Who is filling the form (name & relation): Date: Referred by: Ethnicity: Present height: Name of mother: Name of father:
|
|
|
- Baldric Snow
- 6 years ago
- Views:
Transcription
1 Pnam Patel, B.Sc., N.D. Dctr f Naturpathic Medicine PEDIATRIC INTAKE FORM Please print clearly and fill ut this frm t the best f yur ability. It will help t assess the child s present health and will assist in facilitating the healing prcess. Wh is filling the frm (name & relatin): Date: Referred by: Name: Age: Gender: Male/Female Present weight: Ethnicity: Present height: Name f mther: Name f father: Emergency Cntact Infrmatin: Name: Address: Relatin: Hme phne #: Wrk phne #: Cell phne #: Names f ther health care practitiners (pediatrician/medical dctr, specialists, etc.) the child is seeing: Name: Practitiner: Address: Phne: ( ) Name: Practitiner: Address: Phne: ( ) Name: Practitiner: Address: Phne: ( ) CHIEF HEALTH CONCERNS: List the child s health cncerns (in rder f imprtance): MEDICAL HISTORY: Describe the child s general state f health: Indicate any serius cnditins, illnesses r injuries, and any surgeries r hspitalizatins (prvide apprximate dates): List any allergies (fd intlerances/allergies, medicines, envirnmental, etc.) the child has:
2 Pnam Patel, ND Dctr f Naturpathic Medicine List all vitamins, minerals, btanical (herbal) medicines, Asian medicines (Chinese Patent drugs), r hmepathic remedies that the child is currently taking. Indicate daily dsage: List all names f prescribed medicatin currently being taken. Include dsage, frequency, hw lng the child has been taking it, and any adverse reactins/allergies t medicatins: Medicatin Dse (i.e. mg) Frequency (#times/day) Since Hw Lng Adverse Reactins Allergies (Describe) List all ver the cunter medicatin that the child takes (e.g.: Aspirin, cugh syrup, etc.). Include dsage and frequency and any adverse reactins/allergies t medicatins: Medicatin Dse (i.e. mg) Frequency (#times/day) Since Hw Lng Adverse Reactins Allergies (Describe) Hw many times has the child been treated with antibitics? Which f the fllwing has the child had in the past? (n-never, m-mild, a-average, s-severe) Rubella (German measles) n m a s Rsela n m a s Measles n m a s Scarlet Fever n m a s Chicken px n m a s Mumps n m a s Whping cugh n m a s Strep thrat n m a s Mnnuclesis n m a s Impetig n m a s Ear infectins n m a s Other: n m a s What screening test(s) has the child had (bld, hearing, visin, etc.)? PRENATAL AND BIRTH INFORMATION: What was the health f the parents at cnceptin? Mther: Pr Fair Gd Excellent Unknwn Father: Pr Fair Gd Excellent Unknwn During the pregnancy: Hw was the health f the mther during the pregnancy? Pr Fair Gd Excellent Unknwn Hw was the mther s diet during pregnancy? Pr Fair Gd Excellent Unknwn Did the mther receive prenatal medical care? Y/N/Unknwn Please check ( ) any f the fllwing that applied t the pregnancy. Diabetes Nausea Bleeding Vmiting Thyrid prblems Infectins Alchl/drug use High bld pressure Other:
3 Pnam Patel, ND Dctr f Naturpathic Medicine Did the mther use any f the fllwing during the pregnancy? Tbacc Over-the-cunter/Prescriptin medicatins: Alchl Supplements: Recreatinal Drugs Other: Was there any physical r emtinal trauma (accidents, abuse, death in the family, etc.)