Ayurvedic Propreitory Medicines Liquid Section

Size: px
Start display at page:

Download "Ayurvedic Propreitory Medicines Liquid Section"

Transcription

1 1 Ashwashila Gold 2 ElBas (Sugar Free) Useful in general debility due to premature ejacualation, nocturnal emission and retain vigour & vitality Ayurvedic Alkaliser Syrup useful in Stone Disorders, Dysuria, Burning Micturition, Crystalluria, Renal Calcui etc. 200 Ml. 3 Elz-Kuf Ayurvedic Cough Syrup with strong Formula 100 ml Ayurvedic Blood Purifier Syrup useful in Pimples, 4 Elz-Pure Boil abscess, itching, and allied skin complaints due 200 Ml. to blood impurity etc. 5 Elzym 6 Elzym-L 7 Elcid Elzac Herbal India V.P.O. Gheer, Karnal Contact: Contact@elzac.in Visit: Ayurvedic Propreitory Medicines Liquid Section Enzyme and Digestive Syrup useful in Indigestion, Loss of appetite, Flatulence, Dyspepsia etc. Liver tonic plus Enzyme Syrup useful in approving apetite and metabolism, useful in all type of infective hepatitis, provides protection against hepatotoxicity etc. Antacid and Antiflatulent Syrup useful in heartburn, Dyspepsia, Anorexia & Flatulence etc 8 Feezac Iron and Calcium Tonic 9 Fire-UP Appetizer 10 Five Nine Height Booster Syrup 11 Heptoliv Plus 12 Heptoliv Plus Ayurvedic Liver Tonic useful in loss of appetite, Jaundice, Enlarged liver, Heptotoxicity & Malabsorption, Cirrhosis of Liver & Alcoholism etc Ayurvedic Liver Tonic useful in loss of appetite, Jaundice, Enlarged liver, Heptotoxicity & Malabsorption, Cirrhosis of Liver & Alcoholism etc 100 ml 13 Orthozac Pain Relief syrup - Useful in Backache, joint pains, Arthritis, gout etc 14 Plat Pill Increases Platelets counts, increases body immunity, stimulates body enzymatic system, increases red blood cells, Cleanse body organs and gastrointestinal system from debris etc 15 Remind Brain Tonic 16 Retake Multivitamin, multimineral and health supplement syrup for whole family 17 Slimzac Slimming Syrup 18 Trikatu Useful in stimulating the digestive fire, or agni, allowing for more efficient digestion in the stomach while promoting proper bile flow, healthy detoxification and fat metabolism

2 19 Udramrit Antacid Syrup Useful in Anorexia, Dyspepsia and Flatulence 100 ml 20 An Ayurvedic Uterine Tonic useful in Menstrual cycle UtiZac (Sugar regulation, Dysmenorrhea, Menorrhagia, 200 Ml. Free) Leucorrhoea, Menopausal Syndroms etc 21 Uvi-Tone An Ayurvedic Uterine Tonic useful in Menstrual cycle regulation, Dysmenorrhea, Menorrhagia, Leucorrhoea, Menopausal Syndroms etc 22 Uvi-Tone An Ayurvedic Uterine Tonic useful in Menstrual cycle regulation, Dysmenorrhea, Menorrhagia, Leucorrhoea, Menopausal Syndroms etc 23 Anti-Cough Ayurvedic Cough Syrup with strong Formula useful in cold, dry cough, whooping cough, productive cough 100 ml & cough due to tonsilitis etc 24 Cough Care Ayurvedic Cough Syrup with strong Formula 100 ml 25 Apple Cider 26 Arjun Swaras Weight Loss, Digestion, memory booster, Skin cleanser etc Beneficial in clearing the arteries, blood clotting and increase oxygen flow to the heart. It also improves metabolic parameters, promotes thermogenesis, nourishes and strengthens the heart muscle etc 27 Datu Poshtik Helpful in Balya, Increasing Sperm Count, Rasayana & Sexual Desire etc 28 DiabaZac Best Ayurvedic Preparation for Diabetic Patients Useful in viral infections ( like Dengue, Maleria, 29 Giloy Plus Ras Chickengunea), gouts, vomiting, cardiac debility, skin diseases, anemia, cough, jaundice, seminal weakness etc helps to dissolve calculus in the urinary tract. It gives Shahi Gokhru relief from the symptoms of dysuria, hematuria, Kada frequency and burning micturition etc 31 Jamun Shrika Useful in Diabetes, Stomach disorders and anemia etc 32 Kerala Ras Useful for Diabetic Patients Shahi Aloevera Shahi Amla Plus Shahi Noni Plus Shahi Triphala Juices, Ras and Kadas Immunity Boaster, useful in ageing, high blood pressure, mental stress, liver weakness, eye sights, gas, constipation, acidity etc Useful in high blood pressure, mental stress, liver weakness, acidity, chronic fevers, immunity boaster, increasing digestion, provides strenght etc Useful in providing strenght, relieves mental stress, liver weakness, acidity, chronic fevers, immunity boaster, increasing digestion etc Useful in Diabetes, Bronchitis, Joint pains, Pimples, Cancer, Asthma, Psoriasis, Arthritis, Eczema, Sun Burn, Body Pain, cervical, hair loss, Graying of hair, Heart problems, Cholesterol, Digestive System, stamina, immunity, skin problems, bleeding gum, Toxins, stress, liver and kidney problems etc let/capsule Section

