J. B. Chapman Dr. Schussler's Biochemistry
|
|
|
- Anissa Boyd
- 5 years ago
- Views:
Transcription
1 J. B. Chapman Dr. Schussler's Biochemistry Reading excerpt Dr. Schussler's Biochemistry of J. B. Chapman Publisher: B. Jain In the Narayana webshop you can find all english books on homeopathy, alternative medicine and a healthy life. Copying excerpts is not permitted. Narayana Verlag GmbH, Blumenplatz 2, D Kandern, Germany Tel info@narayana-verlag.com
2 INDEX A Abdomen Repertory A b s c e s s Acne (see Skin Disorders) Agu e (see Malaria) A m e n o r r. i e a A n e m i a A p h t h a e A p o p l e x y A p p e n d i c i t i s A p p e t i t e A r t h r i t i s A s t h m a Atrophy (see Marasmus) B B a c k a c h e B e d Wetting B i l i o u s n e s s Biochemistry? Wh at is B l a d d e r Bladder, Inflammation of (Cystitis) Bleeding of the Nose (see Hemorrhage) B o i l s B o n e s, D i s e a s e s o f B o w e l s Bright's Disease (Kidney Disorders) B r o n c h i t i s B u r n s C C a l c a r e a F l u o r C a l c a r e a P h o s Calcarea Sulph
3 294 DR. SCHUESSLER'S BIOCHEMISTRY Cancer Canker Carbuncles (see Boils) Catarrh Change of Life Chicken-pox Chlorosis Cholera Infantum Cholera Morbus Chorea Colds Colic Constipation Consumption Convulsions Cough Cramps Croup..., Cystitis D Deafness (see Ear, Diseases)... Ill Debility Delirium...97 Dentition Diabetes Diarrhea Diet Diphtheria Dizziness (see Vertigo) Dose of the Schuessler Remedies Dropsy Dysentery Dysmenorrhea Dyspepsia (Stomach Disorders)
4 INDEX 295 E Ear, Diseases of...ill Ear Symptoms Repertory Earache (see Ear, Diseases of)...ill Eczema Enuresis Epilepsy Erysipelas Exercise Eye, Diseases of Eye Symptoms Repertory F Face Symptoms Repertory Fainting Falling of the Womb Febrile (Fever) Symptoms Repertory Feeding of Infants Feeding of Children Felon (Boils) Female Organs Repertory Ferrum Phos Fever G Gall Stones Gastric (Stsmach) Symptoms Repertory Genuine Biochemic Remedies Glands, Diseases of Goiter (see Glands, Diseases of, 134) Gonorrhea Gout Grip Influenza
5 296 DR. SCHUESSLER'S BIOCHEMISTRY H Habits Hay Fever Head Symptoms Repertory Headache Heart Disorders Heatstroke Hemorrhage Hemorrhoids Hiccough Hip Joint Disease History of the Twelve Schuessler Remedies... 9 Hoarseness Hysteria I Incontinence of Urine (see Enuresis) Indigestion (Stomach Disorders) Inflammation of Bladder (Cystitis) Inflammation of Lungs (Pneumonia) Inflammation of the Tonsils (Tonsillitis) Inflammations Influenza Insomnia Intermittent Fever (Malaria) J Jaundice K Kali Mur Kali Phos Kali Sulph...31 Kidney Disorders...162
6 INDEX 297 L La Grippe (Influenza) Laryngitis Leucorrhea Loss of Appetite (see Appetite) Lumbago Lungs, Inflammation of (Pneumonia) M Magnesia Phos Malaria Marasmus Measles Meningitis Menopause Menorrhagia Menstruation Mental Disturbances Mental Symptoms Repertory Morning Sickness (see Vomiting) Mouth, Diseases of (see Aphthae or Canker) Mouth Symptoms Repertory Mumps N Natrum Mur Natrum Phos Natrum Sulph Nervous Symptoms Repertory Nettle-rash (see Skin Disorders) Neuralgia Neurasthenia Neuritis Nose Symptoms Repertory...257
7 298 DR. SCHUESSLER'S BIOCHEMISTRY P Pain Painful Menstruation (see Dysmenorrhea) Palpitation (see Heart Disorders) Paralysis Piles (Hemorrhoids) Pleurisy Pneumonia Pregnancy Prevention of Seasonal Illness Proper Preparation of Biochemic Remedies Prostatic Disorders Repertory of the Application of the Twelve Schuessler Biochemic Remedies: Abdomen Ear Symptoms Eye Symptoms Face Symptoms Febrile (Fever) Symptoms Female Organs Gastric (Stomach Symptoms) Head Symptoms Mental Symptoms Mouth Symptoms Nervous Symptoms Nose Symptoms Respiratory Organs Skin Symptoms Sleep Stools Teeth and Gums Throat Symptoms Tongue and Taste Urinary Organs R
8 INDEX 299 R Respiratory Organs Repertory Rheumatism Rickets (Rachitis) S Scarlet Fever Sciatica Silicea Sinus Disease Skin Disorders Skin Symptoms Repertory Sleep, Disturbances of Sleep Repertory Sore Mouth Aphthae Sore Throat Spasms St. Anthony's Fire (see Erysipelas) St. Vitus' Dance (see also Spasms, 86; Epilepsy, 120) Stomach Disorders Stools Repertory..., Summer Complaint Sunstroke Syphilis T Teething Teeth and Gums Repertory Tetter (see Skin Disorders, 213) Throat, Sore Throat Symptoms Repertory Thrush Tongue and Taste Repertory Tonsillitis Tuberculosis, Pulmonary Typhoid Fever