? Y/N What? Any expsure t diseases? Y / N Which ne(s)? Any traveling? Y / N Where? Occupatin (type and lcatin): BIRTH HISTORY: What was the mther s age at child s birth? Length f pregnancy term: Full Premature: weeks Late: weeks Please check ( ) any f the fllwing that applied t the birth: Induced Vaginal Pitcin C-sectin Pain medicatin Episitmy Epidural Frceps Vacuum extractin Birth injuries Other: Hw lng was the labur (hurs)? Any cmplicatins? Infant weight: Length: Head circumference: APGAR scre (if knwn): Birth: 1 minute: 5 minutes: NEONATAL HISTORY: Please check ( ) any f the fllwing that apply: Anemia Pr feeding Jaundice Rashes Seizures Respiratry Infectins distress Clic Cngenital/birth defects: Other: Was the infant breastfed? Y / N Hw lng? Was the infant frmula fed? Y / N Which ne was/is used? Is the child fed cw s milk? Y / N Since when? At what age was slid fd intrduced? Which fds? Please check ( ) any f the fllwing vaccinatins that have been given: Chicken px (Varicella) Influenza (flu sht) Rabies Chlera MMR (Measles/Mumps/Rubella) Typhid DTP Meningcccal (meningitis) BCG (Diphtheria/Tetanus/Pertussis) Pneumcccal (Tuberculsis) Hepatitis A Pli Yellw Fever Hepatitis B Travel Vaccinatins Dn t knw Were there any reactins (within ne week) t any f the abve? Y / N (if yes, please describe):
4 Pnam Patel, ND Dctr f Naturpathic Medicine DEVELOPMENTAL MILESTONES: Indicate the age at which each f the fllwing was reached: Rlling ver Running Asking questins Crawling Tilet training 1 st tth Spken wrds Cunting t 10 All teeth Walking alne Dressing self FAMILY HEALTH HISTORY: Family member Age Illnesses Mther Father Maternal grandmther Maternal grandfather Paternal grandmther Paternal grandfather Sibling: Sibling: I dn t knw the family medical histry LIFESTYLE: Des yur child have any dietary restrictins (religius, vegetarian/vegan, allergens, etc.)? Y/N If yes, describe: Describe a typical day s diet: Breakfast: Lunch: Dinner: Snacks: Beverages (and ttal quantity): List fds mst frequently eaten and hw ften: Hw wuld yu describe the child s temperament? Is the child in: (circle ne) schl daycare hme care ther: Describe the child s general schl/daycare perfrmance: Has the child been diagnsed as having any learning disabilities? Y / N If yes, what disability? List any interests: Favurite activity: Hw much televisin des yur child watch? hurs a day/week Des the child exercise regularly? Y/N If yes, describe what type, hw lng & hw ften:
5 Pnam Patel, ND Dctr f Naturpathic Medicine Number f hurs f sleep: Naps (hurs): Des anyne in the child s husehld smke? Y/N Are there animals in the hme? Y/N If yes, what: D yu knw f any txins r ther hazards the child is regularly expsed t (hme, ther s wrk, hbbies, etc.)? Please describe: Please check ( ) any f the fllwing that applies t the present living cnditins: Rental apartment Old huse (> 20 years) City living Basement dwelling Cndminium Suburb living New huse (< 5 years) Recent renvatins Carpets Pets: Smking adults Hw wuld yu describe the emtinal climate f the child s hme? Is there anything that yu feel is imprtant that has nt been cvered? REVIEW OF SYSTEMS: Please circle the cnditin if the child has it nw r has had it in the past: Skin rashes, eczema, psriasis, acne, itching, lumps, clur change, dry, mist, easy bruising Nails clur changes, fungal infectins, brittle/shear, vertical/hrizntal lines, hangnails Head headaches, dizziness Eyes crrected visin, pain, tearing, dryness, blurring, redness, discharge, itching Ears impaired hearing, earache, discharge, infectins Nse & Sinus frequent clds, nse bleeds, stuffiness, hay fever, sinus prblems Muth & Thrat frequent sre thrat, gum prblems, harseness, dental cavities, lss f taste Neck lumps, swllen glands, pain/stiffness, enlarged thyrid Lungs cugh, phlegm, spitting up bld, wheezing, difficulty breathing r shrtness f breath, pain n breathing, asthma, brnchitis, tuberculsis, pneumnia Cardivascular