3 37 Ashvagandha Plus Elzac herbal India Ashvagandha 250 mg with Lakshadi guggul 125 mh 38 Calcizac-I Ayurvedic Remedy for Calcium and Iron Deficiency 39 Curzac Gold Curcumin 500 mg Capsule 40 Diabazac let Useful in Diabetes 41 Dr. Relax Ayurvedic Analgesic Joint Pain Relief Cap 10*10 42 Elbas Ayurvedic Alkaliser Syrup useful in Stone Disorders, Dysuria, Burning Micturition, Crystalluria, Renal Calcui etc. 43 Elz-Plate UP Useful in chronic fevers like dengue, malaria etc, Enhance Platelets Count 44 Elzym Enzyme lets Elzym Enzyme lets Glizac-T Giloy 500 mg with Tulsi 100 mg let 47 Heptoliv Plus Hepato-Protective Capsules 48 Heptoliv Plus Hepato-Protective lets Heptoliv Plus Hepato-Protective lets Livol Hepato-Protective lets 51 Neem Plus Neem Extract 500 mgwith Giloy 100 mg & Khadira 100 mg, Useful in Skin disorders, Anti Bacterial, Natural Antibiotic lets 52 OrthoZac Analgesic/Pain Killer Capsules 53 OrthoZac Gold Analgesic/Pain Killer lets 54 Plat Pill Increases Platelets counts, increases body immunity, stimulates body enzymatic system, increases red blood cells, Cleanse body organs and gastrointestinal system from debris etc 55 Pilzac Useful in Piles 56 Raktpitt Nasak Useful in all types of allergies. It also works as blood Gutika purifier and Anthelminic 57 Rejuvenator (Blister Pack) Sexual Enhancer Capsules 3*1*10 58 Retake Multivitamin, multimineral and health supplement syrup for whole family 60 Cap 59 Saptras Immunity Booster 60 Seven Power Sexual Enhancer Capsules Cap 61 Women Sure Female Health Capsule 60 cap Capsules, lets and also available in 1000's Jar /Powder Section 62 Elz-Fibe (Sugar Free) Ispaghula Husk etc, Useful in Constipation 100 mg 63 Elz-Fibe (Sugar Free) Orange Ispaghula Husk etc, Useful in Constipation 100 mg 64 No Gas Gas, Constipation, acidity, Heart burn etc

