Mayflower Acupuncture LLC

Size: px
Start display at page:

Download "Mayflower Acupuncture LLC"

Transcription

1 Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this form as completely as you can. All information provided here will be held in strictest confidence. Feel free to ask if you have any questions. First Name Last Name Middle Initial Age Date of Birth Gender Marital Status Address City State Zip Occupation Phone Number Cell Phone/work phone/home phone Employer Emergency Contact Relationship Contact Number Physician Phone Number May we contact this person? Have you received acupuncture or herbal therapy before? Acupuncture Herbs Both Neither How did you hear about Mayflower Acupuncture? PRIMARY REASON(S) FOR SEEKING TREATMENT: When did this/these problem(s) begin? What makes your symptom(s) better? What were the causes? Worse? Please rate your current pain or discomfort on a scale of 1 to 10: Very Slight: : Unbearable Have you received a diagnosis? If so, what? What other treatments have you tried? FOR OFFICE USE ONLY Medical Record # 1 Form 103 Revision Date 11/2015

2 MEDICAL HISTORY (Include Dates) Medications you are currently taking Supplements/Herbs you are currently taking Allergies (food, drugs, chemicals, etc.) Major illnesses or significant traumas Surgeries Check All That Apply: Anemia Hepatitis Lyme Disease Tuberculosis Asthma Heart Disease Pneumonia Other Cancer High Blood Pressure Seizures Diabetes HIV/AIDS Stroke FAMILY MEDICAL HISTORY (Check All That Apply) Alcoholism/Addiction Cancer Heart Disease Psychological Disorder Arthritis Diabetes High /Low Stroke Blood Pressure 2

3 PERSONAL Height Weight Weight Maximum When? Exercise (Please describe) Stress (occupational, emotional, etc. Do you smoke? Did you used to smoke? How much? For how long? Do you drink alcohol? How many drinks per week? Do you drink caffeinated beverages? What kind? How many per day? Please list any other drug use Country visited outside US for the past 6 months PERSONAL SIGNS AND SYMPTOMS (Please check any that apply to you) General Bleed or Bruise Easily Localized Weakness Poor Sleep Weight Gain Chills Night Sweats Strong Thirst Weight Loss Cravings Poor Appetite Sudden Energy Drop Fatigue Poor Balance Sweat Easily Musculoskeletal Back Pain Joint Pain / Stiffness Neck Pain / Tightness Swollen Hands/Feet Cold Hands/Feet Knee Pain Numbness Tingling Foot / Ankle Pain Muscle Atrophy Paralysis Tremor Hand / Wrist Pain Muscle Pain Sciatica Vertebral Disorder Hernia Muscle Twitches Shoulder Pain Hip Pain Muscle Weakness Spinal Curvature Head & Throat Blurry Vision Earaches Hearing Loss Ringing in Ears Cataracts Eye Pain / Strain Jaw Clicks / TMJ Sinus Problems Concussions Facial Pain Migraines Spots in Vision Difficulty Swallowing Frequent Sore Throats Mouth / Lip Sores Tearing Dizziness Headaches Night Blindness Teeth Grinding Dry Eyes Head Injury Nose Bleeds Tooth Pain 3

4 Skin & Hair Acne Dry Skin Itching Recent Moles Change of Hair Texture Eczema Psoriasis Ulcerations Change of Skin Texture Hair Loss Purpura Dandruff Hives Rashes Respiratory Allergies Chest Pain Difficulty Breathing Persistent Cough Asthma Coughing Blood Emphysema Pleurisy Bronchitis Coughing Up Phlegm Frequent Common Colds Wheezing Cardiovascular Blood Clots Heart Murmurs Low Blood Pressure Rapid Heartbeat Chest pain High Blood Pressure Palpitations Varicose Veins Fainting Irregular Heartbeat Phlebitis Gastrointestinal Abdominal Pain / Cramps Crohn s Disease Hemorrhoids Rectal Pain Acid Reflux Constipation IBS Ulcers Bad Breath Diarrhea Indigestion Undigested Food in Stools Belching Gallbladder Problems Mucus in Stool Vomiting Black Stools Gas/ Bloating Nausea Blood in Stools Heartburn Parasites Neuro-Psychological ADD / ADHD Concussion Loss of Balance Stress Anxiety Depression Memory Loss Vertigo Bad Temper / Irritability Dizziness Mood Swings Bipolar Lack of Coordination Seizures Genito-Urinary Blood in Urine Frequent Urination at Night Inability to Hold Urine Pause of Urine Flow Burning Urination Genital Itching Kidney Stones Urinary Tract Infection Dribbling Genital Pain Painful Urination Urinary Urgency Frequent Urination 4