heart disease, murmurs, palpitatins, chest pain Peripheral vascular deep leg pain, cld extremities, swllen arms/legs, ulcers Gastrintestinal heartburn, indigestin, nausea, vmiting, belching, passing gas, stmach pain Gastrintestinal cnstipatin, diarrhea, bld in stl, mucus in stl, hemrrhids, black stl Urinary pain, frequent urinatin, inability t hld urine, bld in urine, urgency, infectins Musculskeletal jint pain/stiffness/swelling, muscle pain/stiffness/weakness/cramps, brken bnes Neurlgic fainting, seizures, paralysis, numbness/tingling Neurlgic lss f balance, invluntary mvement, speech prblems, memry lss Endcrine fatigue, heat/cld intlerance, thyrid prblems, excess thirst/hunger/sweating Female health nipple discharge, vaginal discharge, vaginal itching, hernias Male health - testicular masses/pain, discharge frm penis, hernias Emtinal md swings, anxiety/nervusness, insmnia Expsure t pest, tbacc smke, txins/chemicals at hme Date f last physical exam:
Pediatric Health History Form
Pediatric Health Histry Frm Child s Name Date f Birth Mther s Name Father s Name Parent Cncerns - Please explain any ther cncerns r questins yu have abut yur child Des yur child have any allergies? Yes
Urology CHIEF COMPLAINT ALLERGIES. What is the main reason for your visit today? Allergen Yes No Reaction
Urlgy Kari White, NP Phne: 646-962-9600 Name: Date f Birth: Date: CHIEF COMPLAINT What is the main reasn fr yur visit tday? ALLERGIES Are yu allergic t any f the fllwing? Please check YES r NO fr each.
Please list any other health concerns (physical, emotional or mental) in order of importance:
1281 Shppers Rw NATUROPATHIC ADULT INTAKE Naturpathic medical care requires a healthy relatinship between prvider and patient. Yur respnses t the fllwing questins will significantly cntribute t yur dctr's
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
Do you have any of the symptoms listed below? Please circle all that apply.
D yu have any f the symptms listed belw? Please circle all that apply. Parkinsn s Symptms: Truble walking Falls Feet sticking t the flr Tremr Medicatins wearing ff Truble sleeping Vivid dreams Thrashing
Patient Information Packet Date:
Patient Infrmatin Packet Date: We knw paperwrk is nt fun, but thank yu s much fr taking the time! Last Name: First Name: MI Address: Phne: City State: Zip Cde: Mbile: D.O.B: / / Scial Security: / / Email:
New Patient Registration and Medical History. Address City State Zip code
Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719 2441 / Fax (724)719 2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date
New Patient Information Sheet PLEASE COMPLETE THIS ENTIRE FORM. Date of Appointment: / /
New Patient Infrmatin Sheet PLEASE COMPLETE THIS ENTIRE FORM The frm may seem lengthy but it is very imprtant t help us understand yur pain cmplaints. This will help us prvide yu with the highest level
9631 N Nevada St. Suite 210. Spokane, WA Phone: (509) and Fax: (877) Jeffrey R. Jamison, D.O. and Mark J Erwin, PA-C
9631 N Nevada St. Suite 210 Spkane, WA 99218 Phne: (509) 319-2430 and Fax: (877)568-2402 Jeffrey R. Jamisn, D.O. and Mark J Erwin, PA-C Yu are scheduled fr a medical examinatin with n. The fllwing instructins
PATIENT INFORMATION. Last Name: First Name: Address: City/State/Zip: Phone: (H): (W): (C): Date of Birth: Gender: Male Female
PATIENT INFORMATION Date Last Name: First Name: Address: City/State/Zip: Phne: (H): (W): (C): Email: Date f Birth: Gender: Male Female EMERGENCY CONTACT INFORMATION Last Name First Name Middle Initial
Idaho Naturopathic Medicine 6550 W Emerald, Ste 112 Boise, Idaho Ph: Fax:
Idah Naturpathic Medicine 6550 W Emerald, Ste 112 Bise, Idah 83704 Ph: 208-275- 0007 Fax: 208-323-9909 www.idahnaturpathicmedicine.cm Welcme t Idah Naturpathic Medicine We lk frward t meeting yu sn. It
Scottsdale Family Health
Scttsdale Family Health New Patient Frm Patient Name: Date f Birth: Tday s Date PHARMACY: (Please list name and number f pharmacy yu wish t have prescriptins sent t.) Pharmacy Pharmacy Number MEDICAL HISTORY
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Female Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy
Medical History. hallucinations? 27 Would you describe your sleep as refreshing? 28 Do you need a minimum amount of sleep to feel
Pediatric Neurlgy Pediatric Pulmnlgy Pediatric and Adult Sleep Medicine The Offices f Dr. Jshua Rtenberg, Dr. Sarat Susarla, Dr. Michelle Nwsu, & Rebekah Mats, DNP, FNP-BC Medical Histry Patient Name:
Dr. Rajsree Nambudripad, MD, ABIHM Dr. Roy Nambudripad, MD NEW PATIENT HISTORY FORM
Dr. Rajsree Nambudripad, MD, ABIHM Dr. Ry Nambudripad, MD NEW PATIENT HISTORY FORM Name Date File N. Phne number Email Hme address City State Zip Date f birth Age Sex M F Height Weight Emplyer Occupatin
NEW PATIENT QUESTIONNAIRE-ADULT
3700 WASHINGTON AVENUE EVANSVILLE, IN 47750 (812) 485-7680 NEW PATIENT QUESTIONNAIRE-ADULT PART 1. PATIENT INFORMATION Name Hme Phne Date f Birth Scial Security Number Wrk Phne Tday s Date Physicians Caring
NEW PATIENT FORMS FOR ADULT. Patient Last Name First Name Middle Name. DOB Age Race SSN. Sex Single Married Widowed Divorced
The Allergy and Asthma Center f Crpus Christi 1718 Braeswd Dr, Crpus Christi TX 78412 text: 361-992-8500 Fax: 361-992-6711 www.allergycrpustx.cm NEW PATIENT FORMS FOR ADULT Patient Last Name First Name
Health for Life Chiropractic At Cloverdale Mall Unit # The East Mall Etobicoke, ON, M9B 3Y
Health fr Life Chirpractic At Clverdale Mall Unit #143-250 The East Mall Etbicke, ON, M9B 3Y8 416-232-1822 416-232-0060 Child and Adlescent Health Questinnaire Name:_ Birth date: Address:_ Telephne: Medical
Patient Health History
Patient Health Histry Name: Date f Birth: Age: SS #: Tday's Date: Sex: Male Height: Primary Care Physician: Phne Number: Referring MD: Phne Number: Other MD's: Name/Specialty Pharmacy Name: Pharmacy Number:
Address: City: State. Phone: (Home) (Work): (Cell): Age Date of Birth / / Occupation. Referred by: Patient s condition: Duration of Problem:
Patient s Last Name: First Name: Address: City: State Zip Phne: (Hme) (Wrk): (Cell): Age f Birth / / Email: Occupatin Referred by: Patient s cnditin: Duratin f Prblem: Dctr: Dctr s Telephne: N. in husehld
Influenza (Flu) Fact Sheet
Influenza (Flu) Fact Sheet What is the flu? The flu is a cntagius respiratry illness caused by influenza viruses. It can cause mild t severe illness, and at times can lead t death. Sme peple, such as lder
MEDICATION GUIDE LEMTRADA (lem-tra-da) (alemtuzumab) Injection for intravenous infusion
MEDICATION GUIDE LEMTRADA (lem-tra-da) (alemtuzumab) Injectin fr intravenus infusin Read this Medicatin Guide befre yu start receiving LEMTRADA and befre yu begin each treatment curse. There may be new
Medical History. Yes or No
Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have
Patient Intake Form - Child. Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling out this form? (name, relationhip):
Patient Intake Form - Child Dr. Daria Novy, ND 2-228 Second St. West Cornwall, ON K6J 1G7 T: 613 938-9500 F: 855 820-1240 Last Name: First Name: Middle Name: Birth Date (dd/mm/yyyy): Age: Sex: Who is filling
PRIMARY COMPLAINT When did your pain start?