4 65 DiabaZac Best Ayurvedic Preparation for Diabetic Patients 100 gm Oil/Spray Section 66 Dr. Relax Ayurvedic Analgesic Joint Pain Relief Oil 60 ml 67 Nenel Hair Oil 100 ml 68 Orthozac Ayurvedic Analgesic Joint Pain Relief Oil 60 ml 69 OrthoZac Gold Ayurvedic Analgesic Joint Pain Relief Oil 60 ML. 70 OrthoZac Gold Ayurvedic Analgesic Joint Pain Relief Spray 100 ml 71 OrthoZac Gold Ayurvedic Analgesic Joint Pain Relief Roll On 50 ml 72 OrthoZac Gold Ayurvedic Analgesic Joint Pain Relief Roll On 75 ml Ayurvedic Classical Medicines Asava/Arishta 73 Abhayarishta Supportive remedy for piles and fistula-in-ano 74 Amritarishta Immunostimulant in recurrent liver, spleen and pyrexic dysfunctions 75 Arjunarishta Cardioprotective, hypocholesterolemic 76 Arvindasava useful in child digestive power etc. 77 Ashokarishta Menstrual cycle regulator 78 Ashwagandharis hta Anti-stress and nervine tonic 79 Babbulyadharist ha Useful in all cough etc. 80 Balaristha Complete body tonic and increases power and strength etc. 81 Bharingrajasava Useful in treating mucus cough and asthma etc. 82 Chandasava Useful in stone and burning sensation in Urine 83 Dashmularishta Female reproductive health normaliser after delivery, general tonic for females 84 Drakshasava Anabolic tonic 85 Jeerakaghristha Useful in weakness and fever after delivery in women etc. 86 Kanakasava useful in old cough and asthma etc. 87 Khadirarishta Anti-dermatophytosis 88 Kumariyasava useful in anaemia, blood loss etc. 89 Kutjaristha useful in diarrhea etc 90 Lodhrasava Useful in Gynaecological Disorder 91 Lohasava Useful in anaemia 92 Maha Mjishtha Dharishta Useful in itching, ring worm and other skin diseases 93 Maharasnadi Anti-rheumatic, Anti-inflammatory 94 Mustakaristha Increase digestive power and helpful in increasing hungerness etc. 95 pantragasava Weakness remover specially helpful in women etc. 96 Punarnavasava Useful in stomach, liver diseases 97 rohitakaristha Useful in liver problems and jaundice etc. 98 sarivaghasava Blood purifier and useful in all skin diseases etc. Increase memory power and treats mental problems 99 sarshvtaristha etc. 100 ushirasava Useful in raktpit and ajirnh etc.

5 101 Vasakasava useful in asthma and respiration diseases etc. 102 Vidangaristha Useful in removing worms and treating all stomach problems etc. All Asava and Aristha are also available in, 900 ml and 5 Litre Pack on demand with Fixed Minimum Order Quanity Anand Bairav 103 Ras Arogya Vardhani 104 Useful in acute and chronic fever, diarrhoea, rheumatoid arthritis etc. Useful in Constipation, Pimples, Diabetes, Joint pain and Fat 105 ArshKuthar Ras Useful in all types of Piles Chandra Prabha Maha Yograj Guggul 108 Mukta Pishti Useful in Leucorrea, irregular menstrution, weakness, urine infeaction etc Rheumatoid Arthritis, Osteoarthritis Useful in diarrhea with bleeding, Mania, Psychosis etc Prataplankeswar Ras Useful in chronic fever, diarrhoea etc 110 Praval Pishti Natural Calcium Source Sarivadi Useful in hearing problems such as tinnitus, ear infection etc Vatkulantak Ras Useful in Epilepsy, paralysis, facial palsy, lumbar and cervical spondylosis 113 Brahmi Ayurvedic Brain Tonic - useul in the treatment of depression, blood pressure etc 114 Kaishor Guggul useful for raised uric acid, mild to severe attacks of gouty arthritis, inflammatory diseases, wounds, abdominal diseases, constipation, indigestion, diabetic carbuncles etc. 115 Helpful in diaphoretic and pain reliever, used in Amar Sundari hysteria, epilepsy delirium, nervous debility & join pain, piles 116 Chitrakadi 117 Shul Varjini 118 Ghrini Kapat Ras 119 Bolbadha Ras 120 Gadhak Rasayan let/capsule Section good to improve the digestion power of body, useful in treat the problems like anorexia and indigestion. has the digestive and detoxifying properties usefulin digestive track problems, gas, the hiccups, respiratory problems etc. malasborption syndrome, anorexia, indigestion, lack of strength, muscle wasting, difficulty in breathing etc Useful in liver diseases with Pitta predominance, diabetes, bleeding hemorrhoids, abscess, hematurea and menorrhagia etc useful in the treatment of skin diseases, itching, chronic fever, urinary tract disorders etc

