation anywhere in body Eczema, skin rashes, hives Asthma, hayfever, or airborne allergies Confusion, poor memory, mood swings Use of nonsteroidal anti-inflammatory drugs History of antibiotic use Alcohol consumption makes you feel sick Ulcerative colitis, Chrone s disease, celiac disease Headaches or migraines Gastric Reflux Sour taste in mouth Regurgitate undigested food in mouth Frequent nocturnal coughing Burning sensation from citrus in esophagus Heartburn Burping Difficulty swallowing solids or liquids Thyroid Health Fatigue, sluggish Cold hands and feet, general cold feeing Difficult, infrequent bowel movements Dryness of skin or hair Thick, brittle nails Outer third of eyebrow thins Puffy face, hands, feet Swollen upper eyelids Eyeballs move involuntarily Muscles are weak, they cramp and tremble Slow mental processes, forgetfulness Slow heart beat Loss of appetite Abdominal swelling Unsteady gait, movements Lack of interest in sex Premenstrual tension Infertility Heavy menstrual bleeding Gain weight easily Swelling of the neck Thinning hair on scalp, face, and genitals Adrenal Health Progressive, mild fatigue after exertion or stress General weakness Blurred vision, dizzy when rising Depression Rapid mood swings Irritable, nervous Dark circles under eyes Disinterest in food Abdominal pain Indigestion Blotchy skin (white patches) Tan skin, no sun Black freckles on upper forehead, face, neck Craving for salty foods Gradual loss of body hair Sensitive to subtle changes in surroundings, weather Bone Integrity Generalized bone tenderness and achiness Localized bone pain Bone deformity or swelling Shins hurt during or after exercises Low back or hip pain Limp, walking difficulties Crunching or creaking sounds when info@leonaharter.com info@vibrantliving4life.com (912)
8 joints move Hands, feet, throat spasms, feel numb Joint pain and stiffness in hips, knees, spine Hearing loss, headaches, ringing in ears Established bone loss Calcium deposits Spinal curvature Recent loss of height Bowed legs Stooped posture Hump at base of neck Unexplained bone fracture Tooth loss, gum disease Muscle Health General muscle aches and pains Localized muscle stiffness, tension, pain Specific points on body feel sore when pressed Headaches Fatigue, tired, sluggish Difficulty sleeping Do not feel refreshed upon awakening Muscle weakness or loss Difficulty speaking or swallowing Muscle cramps or spasms Muscle twitch or tremble, eyelids, thumb, calf Irresistible urge to move legs Legs move during sleep Numb, tingling sensation Excessive joint mobility Unable to fully straighten or extend legs/arms Upper or lower back pain Total Connective Tissue/Joints Joint stiffness, soreness Red, swollen painful joints Joint stiffness worsens with rest, improves with movement Cracking joints Shooting, aching, tingling pain in back of leg Join pain in multiple joints Joints hurt when moving or carrying weight Limited range of motion Difficulty standing up from sitting position Headache Difficulty chewing food or opening mouth Numbness, prickling, tingling sensation in neck, shoulders, or arms Involuntary muscle spasms Deliberate movement with hands is difficult Injure, strain, sprain easily Discomfort or pain in neck, shoulder, arm Yes or no? One leg shorter than the other? Double jointed? Knobby overgrowths on joints close to fingertips? Are there any other symptoms or comments you have in regards to your health?