1 NEW PATIENT HISTORY FORM (This frm must be cmpleted prir t being seen) Name: DOB: Date: Referring Physician Primary Physician PRIMARY COMPLAINT When did yur pain start? Under what circumstances did yur
Cayuga Center for Healthy Living Health and Lifestyle Questionnaire. Name: Date of Birth: Today s date: Clinic visit date:
Cayuga Center fr Healthy Living Health and Lifestyle Questinnaire Name: Date f Birth: Tday s date: Clinic visit date: Histry f weight lss/gain: Desired r gal weight: Lwest adult weight: Highest adult weight
Health and Lifestyle Questionnaire
Health and Lifestyle Questinnaire Name Tday s date Date f birth Clinic visit date Please tell us the reasn fr yur visit Weight histry Desired r gal weight Height Lwest adult weight When? Highest adult
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
CHILDREN AGES 5 through 13 YEARS OLD Intake Questionnaire
KIDSPACE Adaptive Play and Wellness 469 Buckland Rad, Suite 102 Suth Windsr, CT 06074 CHILDREN AGES 5 thrugh 13 YEARS OLD Intake Questinnaire Tday s : / / Name: f Birth: / / Age: Gender: Street Address:
Vaccine Information Statement: LIVE INTRANASAL INFLUENZA VACCINE
Vaccine Infrmatin Statement: LIVE INTRANASAL INFLUENZA VACCINE Many Vaccine Infrmatin Statements are available in Spanish and ther languages. See www.immunize.rg/vis. Hjas de Infrmacián Sbre Vacunas están
Avicenna Acupuncture PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS)
PEDIATRIC INTAKE FORM (BIRTH TO 5 YEARS) Date: Address: City: State: Zip: Parents Name: Telephone (cell): Parent s work #: Parent s email address: Date of Birth: Gender: How did you hear about this clinic?
Dr. Michelle Mackay Patel, ND
NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight:
Pediatric Intake Form
Patient Name DOB Pediatric Intake Form 1 Pediatric Intake Form Welcome. Our philosophy and approach to medicine is wholistic and seeks to understand all factors that may be affecting your health. This
PATIENT INFORMATION. effective for the treatment of the flu in people with long-time (chronic) heart problems or breathing problems.
PATIENT INFORMATION capsules, fr ral use fr ral suspensin What is TAMIFLU? TAMIFLU is a prescriptin medicine used t: treat the flu (influenza) in peple 2 weeks f age and lder wh have had flu symptms fr
Head to Heal Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian s Occupation:
We look so forward to seeing you at your first visit! If you have any questions, don t hesitate to call us at (705)
Welcome to StoneTree, and to the first steps on your way to feeling better! Thank you for choosing us as a part of your health care team. Your Forms and Health History Your new patient intake forms are
Pain relief after surgery
Pain relief after surgery Imprtant infrmatin fr patients www.mchft.nhs.uk We care because yu matter This leaflet is designed t help yu cntrl any pain yu may have at hme fllwing yur peratin. Please read
Vaccine Information Statement: PNEUMOCOCCAL CONJUGATE VACCINE
Vaccine Infrmatin Statement: PNEUMOCOCCAL CONJUGATE VACCINE Many Vaccine Infrmatin Statements are available in Spanish and ther languages. See www.immunize.rg/vis. Hjas de Infrmacián Sbre Vacunas están
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:
The Dizziness Handicap Inventory ( DHI )
The Dizziness Handicap Inventry ( DHI ) P1. Des lking up increase yur prblem? Yes E2. Because f yur prblem, d yu feel frustrated? Yes F3. Because f yur prblem, d yu restrict yur travel fr business r recreatin?
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
CHILD INTAKE (Please Print Clearly)
Jeremy Hayman, ND CHILD INTAKE (Please Print Clearly) Doctor of Naturopathic Medicine Child s name (First/Last) Date of birth (M/D/Y) Sex M F Referred by Who is filling out this form (name and relation)?