5 FEMALE Breast Lumps Irregular Menstruation Polycystic Ovarian Syndrome Breast Tenderness Menopausal Symptoms Sexually Transmitted Disease Clotting During Menstruation Nipple Discharge Spotting Difficult / Painful Intercourse Ovarian Cysts Uterine Fibroids Endometriosis Painful Menstruation Vaginal Discharge Frequent Vaginal Infections Pelvic Infection Vaginal Dryness Infertility PMS Is there any possibility that you may be pregnant? Date of last menses Length of menstrual cycle Duration of period Number of Pregnancies Number of births Number of miscarriages MALE Erectile Dysfunction Frequent Seminal Emissions Premature Ejaculation Fertility Problems Painful / Swollen Testicles Prostate Problems Frequent Nocturnal Emissions Penile Discharge Sexually Transmitted Disease CONSENT FOR ACUPUNCTURE / ACUPRESSURE / MANIPULATION I, the undersigned, realize that acupuncture may be considered as an investigative procedure in some jurisdictions. I fully understand that there is no implied or stated guarantee of success of effectiveness of a specific treatment or series of treatments. Every attempt will be made to protect me from harm. Although the possibility is remote, there may be unfavorable skin reaction, possible infection, unexpected bleeding and/or other complications not anticipated. I may withdraw from treatment at any time. OFFICE POLICIES PLEASE READ AND SIGN BELOW 1. In fairness to all patients, we regret that appointments cancelled less than 24 hours before appointed time are charged $ Herbs are refundable within 7 days of purchase. 3. Herbal prescriptions are intended only for the person for whom they are prescribed. Please do not give your herbal prescriptions to anyone else. 4. Payment is due at time of service. Any outstanding balance remaining after 90 days is subject to a 10% charge. 5. I acknowledge that I have read and consent to the Notice of Privacy Practices of Mayflower Acupuncture, LLC. I understand that I may receive a copy of the above Notice of Privacy Practices and may ask any questions about the notice prior to signing this document. Patient s Signature: Date: 5

6 Insurance Information: Insurance Carrier ID Number Group Number Provider Service Phone #: Insured s Name Insured s Date of Birth Insured s Address (If different from patient s address) Insured Phone Number: Relationship to Insured: T h a n k y o u OFFICE USE ONLY - Coverage (IN) Co-Pay (IN) Coverage (OUT) Co-Pay (OUT) Deductible (IN) Accumulations: Deductible (OUT) Accumulations: Out of Pocket (IN) Accumulations: Out of Pocket (OUT) Accumulations: Limitations/ Restrictions (IN) Limitations/ Restrictions (OUT) Visits/year allowed Plan Year Reference #: Date Taken By: 6

7 7

Mayflower Acupuncture LLC

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

More information

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

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

More information

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 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

More information

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

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

More information

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

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

More information

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

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:

More information

NEW PATIENT HEALTH HISTORY

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

More information

HIPAA Acknowledgement and Appointment Reminder Form

HIPAA Acknowledgement and Appointment Reminder Form HIPAA Acknowledgement and Appointment Reminder Form I acknowledge that I have been provided access to Salado Acupuncture s Notice of Privacy Policies. I understand that I have the right to review Salado

More information

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone  . Date of Birth Occupation Island Acupuncture & Massage Therapy Patient General Information GENERAL PATIENT INFORMATION Last Name First Name Home Phone Cell Phone Work Phone Email Address (street) (city) (state) (zip) Date of Birth

More information

Medical History Form

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:

More information

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

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

More information

Avery Acupuncture & Natural Medicine New Patient Registration

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

More information

Inner Balance Acupuncture

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:

More information

Acupuncture & Herbal Therapies

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#:

More information

Eastern Body Therapy

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

More information

Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star **

Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Date: Name: Street Address: City: State: Zip: Home phone: Work phone: Cell: ** Please mark preferred contact number for reminder calls with a star ** Email: Date of Birth: Place of Birth: Age: Employer

More information

Health History Questionnaire Date: / /.

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:

More information

2. Approx. Date of Onset: 3. Approx. Date of Onset:

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.

More information

I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION

I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION PERSONAL INFORMATION NAME: TODAY'S DATE: ADDRESS HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: PHONE: HOME MOBILE WORK EMAIL ADDRESS: EMERGENCY CONTACT: STATUS: SINGLE MARRIED DIVORCED WIDOWED OTHER: NUMBER

More information

Health History Questionnaire

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

More information

Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM

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

More information

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):  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

More information

New Patient Information

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

More information

Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042

Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042 Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042 Date: Name: Sex: M F Date of Birth: Drug Allergies: Address: City: State: Zip: Phone Numbers ( ) ( ) ( ) Home

More information

Patient Health History Questionnaire

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

More information

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information.

Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form. Patient Information. Emergency Contact Information. Carlette Zottola Lac, MSTOM Acupuncture New Patient Intake Form Patient Information Name: Date of Birth: Age: Gender(please circle) M or F Occupation: Address: City, State, Zip: Email: Home Phone: Cell

More information

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:

Condition #2: What is the next important condition you would like help with, and how long ago did it begin?: NAME _ Please take the time to fill this form out completely. The more information we have, the better we can assist you, and will make better use of your initial visit. What is the main problem you would

More information

Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History

Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History Chagrin Valley Chiropractic and Acupuncture Center, LLC Acupuncture Chief Complaint and Health History Name: Date: PRESENT HEALTH CONCERNS: Please list your most important health concerns in order of their

More information

Judy Simonsen-Cazier, LAc, PT 2450 SE Belmont St. Portland, OR

Judy Simonsen-Cazier, LAc, PT 2450 SE Belmont St. Portland, OR Acct # Judy Simonsen-Cazier, LAc, PT 2450 SE Belmont St. Portland, OR 97214 503-806-6184 judy@sunnysideholisticgroup.com Health History Successful health care and preventative medicine are only possible

More information

Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:

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:

More information

Oriental Medicine Questionnaire

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

More information

Health History New England Community Acupuncture

Health History New England Community Acupuncture Health History New England Community Acupuncture Name: Contact - Cell: Street: Home: City: Work: State: Zip: Email: DOB: Height: Occupation: Age: Weight: Physician: Emergency Contact - Name & Phone Number:

More information

Average Daily Diet: Morning Afternoon Evening

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

More information

New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip

New Patient Intake. Last Name First Name MI Suffix I would prefer to be called. Mailing Address City State Zip About You Pulley Chiropractic & Acupuncture, LLC Janine Pulley, D.C., L.Ac. 102 Peters Street, Suite 1, North Andover, MA 01845 P: 978-237-5106 * F: 978-420-4399 drjanine@pulleychiropractic.com * www.pulleychiropractic.com

More information

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

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

More information

HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM

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

More information

NorthPointe Medicine, P.C.

NorthPointe Medicine, P.C. NorthPointe Medicine, P.C. Patient Information Name: Today s Date: Male Female Date of Birth: Age: _ Blood Type: Phone: Home# Work# Cell# Address: City: State: Zip: Email Address: Marital Status: Single

More information

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: 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

More information

Healthworks Nutrition Centre. Naturopathic Medical Questionnaire. Name Date of First Visit. Address. Province Postal Code. Telephone # (home) (work)

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

More information

CURRENT MEDICAL HISTORY

CURRENT MEDICAL HISTORY Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form

More information

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

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:

More information

New Patient Medical History Intake Form

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

More information

Headache Follow-up Visit Form

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:

More information

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805) Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:

More information

Acupuncture & Oriental Medicine of Sturbridge 48 Main Street, Sturbridge MA PHONE: FAX:

Acupuncture & Oriental Medicine of Sturbridge 48 Main Street, Sturbridge MA PHONE: FAX: Acupuncture & Oriental Medicine of Sturbridge 48 Main Street, Sturbridge MA 01566 PHONE: 508.347.0055 FAX: 508.347.7576 EMAIL: aoms@charter.net HEALTH HISTORY Name Date DOB Age Height Weight Referred By

More information

Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060

Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060 Wei Qi Acupuncture, LLC 57 Palm Street, Suite 7 Nashua, NH 03060 Welcome! I look forward to helping you to meet your health goals. Please take a few minutes to fill out this questionnaire to help me to

More information

If you have any questions, feel free to contact us at 475- WLNS (9567) or

If you have any questions, feel free to contact us at 475- WLNS (9567) or UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH

More information

Holistic Health Care New Patient Intake Form

Holistic Health Care New Patient Intake Form Holistic Health Care New Patient Intake Form Name * Address * Telephone number: * Email Address * May we use your email address occasionally for health related information? * Are you a current or past

More information

What do you believe is causing your most important health concern?

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

More information

PATIENT INFORMATION Please print clearly and complete all blanks

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

More information

Patient Health History

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

More information

Rockwood Natural Medicine Clinic

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

More information

New Patient Intake Form

New Patient Intake Form PERSONAL INFORMATION New Patient Intake Form 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

More information

Pure Health Natural Medicine

Pure Health Natural Medicine Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell

More information

Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT

Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT Rebecca Shatles M.Ac, L.Ac Dipl.Ac, LMT 801 623 8253 1291 South 1100 East #202 Salt Lake City, UT 84105 www.peakacupunctureclinic.com info@peakacupunctureclinic.com CLIENT INFORMATION Client Name: If Patient

More information

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: 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.

More information

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

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

More information

stoneburner acupuncture

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:

More information

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):   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:

More information

PATIENT INFORMATION. GENERAL INFORMATION Have you had acupuncture before? Yes No Have you used Chinese herbal medicine? Yes No

PATIENT INFORMATION. GENERAL INFORMATION Have you had acupuncture before? Yes No Have you used Chinese herbal medicine? Yes No PATIENT INFORMATION PATIENT INFORMATION Date Name Address City State Zip Sex: M F Age Birthdate Single Married Significant Other Widowed Separated Divorced Patient SS# Occupation Employer Emp. Address

More information

Birch Wellness Center

Birch Wellness Center Dr. Kelly Brown drkbrownnd@gmail.com Birch Wellness Center 34 Carlton Street, Winnipeg, Manitoba R3C 1N9 204 505 0325 (f) 204 505 0327 Full Legal Name: (Last, First) / Preferred Name: Date of Birth: Age:

More information

55 S. Main Street, Driggs, ID (208)

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

More information

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4 Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: 905-793- 8868 Fax: 905-793- 8957 630 Peter Robertson Blvd, Brampton ON L6R 1T4 ADULT INTAKE FORM Name: (Last) (First) (Preferred Name) Address:

More information

135 Delaware Ave. Buffalo, NY (716)

135 Delaware Ave. Buffalo, NY (716) New Patient Packet Toni Haugen L.Ac MSTOM 135 Delaware Ave. Buffalo, NY 14202 haugentoni@gmail.com (716) 218-9338 Thank you for choosing Queen City Acupuncture. I look forward to working with you soon.

More information

Medical History Form

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

More information

Signature: Today s date: (Parent or Guardian if a minor)

Signature: Today s date: (Parent or Guardian if a minor) 487 Davie St. Vancouver, V6B 2G2 Ph:604-697-0397/ Fax:604-697-0883 PERSONAL INFORMATION Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship

More information

Emotional Relationships Social Life Sexually Recreation

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

More information

Laser Vein Center Thomas Wright MD Page 1 of 4

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

More information

Symptom Review (page 1) Name Date

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

More information

MEDICAL QUESTIONNAIRE (female)

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.

More information

LAKES INTERNAL MEDICINE

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

More information

New Patient Intake Form

New Patient Intake Form New Patient Intake Form Today s Date: / / Name: Birthdate: / / Address: City / State: Zip: Home Phone: Email: Cell Phone: Work Phone: Male Female Ht Wt Occupation: Referred by: Reason for visit today:

More information

Medical History Form

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

More information

American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ (520)

American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ (520) American Health Acupuncture LLC Healing the Body, Mind, & Spirit 7130 N Omar Dr Tucson AZ 85741 (520) 544-6603 Notes for new Patients: Your first session * Can you imagine not having to wait at a doctor's

More information

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 #: - - 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:

More information

Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program

Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Zammito at

More information

Greg Garcia ND, LAc S.W. Watson Ave., Beaverton OR ~ Office: ~ Office Fax: ~

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

More information

Questionnaire for Lipedema Patients

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

More information

Dr. Keri Marshall 5415 W Cedar Ln, Suite 202a, Bethesda, MD 20814

Dr. Keri Marshall 5415 W Cedar Ln, Suite 202a, Bethesda, MD 20814 Dr. Keri Marshall 5415 W Cedar Ln, Suite 202a, Bethesda, MD 20814 PERSONAL INFORMATION: Name Date Address City State Zip Telephone (home) (work) E-mail Date of Birth Age Gender Female Male Relationship

More information

Patient History Form

Patient History Form Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:

More information

CANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR P: (541) F: (541)

CANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR P: (541) F: (541) CANYONVILLE ACUPUNCTURE Carrie Lovemark L.Ac, MTCM 115 SE Main Street Canyonville, OR 97417 P: (541)517-9869 F: (541)543-2220 PATIENT INFORMATION Name: Age: DOB: Sex : Address: City: Zip: Home Phone: Cell

More information

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

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

More information

To: New patients for acupuncture and Oriental medicine

To: New patients for acupuncture and Oriental medicine To: New patients for acupuncture and Oriental medicine Thank you for your interest in becoming an acupuncture and Oriental medicine patient. As part of your first visit to our clinic, you will take part

More information

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. 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

More information

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist

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:

More information

Joseph S. Weiner, MD, PC Patient History Form

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:

More information

Dear Valued Patient, Revised 09/24/2018 UC Health Integrative Medicine Page 1 of 5

Dear Valued Patient, Revised 09/24/2018 UC Health Integrative Medicine Page 1 of 5 UC Health Integrative Medicine UC Health Physician s Office Midtown 3590 Lucille Drive, Suite 2400 Cincinnati, OH 45213 UC Health Physician s Office South 7675 Wellness Way, 4 th Floor West Chester, OH

More information

Naturopathic Medicine Intake Form Adults (16+)

Naturopathic Medicine Intake Form Adults (16+) Naturopathic Medicine Intake Form Adults (16+) Name: Date of birth: Gender: Address: City: Postal Code: Home Phone: Mobile/Work: Email: Marital status: Spouse/Partner s name: Emergency Contact: Phone Number:

More information

Integrative Health and Fitness

Integrative Health and Fitness Integrative Health and Fitness Robert Guiel, M.S., A.C.N. 1029 North Road, Westfield, MA 01085 (413) 519-7166 Health History Questionnaire of 1 st visit: / / Name: of Birth: Age: Address: City: State:

More information

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

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

More information

Name: Date of Birth: Age: Address: City State Zip

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?

More information

Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:

Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Date: Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: E-mail: Person to Contact in Case of Emergency: Relationship

More information

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patient General Information

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 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:

More information

Patient Intake Form. Relationship. Contact information

Patient Intake Form. Relationship. Contact information Acupuncture & Massage Therapy 895 rue St. Francois, Florissant 314 921-3366 Mary S. Wallis, L.Ac, L.M.T. National Board Certified in Acupuncture (NCCAOM) MO License No. 2007002923 Patient Intake Form Today

More information

MEDICAL QUESTIONNAIRE (male)

MEDICAL QUESTIONNAIRE (male) MEDICAL QUESTIONNAIRE (male) Slievemore Clinic, Old Dublin Road, Stillorgan, Co. Dublin. Tel 01-2000501/502 Fax: 01 2780248 The appointment comprises of a discussion about this questionnaire and a subsequent

More information

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other)  Address: Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:

More information

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip:

Patient Intake Form. Name: Date of Birth: Social Security No.: Address: City: State: Zip: Patient Intake Form Name: Date of Birth: Social Security No.: Address: City: State: Zip: Phone (circle 1) home / cell / work: Marital Status: Single / Married / Divorced / Widowed Work Status: Employed

More information

Consent for Treatment Form

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

More information

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax: PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:

More information