6 121 Triyodasang guggul 122 Lakshadi Guggul 123 Kanchnar Guggul Elzac herbal India Useful in all types of diseases related to nervous system and musculoskeletal system. Beneficial in gout, pain disorders, paralysis, hemiplegia, sciatica pain and all types of joint pain useful to treat the diseases of bones. useful to treat the various problems like low bone mineral density, osteoporosis, osteoarthritis and other diseases related to bones, teeth, joints and muscles Useful in hypothyroidism, hormone imbalances, PCOS and joint pains. 124 Shilajit Capsule Herbal Stamina Enhancer Capsules 125 Abhrak Bhasam Avipattikar Dant Prabhakar Manjan Hingwastak Lavan Bhaskar Useful for respiratory disorders, liver & abdominal diseases, mental diseases and psychosomatic disorders Supportive remedy for hyperacidity and constipation Useful for sensitive teeths, Bad breath, Pyrrhea etc Digestive and anti-flatulent Digestive, carminative 10 gm 1 Mushli Pak Sexual Enhancer 100 gm 131 Panchasakar 132 Praval Pishti 133 Sitopaladi Useful in increasing digestive power and hunger Useful in cough, cold excessive burning sensation, improves immunity. Natural Calcium and Vitamin C Source Bronchial antiseptic, anti-inflammatory and expectorant, with honey 10 gm 134 Supari Pak General tonic for reproductive health in females 100 gm 135 Triphala Mild laxative, antibacterial 100 gm 136 Vang Bhasam Useful in vomiting, anorexia, non healing wounds, helminthiasis, premature ejaculation, noctural emission, cough, cold, bronchitis, asthma, emaciation, weight loss, and chronic bronchial diseases Capsules, lets and also available in 1000's Jar 10 gm 137 Maha Narayana Oil Ayurvedic Analgesic Joint Pain Killer Oil 60 ml 138 Shri Gopal Oil Sexual Enhancer Oil ml 139 Chyawanprash 140 Vasavleha /Powder Section Oil/Spray Section Avela Section All-in-One' rejuvenating, age-sustaining and 500 gm immunostimulant tonic Useful in Respiratory diseases like Cough and Troat, 250 gm stomach Diseaese

7 Sno Type Elzac herbal India Food Supplements Product 141 Elz-Pro Protein Supplement Powder 200 gm 142 Lycobank 143 Folinex-D Sno. 144 Lycopene 5000 mcg with multivitamins, multimineral Capsule L-Methyl folate 1mg, DHA 250 mg, Methylcobalamin 1500 mcg, Pyridoxal 5 Phosphate 1.5 mg 10*10 (Alualu) 10*10 (Alualu) Product Uses Packin g Sharbat Bazoori Motadil 145 Arq Badyan 146 Arq Zeera Sno. Type 1 Bhasma Unani Medicines Used as liver tonic, diuretic and beneficial in urinary diseases, restlessness, hyperacidity, kidney disorders and fevers. Useful in Liver, Kidney, Stomach and intestinal disorders, releases gas etc Useful in Liver, Kidney, Stomach and intestinal disorders, releases gas etc On Demand Available Product Abhrak Bhasam, Kasis Bhasam, Godanti Bhasam, Mandur Bhasam, Loh Bhasam, Shank Bhasam, Swarn Makshik Bhasam, Kukkuthandhtvk Bhasam, Vang Bhasam, Tankan bhasam, Ras sindhur Bhasam etc Mukta Pishti, Jaharmohra Khatai Pishti, Maha Laxmi Vilas 2 Pishti/ Ras, Praval Pishti, Mahayograj guggul vati, Giloy Gan, Balbadha Ras, Vyosadhi, Punarvadhi Mandur, Prataplankeswar Ras etc Term & conditions: 1 GST as applicable will be charged. Propreitory 12% & Classical 5% 2 Price Subject to change without Notice ( only unavoidable circumstances ) 3 Orders will be executed subject to availabililty to stocks 4 Breakage and Manufacturing Defects goods are replaceable. 5 Expiry is not replaceable. 6 Payment : Advance 7 Transport: Topay Basis 8 All disputes are subject to Karnal jurisdiction only

TABLET CAPSULE( ALL ARE VEGETARIAN CAPSULES)

TABLET CAPSULE( ALL ARE VEGETARIAN CAPSULES) S.NO PRODUCT INDICATIONS PACKING 1 HEAL HERB 2 BP HERB 3 4 5 6 7 DIABETIC HERB GARLIC CAP CAOSULE) STRESS HERB HAIR HERB CARDIAC HERB TABLET USEFUL IN FRACTURE HEALING, PAIN & SWELLING CAUSED BY SPRAIN

More information

Mittal Ayurved. Product s Overview Document. Puneet Mittal

Mittal Ayurved. Product s Overview Document. Puneet Mittal Product s Overview Document Mittal Ayurved Puneet Mittal Mittal Ayurved Sansthan 121-B, Mansarovar Ind Area Ext, Meerut, INDIA +91-8937015757[INDIA] +1-336-265-9909[USA] Pure Herbs-Powders [Size 100gms]

More information

Health Benefits of Lemongrass

Health Benefits of Lemongrass 1 Health Benefits of Lemongrass Lemongrass, also called fever grass, is a perennial plant with thin, long leaves that is indigenous to many Asian countries. As the name implies, lemongrass smells like

More information

Apple Cider Vinegar Research has shown Apple Cider Vinegar cure high cholesterol, diabetes, sore throats and heart burn.

Apple Cider Vinegar Research has shown Apple Cider Vinegar cure high cholesterol, diabetes, sore throats and heart burn. Home Remedies Winter home remedy drink What you need: Ginger juice one cup Lemon Juice one cup Garlic Juice one cup Apple cider Vinegar one cup How to make: Crush ginger and garlic separately Squeeze to

More information

FHP BODY DETOX CAPSULE

FHP BODY DETOX CAPSULE FHP PRODUCTS FHP BODY DETOX CAPSULE FHP UREE CARE CAPSULE FHP MORINGA CAPSULE FHP SHAANT CAPSULE FHP HERBAL Curcuma CAPSULE FHP WOMAN CARE SYRUP FHP SUPER MEMO SYRUP FHP SHUDH SYRUP FHP BODY DETOX CAPSULE

More information

Natural Healing Herbal Supplements & Oils

Natural Healing Herbal Supplements & Oils Natural Healing Herbal Supplements & Oils www.naturalhealings.in OilHerbs@gmail.com Vigor Plus is a herbal supplement to help Men and Women in improving stamina and vigor in both partners. It helps in

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

J. B. Chapman Dr. Schussler's Biochemistry

J. B. Chapman Dr. Schussler's Biochemistry J. B. Chapman Dr. Schussler's Biochemistry Reading excerpt Dr. Schussler's Biochemistry of J. B. Chapman Publisher: B. Jain http://www.narayana-verlag.com/b1476 In the Narayana webshop you can find all

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

We are a leading manufacturer and exporter of a safe and effective range of Ayurvedic Drugs And Herbal Drugs. Further, we also offer clinical

We are a leading manufacturer and exporter of a safe and effective range of Ayurvedic Drugs And Herbal Drugs. Further, we also offer clinical We are a leading manufacturer and exporter of a safe and effective range of Ayurvedic Drugs And Herbal Drugs. Further, we also offer clinical treatments like therapeutic & health care treatment for curing

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

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

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

Herbal Properties Glossary

Herbal Properties Glossary Herbal Properties Glossary Adaptogen A non-toxic compound that increases resistance to physical, chemical, and emotional stresses. These compounds seem only to be activated when one is under stress. They

More information

PUNARNAVA Boerhavia diffusa Linn

PUNARNAVA Boerhavia diffusa Linn PUNARNAVA Boerhavia diffusa Linn Shekhar Annambhotla Founder Ojas, LLC Ayurveda Wellness Center Founder - Association of Ayurvedic Professionals of North America, Inc. Founder Global Ayurveda Conferences,

More information

NEUROLOGICAL SURGERY, P.C.

NEUROLOGICAL SURGERY, P.C. NEUROLOGICAL SURGERY, P.C. PATIENT INFORMATION Name Date of Birth Age Address City Sate NY Zip Home ( ) - Cell ( ) - Work ( ) - Ext: Email Address _ Sex M F Soc. Sec. #: / / Single Married Widowed Separated

More information

Liver Health: Do you have liver problems? Yes No If so, please specify:

Liver Health: Do you have liver problems? Yes No If so, please specify: Medical History General Last Name: First Name: Date of Birth: Age: Contact Number: Are you in good health to the best of your knowledge Medical Information: Please list any physicians you see and their

More information

The Campbell M Gold Newsletter Vol. 07 - Issue 18 Campbell M Gold Consultant Self-Help and personal Development through New Thinking, and Hypnosis and Subliminal Programs Welcome to this special newsletter

More information

Weight loss with raw, organic, Apple Cider Vinegar is slow and steady but permanent. DC Jarvis M.D. Vermont

Weight loss with raw, organic, Apple Cider Vinegar is slow and steady but permanent. DC Jarvis M.D. Vermont FREE REPORT Discover How 13 Of The Most Potent Foods And Common Herbs Can Be Combined To Increase Health AnVitality, Assist In Melting Fat And Reduce Cravings. Free$Report$$ $ Can A Low-Cost, Tasty Food

More information

AAYUSHANTI GENERIC RANGE

AAYUSHANTI GENERIC RANGE AAYUSHANTI GENERIC RANGE Ayurvedic medicines have been tried and tested over centuries and still hold fort even today. A product like Triphala Churna which since centuries is considered one of the best

More information

RHEUMATOLOGY PATIENT HISTORY FORM

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

More information

MEDICAL DATA SHEET For Patients 18 years of age and older

MEDICAL DATA SHEET For Patients 18 years of age and older MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other

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

PLEASE COMPLETE ALL SECTIONS OF THIS FORM

PLEASE COMPLETE ALL SECTIONS OF THIS FORM PLEASE COMPLETE ALL SECTIONS OF THIS FORM Patient Name: Date of Birth: Referring Doctor? (Name, telephone number and address) Chief Complaint: Why have you come here? How did it start? What are the symptoms?

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

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

UNIT 1: INTRODUCTION AND HERBAL REVIEW

UNIT 1: INTRODUCTION AND HERBAL REVIEW INTERMEDIATE HERBAL COURSE OUTLINE UNIT 1: INTRODUCTION AND HERBAL REVIEW Lesson 1: Let s Get Started! Lesson 2: Introduction to the Intermediate Course Why Choose Herbs? An Ecological Relationship How

More information

HOW TO NATURALLY TREAT INDIGESTION YOGI CAMERON

HOW TO NATURALLY TREAT INDIGESTION YOGI CAMERON HOW TO NATURALLY TREAT INDIGESTION YOGI CAMERON Indigestion is a condition that is often a symptom of another, underlying condition and is associated with various forms of discomfort in the stomach including

More information

MenoChat. City State Zip Code. Employer Job Title. Primary Care Provider Phone: History. Desired Outcome:

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

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

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

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

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications): Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage

More information

New Patient Information

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

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

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

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

ANY FAMILY HISTORY OF ANEURYSM OR DVT? NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK

More information

ESSENTIAL OILS USES CHART

ESSENTIAL OILS USES CHART ESSENTIAL OILS USES CHART Basil OIL PROPERTIES BENEFITS/USES HOW TO USE PRECAUTIONS Spicy Concentration Avoid with pregnancy Warm PMS Herbal Boost immunity Bergamot Soothing Vermifuge Antibiotic Deodorant

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

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

MEDICAL HISTORY (To be filled in by patient)

MEDICAL HISTORY (To be filled in by patient) MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum

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

+91-8447573951 Shriji Herbal Products www.shrijiherbalproducts.net We are a prominent manufacturer and exporter of effectual array of Ayurvedic Herbal Products, Herbal Skin & Hair Care Products. Our range

More information

Initial Consultation

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

More information

NOTICE OF PROCUREMENT FOR THE ANNUAL SUPPLY OF AYURVEDIC MEDICINES MHPQ/PHARM/ /Q68 OAB Description Packing Quantity Selected

NOTICE OF PROCUREMENT FOR THE ANNUAL SUPPLY OF AYURVEDIC MEDICINES MHPQ/PHARM/ /Q68 OAB Description Packing Quantity Selected Notice of Procurement of Contract Notice under section 40(7) of the Public Procurement Act 2006 MHPQ/PHARM/2015-2016//Q68 OAB ANNUAL SUPPLY OF This is notify that, following the bidding exercise carried

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

Natural Balance strives to offer efficacious, holistic, natural health-care, in a personalized, caring and supportive manner.

Natural Balance strives to offer efficacious, holistic, natural health-care, in a personalized, caring and supportive manner. - What do you do at Natural Balance? - What do you treat? - Do you treat children? - Why use a Herbalist? - How fast do these remedies take to work? - Can I take these remedies with these pharmaceutical

More information

LECOM Health Ophthalmology

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

More information

Opti-Balance Naturopathic Medicine Intake Form

Opti-Balance Naturopathic Medicine Intake Form Opti-Balance Naturopathic Medicine Intake Form Personal Information: Name: ( First, Middle, Last ) Birth Date: Age: Blood Type: Gender: M / F Social Insurance Number: Height: Weight: Address: City: Postal

More information

Patient History Form

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

More information

Multiphasic Blood Analysis

Multiphasic Blood Analysis Understanding Your Multiphasic Blood Analysis Test Results Mon General thanks you for participating in the multiphasic blood analysis. This test can be an early warning of health problems, including coronary

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

All product claims should be truthful, not misleading, and should be backed by scientific evidence.

All product claims should be truthful, not misleading, and should be backed by scientific evidence. SHARING YOUNG LIVING the Right Way The U.S. and most other countries have regulations in place designed to protect consumers. Many of these specifically regulate how natural wellness companies like Young

More information

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle

More information

NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name

NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name NEW PATIENT FORM Please print in ink and fill in all blanks Please fill out front and back Patient s Full Name Date of Birth Age Sex Social Security Number Referring Doctor or Family Physician Phone #

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 FORM (WOMEN ONLY)

PATIENT INFORMATION FORM (WOMEN ONLY) PATIENT INFORMATION FORM (WOMEN ONLY) Name: Age: Sex: Birthdate: / / SS # A. Describe briefly your present symptom(s) or the reason(s) for seeing the doctor today: B. Name all illnesses or conditions for

More information

Squalene 100% 100 Capsules

Squalene 100% 100 Capsules Origin-A stands for the origins of Australia. Origin-A s brand is identified through its mission to provide original products stemmed from nature. The range of products promotes clean and pure management

More information

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

PACKAGE LEAFLET: INFORMATION FOR THE PATIENT

PACKAGE LEAFLET: INFORMATION FOR THE PATIENT PACKAGE LEAFLET: INFORMATION FOR THE PATIENT Kopen Sugar Free 125mg/5ml and 250mg/5ml Powder for Oral Solution Phenoxymethylpenicillin Read all of this leaflet carefully before you start taking this medicine

More information

NEW PATIENT QUESTIONNAIRE

NEW PATIENT QUESTIONNAIRE Consultant Name: NEW PATIENT QUESTIONNAIRE Health Care Analysis CONGRATULATIONS! You ve taken an important step in your commitment to managing your weight. We look forward to working with you. Our Program

More information

Margie Petersen Breast Center

Margie Petersen Breast Center Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced

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

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

Dr. Miller s Detox Tea Detailed Product Information

Dr. Miller s Detox Tea Detailed Product Information Dr. Miller s Detox Tea Detailed Product Information LurraLife is honored the join forces with Dr. Miller to bring his original Holy Tea formula to market as Dr. Miller s Detox Tea. For more than twenty-five

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

06/09/2005 Medical history and intake form

06/09/2005 Medical history and intake form Medical history and intake form Please complete this form as accurately as possible - it helps to provide you with the best possible treatment. Address including postcode Contact numbers Home/work/mobile

More information

FULVITE a fulvic acid tonic by JESU-RAPHA

FULVITE a fulvic acid tonic by JESU-RAPHA FULVITE a fulvic acid tonic by JESU-RAPHA Nutritional, mineral and remedial tonic derived from ancient plants 15% fulvic acid concentration, manufactured exclusively for Rapha using a unique process An

More information

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring

More information

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office? CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL

More information

Date of Birth: Age: Sex: male female. Weight: Height: Address: Parents: Mother s Phone: (home) (cell) (work) Mother s

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)

More information

Patient Intake Form for Allegany Ear, Nose, & Throat

Patient Intake Form for Allegany Ear, Nose, & Throat Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?

More information

New Patient Questionnaire/Assessment

New Patient Questionnaire/Assessment Welcome to the St. Joseph Mercy Pain Institute. Your answers to the following questions are important for your evaluation and care. Please read each question carefully and answer all 4 pages as completely

More information

GoPrivateMD General Information & History

GoPrivateMD General Information & History Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.

More information

NEW PATIENT INTAKE FORM

NEW PATIENT INTAKE FORM NEW PATIENT INTAKE FORM Personal Information Name Date of First Visit Address City Province Postal Code Telephone # (home) (work) E-mail Address Relationship Status Age Date of Birth (M/D/Y) Gender: female

More information

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

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:

More information

Athens Rheumatology Clinic, LLC Sana Makhdumi, MD

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

More information

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children? PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:

More information

Integrative Consult Patient Background Form

Integrative Consult Patient Background Form Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a

More information

Irbenida H 150mg/12,5mg film-coated tablets

Irbenida H 150mg/12,5mg film-coated tablets PACKAGE LEAFLET: INFORMATION FOR THE USER Irbenida H 150mg/12,5mg film-coated tablets IRBESARTAN/HYDROCHLOROTHIAZIDE This leaflet is a copy of the Summary of Product Characteristics and Patient Information

More information

MEDICAL DATA SHEET For Patients 18 years of age and older

MEDICAL DATA SHEET For Patients 18 years of age and older MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other

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

Nutrient Assessment Chart

Nutrient Assessment Chart Vitamin A Assessment Chart Chicken skin on backs of arms Chronic acne Dry eyes Food allergies Poor night vision Recurrent infections and colds Reduced hair growth in children Ulcers B Vitamins Afternoon

More information

Soft Gelatin Capsules. Oil Based Formulation s

Soft Gelatin Capsules. Oil Based Formulation s Soft Gelatin Capsules Pharmaceutical Vaginal Suppositories Herbal Oil Based Formulation s External Cosmetics Therapeutics Dietary Supplements Multi Minerals & Multi Vitamins Coenzyme Q10 Immunosuppressant

More information

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

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

More information

PATIENT INTRODUCTION

PATIENT INTRODUCTION PATIENT INTRODUCTION Personal History: Mr. Mrs. Miss Ms. Dr. Name: First Middle Last Your Address: _ City: Prov: Postal Code: Telephone: Home: Bus: Cell: E-Mail: Check this box if we may contact you via

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 Intake Form

Medical History Intake Form Medical History Intake Form What is your opinion of your overall level of health? Excellent Good Fair Poor In your opinion (not necessarily your health care providers), what are your most important health

More information

CAN I S Ay. A Guide To

CAN I S Ay. A Guide To CAN I S Ay that? A Guide To acceptable product claims Introduction Determining what we can and cannot say about NSP products can be confusing at times. This pamphlet is designed to provide NSP distributors

More information

PLAS/RECON SURGERY PATIENT HEALTH HISTORY

PLAS/RECON SURGERY PATIENT HEALTH HISTORY PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?

More information

CULINARY HERBS AND SPICES

CULINARY HERBS AND SPICES CULINARY HERBS AND SPICES Using Culinary Herbs and Spices Flavour and texture are a huge issue when it comes to introducing new foods to your diet Herb and spices can help make a new food seem like an

More information

Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

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

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

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury

More information

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight:

More information

Nutrition Consultation Intake Form Please write or print clearly

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

More information

BACK TO BASICS HEALTH & NUTRITION COMPREHENSIVE HEALTH HISTORY

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

More information

Candida Questionnaire: Are your health problems yeast connected?

Candida Questionnaire: Are your health problems yeast connected? Candida Questionnaire: Are your health problems yeast connected? The following questionnaire can be given to your clients if you suspect candida is a problem. YES NO Have you taken repeated courses of

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