9 Name:_ Date: Foods and beverages eaten together should be clustered together (leave an empty line in between meals). Food & Liquids (include portion) Time Mood/EnergyObservations Supplements/Medication Physical Activity (type and duration):
10 Name:_ Date: Foods and beverages eaten together should be clustered together (leave an empty line in between meals). Food & Liquids (include portion) Time Mood/EnergyObservations Supplements/Medication Physical Activity (type and duration):
11 Name:_ Date: Foods and beverages eaten together should be clustered together (leave an empty line in between meals). Food & Liquids (include portion) Time Mood/EnergyObservations Supplements/Medication Physical Activity (type and duration): kleona
12 Informed Consent I understand that the evaluation and recommendations of Center, specifically Leona Harter may include but are not limited to: - Medical history - Physical examination - Laboratory tests of blood, urine, stool, and saliva - Dietary advice - Therapeutic foods/supplements Providing all known allergens, prescriptions, and health conditions will reduce your risk of potential allergic reactions to prescribed herbs and supplements. Please note that some conditions will be exacerbated during healing before they are alleviated (i.e. detoxification). Policies: - Payment is expected at time of service or before. Phone, Skype, and consults will be charged 48 hours prior to their appointment. - There are no refunds on supplements or pre-paid packages. Packages expire 6 months after purchase date unless otherwise specified. - Discounts cannot be combined with any other offer. - Programs and pricing are subject to change, depending on the needs and goals of the client. - There is a 24 hour cancellation policy. No-shows charged at full price. Studio etiquette applies. By signing below I, agree to actively participate in making dietary and lifestyle changes to support a nourishing lifestyle. I agree to pay for all services rendered and supplements given according to the personalized payment plan. I acknowledge that no guarantees have been given to me concerning the results intended from the treatment plan created for my unique health conditions and biochemical individuality. I understand that Leona Harter cannot diagnose, treat, or cure disease, but can provide support and guidance through my healing journey. Please Sign Here Today s Date Credit Card # Expiration Date _ Security Code Billing address, if different than physical address:
Symptom Review (page 1) Name Date
v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each
METABOLIC ASSESSMENT FORM
METABOLIC ASSESSMENT FORM Name: Age: Sex: Date: PART 1 Please list the 5 major health concerns in your order of importance: 1. 2. 3. 4. 5. PART 2 Please circle the appropriate number 0-3 on all questions
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
HEALTH APPRAISAL. Name: Address: Phone: ADMIN ONLY Doctor: Tongue: Blood Pressure: Nails: Medication: Iridology: Tests Ordered: Notes:
HEALTH APPRAISAL ADMIN ONLY Doctor: Blood Pressure: Medication: Tongue: Nails: Iridology: Tests Ordered: Notes: Name: Address: Phone: Email: 1 Main Complaint Please describe your main health complaint
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 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
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
Emotional Relationships Social Life Sexually Recreation
Name Date Address City State Zip Married Single Partner Divorced Widowed Date of Birth SS# Email Work Phone Home Phone Cell Phone Occupation Referred by Emergency Contact Family Physician Contact May we
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
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:
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
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
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:
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
Metabolic Assessment Form
Metabolic Assessment Form Approach Wellness and Aesthetics 200 Forsythe Street Fayetteville, NC 28303 Office: (910) 322-7368 Fax: (910) 483-5796 www.tawellness.net Name: Age: Sex: Date: Part 1: Please
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
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:
MEDICAL HISTORY RECORD
MEDICAL HISTORY RECORD Please print and complete all information. Case. Male Female Medicare. Medicaid. Today s Date Birthdate Last Name First Middle Daytime Phone Home Phone Address City Marital Status
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
Symptom Questionnaire
Symptom Questionnaire The following questionnaire is a general assessment of your health developed by Dr Royal Lee D.D.S. Each grouping represents a particular area of your body that may be causing you
MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:
MenoChat Patient Health History Questionnaire Patient Name (last, first, MI): How did you hear of MenoChat? Address City State Zip Code Home Phone #: Cell Phone #: Male or Female Marital Status Email Employer
Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM
Name Date Address City State Zip Home Phone Cell Fax Email Emergency Contact Emergency Number Date of Birth Age Sex Height Weight Lbs Marital Status Occupation Who referred you to this office? Name of
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:
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
Digestion Assessment Scorecard
Name Digestion Assessment Age Height Weight Based upon your health profile for the past 30 days, please select the appropriate number, from '0-3' on all questions (0 as least/never/no and 3 as most/always/yes).
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION
Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION Name Date Address City State Zip Home Phone Cell Phone # Work: Email Address Occupation Employer
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
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:
Patient Intake Form for Acupuncture Treatment at Infinite Healing
Section A: Your Information Patient Intake Form for Acupuncture Treatment at Infinite Healing Last Name: First Name: Middle Initial: Mailing Address: _ City: Postal Code: E-mail: Birth date: M D YR Age:
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
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
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
Name: Date of Birth: Age: Address: City State Zip
Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?
GETTING STARTED INTRODUCTORY FORM
GETTING STARTED INTRODUCTORY FORM I am interested in: In office consultation Questions regarding my appointment: Phone consultation Skype consultation I am interested in the: Getting Started Program Getting
Oriental Medicine Questionnaire
Oriental Medicine Questionnaire Date: Name: DOB Sex: M F SS# Address: City State Zip Cell Phone: Home Phone: Business Phone Occupation: Height: Weight: Who referred you to this office? 1.What brought you
My energy is lower than I would like it to. I feel exhausted after exercising or physical activity.
SYMPTOMS Questionnaire Duplicate your answer across all of the 5 boxes that aren t blocked out. See example ENERGY My energy is lower than I would like it to be. I feel exhausted after exercising or physical
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care
Page 1 of 7 Patient Demographics First Name* Last Name* Date Of Birth* Home Phone* Mobile Phone Phone Gender* Email Preferred Communication Street Address 1* Street Addresss 2 Zip* City* State* Emergency
THE MANY SYMPTOMS ROOTED IN HORMONE IMBALANCES
abdominal pain acne aging process accelerated allergies, including asthma, hives, rashes, sinus congestion anemia (blood hemoglobin low) anorexia anovulatory (no ovulation) anxiety anxious depression appetite
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
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
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
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
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE
WOMEN S FITNESS TIPS HEALTH ASSESSMENT QUESTIONNAIRE Name: Date: This is not a test, or a quiz, and there are NO right or wrong answers here. This health assessment questionnaire is about YOU, and will
Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX
Kimberley A. Schroeder, D.O. 115 Baker Drive Tomball, TX 77375 281.290.0531 www.feelwellagain.com FEMALE MEDICAL QUESTIONNAIRE (POSTMENOPAUSAL) NAME: DATE OF BIRTH: CHIEF COMPLAINT What is your primary
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM Please complete this form and bring it with you to your appointment Appointment Date Appointment Time Name Referring Physician Date of Birth Please
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:
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux)
What type of medication, vitamins, minerals, etc. are you currently taking? For how long? What for? (ie: Prilosec/6 months/acid Reflux) What previous methods have you tried to alleviate your discomfort
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:
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
*All information is important to your intake and valuable to your personal treatment plan. Please answer as thorough as possible. Patient Information: Name: Date: / / (First Middle Last) Address: City:
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY
BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY Thank you for choosing Back To Basics Health & Nutrition to assist you with your natural health care. The ability to draw effective conclusions
Medical History Form
Medical History Form Full Name Title: Mr/Mrs/Ms/Miss Address Date of Birth Date Telephone: Mobile: Email: How did you hear about the Garden of health? G.P s Name and Address Are you currently seeing your
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
All nutrition appointments NOT given 24 hours notice of cancellation will incur a $50 charge.
Nutritional Counseling Food Sensitivity Testing Neurotransmitter Testing Hormone Testing Wellness & Prevention 111 O Fallon Commons Drive O Fallon, MO 63368 Phone: 636-978-0970 Fax: 636-978-7570 Dr. Olivia
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
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information
Patient General Information Name: (first) (middle) (last) Date of Birth: / / (mo) (day) (year) 中 文名字 : Gender: Occupation: Address: (street, apt) Phone #: (city, state, zip code) Email: Emergency Contact:
Medical Health Questionnaire
Medical Health Questionnaire New Patient Name Change Address Change Insurance Change ALL SECTIONS MUST BE COMPLETED FOR ALL PATIENTS: Today s Date / / Patient Name: Last First Middle Initial Date of Birth:
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD
Athens Rheumatology Clinic, LLC Sana Makhdumi, MD Phone: 706-850-8322 Fax: 706-850-8322 PATIENT HISTORY FORM Date of first appointment: / / Time of appointment: Birthdate: Name LAST FIRST MIDDLE INITIAL
HEALTH HISTORY QUESTIONNAIRE
1525 S. Alafaya Trail Unit 105 / Orlando, FL 32828 T: 407-282-4449 F: 407-282-4438 www.synergyspineinjury.com HEALTH HISTORY QUESTIONNAIRE Name: Date: Address: City: State: Zip: S.S. #: Cell Phone: Home
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
Questionnaire for Lipedema Patients
Questionnaire for Lipedema Patients Name Date of diagnosis Date Name of physician making diagnosis Do you also have lymphedema? What areas of the body are affected? Outside of thighs Inner thighs Knees
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Debra Joan Wood, Lic Ac, MAcOM Acupuncture and Herbs Please help me provide you with a complete evaluation by taking the time to fill out this questionnaire carefully. If there
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:
LAKES INTERNAL MEDICINE
LAKES INTERNAL MEDICINE HEALTH HISTORY QUESTIONNAIRE Please print this and complete and bring to your initial appointment. Today's Date Last Name First Name Middle Initial Date of Birth Male Female Education
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
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:
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:
Placer Private Physicians: Patient Health Questionnaire [2]
![Placer Private Physicians: Patient Health Questionnaire [2]](/thumbs/87/96006031.jpg "Placer Private Physicians: Patient Health Questionnaire [2]")
Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History
New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History Name PH#(home) Cell Address City Province Postal Code Date of Birth D/M/YY Age Gender Email address Do you exercise?
Medical Information. (office use) MRN: CMRN: Last Name: First Name: Middle Initial: Date of birth: Age: Sex: M F Height: Weight:
1835 W. County Rd C, Suite 80, Roseville, MN 55113 P: 651-797-6880 F: 651-797-6881 info@spartzvein.com spartzvein.com Medical Information Date of consultation: (office use) MRN: CMRN: Last Name: First
ACUPUNCTURE INTAKE FORM
, ND ACUPUNCTURE INTAKE FORM Thank you for taking the time to complete the following new patient forms. Given this form is extensive, it plays an integral role in achieving our mutual goal of your optimal
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Eastern Body Therapy
2310 Eastern Body Therapy 6th Avenue San Diego, CA 92101 (619)772-4002 Personal Information Name Date of injury/illness Address: Apt. City State Zip Home phone: ( ) Work Phone: ( ) E-mail: Social Security
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION Personal Mr. Ms. Mrs. Miss Dr. Other Last Name First Name MI Home Address City State Zip Mail Address City State Zip Is This a Nursing Home? Facility Name Telephone # Cell Phone
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Bodily Conditions Rooted in Hormone Imbalance
Check this list for all conditions that apply to you. The total possible score is 209. Count the number of symptoms you check. The higher your score, the more likely you need to address hormone imbalances.
/ / - - / / Age: USF Cutaneous Oncology Program. Skin Cancer Questionnaire. Patient Information: Fax completed forms to:
Page 1 of 8 Patient Information: Last Name: First Name: Initial: Address: Address (cont.) : City: State: Zip Code: Phone: - - Social Security Number: Date of Birth: - - Age: Sex: Female Male Email Address:
Metabolic Assessment Form Please list your five major health concerns in your order of importance.
Metabolic Assessment Form Please list your five major health concerns in your order of importance. 1. 2. 3. 4. 5. Please check the appropriate number on all questions below, using zero as least/never to
Eastern Shore MediCann Clinic, LLC
Eastern Shore MediCann Clinic, LLC New Patient Medical History and Intake Form Medical Marijuana Certification Name Date of Birth Social Security Number Gender: Male Female Address: Street: City: State
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
WELLNESS HISTORY. Patient s Name: Date
u:\share\sr dr\wellness history1 08-08-13 1 WELLNESS HISTORY Patient s Name: Date 1) Have you ever been to Acupuncturist? Yes No If Yes: Currently In the past, When: Did it help? What treatment did you
Metabolic Assessment Form
Metabolic Assessment Form Name: Age: Sex: Date: PART I Please list the 5 major health concerns in your order of importance:... 4. 5. PART II Please circle the appropriate number - on all questions below.
205 W Giaconda Way, Suite 135 Tucson, AZ, (520) Name: Birth date: Age: Today s Date:
205 W Giaconda Way, Suite 135 Tucson, AZ, 85704 (520) 219-2400 www.forever-able.com info@forever-able.com Name: Birth date: Age: Today s Date: Address: Email: Home phone: Mobile phone: May we add you to
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
2. Approx. Date of Onset: 3. Approx. Date of Onset:
Healthy Balance Lisa A. Dulac, L.Ac. Acupuncture Patient Intake Form Present Health Concerns: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: 2.
THE HORMONE HEALTH PROFILE
THE HORMONE HEALTH PROFILE The following checklists created by Natasha Turner,N.D. will help identify hormone imbalances quickly. Your profile results from these checklists will be extremely valuable in
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
MEDICAL QUESTIONNAIRE (female)
MEDICAL QUESTIONNAIRE (female) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501 The appointment comprises of a discussion about this questionnaire and a subsequent medical examination.
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
Mayflower Acupuncture LLC
536 Hopmeadow St. Simsbury, CT 06070 Phone: (860) 413-2118 Email: Forms@mayfloweracupuncture.com Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this
Nutrition Consultation Intake Form Please write or print clearly
Artemis in the City, LLC Danielle Heard, MS, MS, HHC Clinical & Functional Nutritionist ph: 866-330-5421 fx: 212-535-3234 www.artemisinthecity.com Nutrition Consultation Intake Form Please write or print
On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the areas below:
Healthcare History djp Pure-Health wellness centre www.pure-health.com Wellness Profile General Health On a scale of 1 10 ("10" being optimal health) please rate where you feel your health is in the the
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.