454-8 (Insert) MEDICATION GUIDE ZUBSOLV (Zub-solve) (buprenorphine and naloxone) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place
MEDICATION GUIDE ZUBSOLV (Zub-slve) (buprenrphine and nalxne) Sublingual Tablet (CIII) IMPORTANT: Keep ZUBSOLV in a secure place away frm children. Accidental use by a child is a medical emergency and
! Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian
You may have a higher risk of bleeding if you take warfarin sodium tablets and:
MEDICATION GUIDE Warfarin (WAR-far-in) Sdium (SO-dee-um) Tablets USP The 7.5 mg tablets cntain FD&C Yellw N. 5 (tartrazine), which may cause allergic-type reactins (including brnchial asthma) in certain
SLEEP-WAKE QUESTIONNAIRE
Shasta Critical Care Specialists Sleep Center: (530) 232-3017, 2701 Old Eureka Way, Suite 1J, Redding, CA 96001 Office: (530) 232-3000, 2701 Old Eureka Way, Suite 1E, Redding, CA 96001 Fax: (530) 242-8545
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)
American Institute of Alternative Medicine Clinic Policies
American Institute f Alternative Medicine Clinic Plicies AIAM ffers prfessinal and student services fr bth Acupuncture and Massage. The AIAM clinic prvides students and interns a place t integrate their
PEDIATRIC HEALTH HISTORY FORM. Patient Name: DOB: / / Height: Weight: Lbs. Parent (s) Name: Address:
PEDIATRIC HEALTH HISTORY FORM Patient Name: Date: DOB: / / Height: Weight: Lbs Parent (s) Name: Address: Is there any other information about your child s health that you would like me to know? (Please
Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor
Paediatric Intake (0-12) George Tardik B.Sc, ND- Naturopathic Doctor Name Date of birth Sex M F Date Address Phone h w other May we leave messages relating to your visits? Y N Which one? Emergency contact:
Head and neck cancers are often treated with radiotherapy. Radiotherapy can lead to faster rates of tooth decay and poor healing in the mouth.
DENTAL EXTRACTION This infrmatin aims t help yu understand the peratin, what is invlved and sme cmmn cmplicatins that may ccur. It may help answer sme f yur questins and help yu think f ther questins that
Patient Name: Date: Address City/State Zip Code. Home. Phone Cell: Work.
Phne: 262-248-6700 Fax: 262-248-6764 Email: inf@excelfamilychir.cm Patient Name: Date: Address City/State Zip Cde Hme. Phne Cell: Wrk. Email Address: Sex: M F (Please circle) Date f Birth: Referred by:
Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine
Dr. Kelly Gillis ND BPHE (Lic. 3095) Doctor of Naturopathic Medicine Naturopathic Pediatric Intake Form (Child 0-13 yrs) Child s name: Parent/Guardian s name(s): Address: Age: Date of Birth: DD/MM/YYYY
MEDICATION GUIDE Pioglitazone (pie-oh-glit-ah-zohn) and Metformin (met-fore-min) Hydrochloride Tablets USP
MEDICATION GUIDE Piglitazne (pie-h-glit-ah-zhn) and Metfrmin (met-fore-min) Hydrchlride Tablets USP Read this Medicatin Guide carefully befre yu start taking piglitazne and metfrmin hydrchlride tablets
What is Asthma? A collaborative effort of Children s Hospital of Pittsburgh of UPMC and The Pennsylvania Child Welfare Resource Center
A cllabrative effrt f Children s Hspital f Pittsburgh f UPMC and The Pennsylvania Child Welfare Resurce Center What is Asthma? Jennifer E. Wlfrd, DO, MPH, FAAP Children s Hspital f Pittsburgh, Divisin
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
Child s Name: Date of Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT
Date f Birth: TAKE THIS SHEET TO EVERY DOCTOR S APPOINTMENT Prtable Medical Summary Name: Date Updated: / / Address: Phne: Mbile: E-mail: DOB: SSN: - - Allergies: Pertinent Persnal Characteristics: What
Date of Birth Work Phone # ( ) Home Phone # ( ) Emergency Contact # ( )
Please complete the following form in order to provide us with the background information we require to ensure you receive comprehensive care. It should take 15-20 minutes. Contact Information: Name Occupation
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
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
Medical Student Immunization Requirements
Medical Student Immunizatin Requirements The State f Illinis cde, Reference: (110 ILCS 20) Cllege Student Immunizatin Act, requires students t prvide prf f immunity: Measles (Rubela), Mumps, Rubella (German
MEDICATION GUIDE. Reference ID:
MEDICATION GUIDE GLYXAMBI (glik-sam-bee) (empagliflzin and linagliptin) Tablets Read this Medicatin Guide carefully befre yu start taking GLYXAMBI and each time yu get a refill. There may be new infrmatin.
Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:
Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?
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
Dr. Michelle Mackay Patel, ND
NATUROPATHIC PEDIATRIC INTAKE FORM (Birth to 12 years) PERSONAL INFORMATION: Child s Given Name(s): Last Name: Date of Birth (mm/dd/yy): / / Age: Gender: MALE / FEMALE Current Height/Length: Current Weight:
CONSUMER MEDICINE INFORMATION
CONSUMER MEDICINE INFORMATION What is in this leaflet This leaflet answers sme cmmn questins abut CEFTRIAXONE lcp. It des nt cntain all the available infrmatin. It des nt take the place f talking t yur
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s
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
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
MEDICATION GUIDE. (canagliflozin) Tablets
MEDICATION GUIDE INVOKANA (in-v-kahn-uh) (canagliflzin) Tablets What is the mst imprtant infrmatin I shuld knw abut INVOKANA? INVOKANA can cause imprtant side effects, including: Dehydratin. INVOKANA can
NATUROPATHIC CHILD INTAKE FORM (0-12 years old)
NATUROPATHIC CHILD INTAKE FORM (0-12 years old) Please fill out this form as accurately and completely as possible. Completing this overview will help to obtain a more complete understanding of your child.
MEDICATION GUIDE Pioglitazone and Metformin Hydrochloride (PYE o GLI ta zone and met FOR min HYE-droe- KLOR-ide)Tablets, USP
MEDICATION GUIDE Piglitazne and Metfrmin Hydrchlride (PYE GLI ta zne and met FOR min HYE-dre- KLOR-ide)Tablets, USP Read this Medicatin Guide carefully befre yu start taking piglitazne and metfrmin hydrchlride
CARY HOLISTIC HEALTH, LLC. Thank you for scheduling an appointment with Cary Holistic Health. Maggie Thibodeau, ND
Maggie Thibodeau, ND CARY HOLISTIC HEALTH, LLC 222 Ashville Avenue, Suite 10 / Cary, NC 27518 (919) 858-1004 / CaryHolisticHealth.com Thank you for scheduling an appointment with. We are located at 222
MEDICATION GUIDE SUBOXONE (Sub OX own) (buprenorphine and naloxone) Sublingual Film for Sublingual or Buccal Administration (CIII)
MEDICATION GUIDE SUBOXONE (Sub OX wn) (buprenrphine and nalxne) Sublingual Film fr Sublingual r Buccal Administratin (CIII) IMPORTANT: Keep SUBOXONE sublingual film in a secure place away frm children.
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
MEDICAL HISTORY QUESTIONNAIRE FOR BMT PATIENTS
MEDICAL HISTORY QUESTIONNAIRE FOR BMT PATIENTS Welcme! Please cmplete the fllwing health histry befre yu see yur physician. Fr yur cnvenience this frm is als available nline at kucancercenter.rg. Please
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
Neighborhood Chiropractic and Acupuncture LLC Registration and History
PATIENT INFORMATION Registratin and Histry Last Name: Date: First Name Middle Initial: Address: City: State: Zip: Cell Phne Number: Hme Phne Number: Email: May we send yu e-mail crrespndence? Yes N Sex:
My Symptoms and Medical History for Adult Chronic Immune Thrombocytopenia (ITP)
My Symptms and Medical Histry fr Adult Chrnic Immune Thrmbcytpenia (ITP) Call t talk t a registered nurse 1-855-7Nplate (1-855-767-5283), Mnday Friday, 9:00 AM 9:00 PM ET Indicatin Nplate is a man-made
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:
Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone. Occupation Employer
Milham Family Chirpractic Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex M F Marital Status M S D W Date f Birth Age Occupatin Emplyer Referred by: Have yu ever received Chirpractic
Florida Orthopaedic Institute David Watson, M.D. Patient Questionnaire. Patient Name: Date: MR#:
Flrida Orthpaedic Institute David Watsn, M.D. Patient Questinnaire Patient Name: Date: MR#: Primary Physician Infrmatin Family/Primary Physician: Family/Primary Physician address and phne #: Wh referred
Package leaflet: Information for the user. GASTROGRAFIN GASTROENTERAL SOLUTION Sodium amidotrizoate and meglumine amidotrizoate
Due t regulatry changes, the cntent f the fllwing Patient Infrmatin Leaflet may vary frm the ne fund in yur medicine pack. Please cmpare the 'Leaflet prepared/revised date' twards the end f the leaflet
Health Questionnaire. Name: Age: Marital Status: Nationality: Occupation: Address: Telephone: (home) (work)
Vitality for Life HEALTH CENTER 560 Bryne dr. Unit 1A Barrie, ON L4N 9P6 705.733.2033 www.vitalityforlife.ca Health Questionnaire Name: Age: Last Name First Name Birthday: / / Sex: M F day/month/year Marital
MEDICATION GUIDE REVLIMID (rev-li-mid) (lenalidomide) capsules What is the most important information I should know about REVLIMID?