9 300 DR. SCHUESSLER'S BIOCHEMISTRY U Ulcers Urinary Disorders (see Kidney Disorders, 162; Cystitis, 93; Incontinence of Urine (Enuresis)) Urinary Organs Repertory Urine, Incontinence of (Enuresis) V Varicose Veins Vertigo Vomiting w Weakness Debility Wetting the Bed (see Enuresis) Whites (see Leucorrhea) Whooping-cough Worms Wounds Writer's Cramp (see Cramps, Spasms)... 86
10 J. B. Chapman Dr. Schussler's Biochemistry Twelve Biochemistry Remedies 300 pages, pb publication 2004 More books on homeopathy, alternative medicine and a healthy life
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
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask. Name Home Phone Work Phone Cell Phone E-Mail
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
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:
NEW PATIENT MEDICAL FORM. Name: Date of scheduled appointment: Address: Skype ID: Date of Birth: Gender: Height: Weight:
NEW PATIENT MEDICAL FORM Circle one: Dr. Tent Dr. Senechal Name: Date of scheduled appointment: Address: City: State: Zip: Home Phone: Cell Phone: Email: Skype ID: Date of Birth: Gender: Height: Weight:
CONTENTS. Foreword to the First Edition Foreword to the Second Edition Preface to the First Edition Preface to the Second Edition List of Medicines
Foreword to the First Edition Foreword to the Second Edition Preface to the First Edition Preface to the Second Edition List of Medicines xvii xxi xxiii xxvii xxix PART-1 INTRODUCTION 1. Introductory 1
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
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
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
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one) Date of
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
PEDIATRIC REGISTRATION FORM
MONTCLAIR HOMEOPATHY LLC Linda Corenthal Robins, M.D. Montclair, NJ 0704 Office 973-746-9888 www.montclairhomeopathy.com PEDIATRIC REGISTRATION FORM Referred by: Name Nickname Birth date Mother s Name
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:
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
Patient Information Form
Patient Information Form Health Card # Version Code Expiry Date (If applicable) (If applicable) Last Name: First Name: Birth date: (Please write the exact name that is on your Health Card) Month / Day
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
David Gemmell Everyday Homoeopathy
David Gemmell Everyday Homoeopathy Reading excerpt Everyday Homoeopathy of David Gemmell Publisher: Narayana Verlag http://www.narayana-verlag.com/b16508 In the Narayana webshop you can find all english
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
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:
B wel Chiropractic & Health Associates 3020 East College Avenue, Suite H Appleton, WI Dr. James M. Benzschawel
DATE: CASE HISTORY SEX: M / F LAST NAME: FIRST: M: DOB: ADDRESS: CITY: STATE: ZIP: APT OR UNIT #: HOME#: CELL#: SS #: - - MARITAL? M S W D # OF CHILDREN? SPOUSE NAME?: SPOUSE DOB?: OCCUPATION: EMPLOYER:
Adult Health History
Carriage House Medicine Jennifer C.Reid, N.D. 27530 SE Division Dr. Bldg C Gresham, OR 97030 (503) 492-9427 Adult Health History SUCCESSFUL HEALTH CARE AND PREVENTATIVE MEDICINE ARE ONLY POSSIBLE WHEN
My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf
Owego Chiropractic, P.C. 115 Temple Street, Owego NY 13827 (607)687-3800 Pediatric Patient Information Patient Name Last First Middle Initial Name you prefer to be called by (nickname) Gender (circle one)
Health screening questionnaire
Health screening questionnaire High Road Buckhurst Hill Essex IG9 5HX Tel: 020 8936 1202 Fax: 020 8936 1191 Visit: theholly.com Title: Surname: Forenames: Date of birth: Age: Address: Tel no. (Home): Tel
Naturopathic Intake Form PERSONAL MEDICAL HISTORY
List any surgeries, hospitalizations, imaging (CT, MRI, EEG, EKG, etc.) Date MM/YY ALLERGIES Do you have any allergies to medications? [ ] Yes [ ] No If yes, list medication and reaction Do you have any
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: _ First Name: Sex: M / F Address: City Postal Code: Home Phone: Work Phone: Cell Phone: Cell Phone Provider: E-mail: Occupation: Marital Status: No. of children:
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.
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
The TMJ Therapy Effects of Joint Manipulation
The overall postural structure associated with TMJ disorders is part of the The TMJ Therapy concern. Chiropractic manipulation has helped realign the joints in your TMJ, neck, and low back and along with
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
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
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
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:
PATIENT MEDICAL HISTORY INTAKE FORM
Northgate Professional Center 1985 Main Street, Suite 209 Springfield, Massachusetts 01103 Tel; 413-455-1081 Fax; 413-391-7489 www.marimedconsults.com PATIENT MEDICAL HISTORY INTAKE FORM Patient Information:
PLEASE NOTE: WE ARE A FRAGRANCE FREE BUILDING. *(Please circle answer where ever there is a multiple question.)
1 Dr. Stephen Maltais ND, Naturopathic Doctor 88 Dover Mills Road, Port Dover, ON. N0A 1N1 Phone: (519) 583-1234 E-mail: docmaltais@kwic.com www.dovernaturoapth.com INTAKE FORM FEMALE (16 years of age
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
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
PATIENT HEALTH QUESTIONNAIRE
PATIENT HEALTH QUESTIONNAIRE Name Date Please check all answers and fill in the blanks where appropriate. In the space below, please describe the major complaint which brought you to this office for care.
Institute for Continuing Theological Education Pontifical North American College
Institute for Continuing Theological Education Pontifical North American College 00120 Vatican City State Europe Medical History and Physician s Report (Applicant completes pages 1-to-3 before taking this
INFORMATION/APPLICATION FOR CARE
INFORMATION/APPLICATION FOR CARE The following information is needed in order to better serve you. Please complete all questions. If you need help please ask the receptionist. (PLEASE PRINT.) Today s Date
P. Banerjee Correct Prescriber
P. Banerjee Correct Prescriber Reading excerpt Correct Prescriber of P. Banerjee Publisher: UBSPD http://www.narayana-publishers.com/b5622 Copying excerpts is not permitted. Narayana Verlag GmbH Blumenplatz
Name: Date: Mark (c) for current problems, check and indicate the age when you had any of the following:
Patient Intake Form Patient information contained within this form is considered strictly confi dential. Your responses are important to help us better understand the health issues you face and ensure
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
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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
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 s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
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
Home Number: ( ) Cell Number: ( ) SSN#: Address: Address: Date of Birth Sex. Place of Birth Marital Status: (Optional) (City & State)
I. APPLICATION INSTRUCTIONS: School of Ultrasound Telephone (225) 756-3327 APPLICATION FOR APPOINTMENT AS STUDENT ULTRASOUND TECHNOLOGIST IN CARDIAC AND VASCULAR Applications for Admissions must include
Name: Gender: m F m M. Mother s full name: Telephone: (work) (mobile) Father s full name: Telephone: (work) (mobile) Name: Telephone:
Du La, ND# 1135 Jonah Lusis, ND# 1248 T: 416 598 8898 Pediatric Intake Date: Name: Gender: m F m M Age: D.O.B.: Address: City: Postal Code: Telephone: (home) E-mail: Mother s full name: Telephone: (work)
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
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
Ageless Acupuncture Patient Health History
Ageless Acupuncture Patient Health History Name: Date: By what name would you like us to refer to you?: Street Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell Phone: How early/late
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
Dr. Jeannie Doig, HBSc, ND Naturopathic Physician Port Alberni (250)
Child Intake Form Child s name Age Date of Birth Date Sex M F Who is filling out this form (name and relation)? Contacts (in order of preference): Name Phone h Address w other Relationship to Child Name
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
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
PATIENT INTAKE SHEET 2016
PATIENT INTAKE SHEET 2016 Patient Name: Last First Middle D.O.B.: Sex: M F Year Month Day Address: Street Address City May we leave a detailed message? Postal Code Phone : Residence Yes [ ] No [ ] Work
Family Naturopathic Clinic
Mark Orbay, B.Sc., N.D. Doctor of Naturopathic Medicine 265 Carling Avenue, Suite 610 Tel: (613) 230-6100 Fax: (613) 230-0070 Name: Phone (Home) Address: (Office) Date of Birth: / / Age: (Month) (Day)
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:
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
PATIENT DATA SHEET GENERAL INFORMATION DATE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE
PATIENT DATA SHEET GENERAL INFORMATION / / DATE LAST NAME FIRST NAME MIDDLE INITIAL ADDRESS CITY STATE ZIP CODE ( ) ( ) ( ) HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS SEX MALE FEMALE (PLEASE CIRCLE)
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
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
Adult Naturopathic Intake Form
Alternative Health Empowerment, Inc. 670 Colonial Road, Suite 5 Memphis, Tennessee 38117 (901) 683-8200 / www.ahe4life.com Personal Information Date: Name: Age: Birth Date: Sex: M F Address: City: State:
Patient Admittance Form
Patient Admittance Form Mah Chiropractic Clinic 7222 Edgemont Blvd. N.W. World Health Club Calgary, AB. T3A 2X7 Phone: (403) 241-1886 Fax: (403) 241-0995 Name: (Family) (First) (Initial) Sex: Male Female
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
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
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
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:
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
Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?
Successful healthcare and preventive medicine require a healthy relationship between provider and patient. Your responses to the following questions will significantly contribute to your doctor's understanding
Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
www.monctonnaturopathic.com 12 Fifth Street, Moncton, NB, E1E 3G9 Ph: 506-382-1329 Fax: 506-382-1828 Pediatric Intake Form (6-12 years) Name: Date: Age: Date of Birth: / / Gender (circle one): female or
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
(Please assign a numerical value from 1-6 to each goal in order of importance) Improve Energy Weight Loss Improve Physical Stamina/Endurance
Through our desire to provide you with the most focused and personalized healthcare experience, we would like to understand the primary reasons that have brought you to the clinic today. Please take a
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
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
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
New You Acupuncture Wellness Center Oriental Medicine - Acupuncture - Herbs - Homeopathy
Patient Contact Information Form Your privacy is being protected per HIPPA guidelines. No information will be given out without your expressed consent. Please indicate any of the following methods of communication
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:
Name: Date: Mark (c) for current problems, check and indicate the age when you had any of the following:
Patient Intake Form Patient information contained within this form is considered strictly confi dential. Your responses are important to help us better understand the health issues you face and ensure
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
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
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
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
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
DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin
Dr. Michelle Mackay Patel, ND
NATUROPATHIC ADULT INTAKE PERSONAL INFORMATION: First Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: What is your current gender identity? Male Female Transgender Male/Transman/FTM Transgender
CHIROPRACTIC ASSOCIATES CLINIC
CHIROPRACTIC ASSOCIATES CLINIC 1127 LAKEWOOD COURT NORTH, REGINA, SK S4X 3S3 PH: (306) 924-5300 FAX: (306) 924-5252 EMAIL: cac.north@accesscomm.ca CHIROPRACTIC INITIAL HEALTH FORM PATIENT INFORMATION Last
UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT
APPLICANT NAME: UCCM ANISHNAABE POLICE SERVICE EMPLOYMENT VISION REPORT REACTION ACCOM. LIGHT PUPILS EQUAL UNEQUAL FUNDI FIELDS OF VISION COLOUR (TEST USED) WITHOUT GLASSES NEAR FAR WITH GLASSES RIGHT
! 1. TISSUE SALTS by Kathleen Taylor
TISSUE SALTS by Kathleen Taylor The biochemical tissue salts were refined by Dr. Schuessler with his theory that the inorganic substances in the blood and tissues are sufficient to heal all the diseases
ORTHOPAEDIC ASSOCIATES of KENTUCKIANA, P.L.L.C Northgate Court, Suite 202, New Albany, Indiana 47150
ORTHOPAEDIC ASSOCIATES of KENTUCKIANA, P.L.L.C. 3605 Northgate Court, Suite 202, New Albany, Indiana 47150 Dear Patient: Welcome to the practice. We are honored that you have chosen us for your care, and
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
T.S. Iyer Beginners Guide to Homeopathy
T.S. Iyer Beginners Guide to Homeopathy Extrait du livre Beginners Guide to Homeopathy de T.S. Iyer Éditeur : Health Harmony http://www.editions-narayana.fr/b1370 Sur notre librairie en ligne vous trouverez
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
Patient Information. Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland
Patient Information Vibrant Health Acupuncture & Wellness Center, LLC 260 Gateway Drive, Suite 7B Bel Air, Maryland 21014 410-913-8322 Patient Name: Date of Birth: Age: Male: Female: Single: Married: Separated:
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
Patient Health History. Name: Date: First Middle Last. Street Address: City: State: Zip Code:
STEPHEN D. SAEKS, PhD, LAc 2 Roads Crossing Healthcare, PC 15455 NW Greenbrier Parkway, Suite 240 Beaverton, Oregon 97006 8116 503 617 0450 Patient Health History Name: Date: First Middle Last Street Address:
Our staff will need to make a photocopy of the following: Insurance Card (front and back) Driver's License or picture identification
Long Island Pulmonary and Sleep Medicine Associates, PLLC Louis Saffran, MD FCCP Frank S. Coletta, MD FCCP Karen Mrejen-Shakin, MD FCCP Aviva Kamath, MD FCCP Sepideh Sedgh DO 200 North Village Avenue Suite