MEDICATION GUIDE REVLIMID (rev-li-mid) (lenalidmide) capsules What is the mst imprtant infrmatin I shuld knw abut REVLIMID? Befre yu begin taking REVLIMID, yu must read and agree t all f the instructins
PACKAGE LEAFLET INFORMATION FOR THE PATIENT
PACKAGE LEAFLET INFORMATION FOR THE PATIENT AMPICILLIN 125mg/5ml and 250mg/5ml ORAL SUSPENSION Please read all f this leaflet carefully befre yu start taking this medicine because it cntains imprtant infrmatin
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
FLORIDA ORTHOPAEDIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE
FLORIA ORTHOPAEIC INSTITUTE SPINE FIRST VISIT QUESTIONNAIRE Please circle answers t questins that pertain t yur prblem. Yu may select mre than ne answer per questin. This infrmatin will help get an accurate
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
What do you feel are your child s strengths at this time?
PEDIATRIC MEDICAL QUESTIONNAIRE Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully
Medication Guide MORPHINE SULFATE (mor-pheen) Oral Solution (CII)
Medicatin Guide MORPHINE SULFATE (mr-pheen) Oral Slutin (CII) IMPORTANT: Keep Mrphine Sulfate Oral Slutin in a safe place away frm children. Accidental use by a child is a medical emergency and can cause
Naturopathic Family Practice of Niagara CHILD INTAKE FORM GENERAL INFORMATION
CHILD INTAKE FORM GENERAL INFORMATION Child s First name: Last name: Today s Date (D/M/Y): / / Child s Age: Child s Date of Birth (D/M/Y): / / Sex: M / F Who is filling out this form (name and relation)?
Patient Information. How did you hear about the BIHC: If you were referred, please state by whom: If yes, by whom: Date of last visit: DD/MM/YYYY
Dr. Kelly Gillis, ND Doctor of Naturopathic Medicine Patient Information Date of initial appointment: DD/MM/YYYY Name: Address: Age: Date of Birth: DD/MM/YYYY Sex: M F Gender (if different than sex): Occupation:
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY
Bahl & Bahl Medical Associates PATIENT MEDICAL HISTORY NAME: _ DATE: Please complete the following questionnaire as completely as possible. 1. MEDICAL HISTORY Please list all current and prior health problems,
MEDICATION GUIDE. (Interferon alfa-2b)
MEDICATION GUIDE INTRON A (In-trn-aye) (Interfern alfa-2b) Read this Medicatin Guide befre yu start taking INTRON A, and each time yu get a refill. There may be new infrmatin. This infrmatin des nt take
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
Street Address: City: State: Zip: Home Ph: Cell Ph: SSN#: Name: Relationship to Patient: Address: City: State: Zip: Home Ph: Cell Ph:
PATIENT INFORMATION Name: Birthdate: Street Address: City: State: Zip: Hme Ph: Cell Ph: Email: SSN#: Sex (circle) M F Emplyer Name & Phne #: PARENT/GUARDIAN INFORMATION (IF UNDER THE AGE OF 18) Name: Relatinship
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address: