New Client Health & Wellness Paper Work
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- Caren Ellis
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1 Nutritionally Yours Health Solutions 604 Macy Drive, Roswell GA / alanepnd@gmail.com New Client Health & Wellness Paper Work Today's Date Patient Name: _ Parents Name (if patient is under age 18) Patient Profession Spouse Profession (if married) Patient D.O.B.:_ Patient Street Address: City: St: Zip: Home Phone:_ Cell Phone: Emergency Contact:_Phone: How did you hear about us (i.e. website, friends name, newspaper, ad, Facebook, etc)? What issue or health concern brought you to Nutritionally Yours How is this issue / concern specifically impacting your life now? What if anything makes it worse? What is anything makes it better? What if anything have your tried that did not work to resolve this issue? ) On a scale from 1-10 (10 being the worst) how important is it to you to resolve this issue? What if anything do you believe you need so you can overcome this issue and reach your desired results? Additional areas of interest or concern: Weight Loss Hormone Balancing Vitamin & Cardiac Mineral Deficiencies Stomach / Digestive Health Reduce Cholesterol/ BP Nutrition Detox / Toxin Diabetes / Auto- Blood Sugar immunity concerns Increase Mental Clarity/ Focus Thyroid Food Sensitivities Increase Energy Gluten Free Diet Support Stress Reduction Herbal / Homeopathic options General Health/ Wellness OTHERS:
2 Have you had any of the following health conditions in the past or present? Cancer Diabetes Heart Disease/ Stroke Headaches Hepatitis High/Low Blood Pressure Autoimmune Thyroid HIV/AIDS Insomnia Arthritis Asthma Skin conditions GERD Ringing in Ears Lyme Auto-immune High Insulin Infertility PCOS Anxiety Depression Joint Pain Chronic Sinusitis Insomnia Cardio-Metabolic Please rate the following on a 0-10 scale with 10 Being Always and 0 Being Never. Heart Palpitations/ Irregular Heart Beat Chest Pain/ Tightness / Shortness of Breath Swelling in Ankles High Blood Pressure High Cholesterol _ Smoking Numbness/Tingling: hands or feet Anxious Feeling/ Anxiety Total Points Hormone Decreased Libido _ Fatigue/ Low Energy Brain Fog/ Forgetfulness Difficulty Sleeping Hair Loss/ Thinning _ Depression/ Mood Swings Difficulty Losing Weight Craving Sweet/ Salty Foods Total Points Nutrition Skip Meals _ Gas/ Bloating/ Re flux_ Constipation/Diarrhea GI Upset with Certain Foods Eat Out Eat Fried Foods Drink Sodas/ Energy Drinks Eat Desserts/ Snacks Eat Breads/ Pastas/ Cereals Drink Alcohol/ Caffeine Total Points
3 EXERCISE / Work Activity Please answer the following: None Moderate Daily Heavy _ Habits: Tobacco Use : Packs / Day Alcohol Use: Drinks / Day / Week Caffeine Use: Type / Amount Day Sleep: What time do you fall asleep? Do you wake during the night? Can you fall back asleep easily? Does lack of sleep effect you during the day (YN) Work Activity: Sitting Standing _ Light Heavy Stress: Rate Your Stress 1-10 (10 is the most) Do you skip meals Y/N What time do you wake up? Do you feel well rested Y/N Environment Headaches _ Sensitivity to smells _ Tired/Hard to Get out of Bed Work w/: Paint, Insecticides, Chemicals, Construction Materials, Burning in Eyes/ Ears/ Nose/ Throat/ Lungs Problems with Balance/ Coordination Exposure to or live in area with mold Confusion/ Memory Problems Consume conventionally grown produce ( non organic) Smoke or exposure to second hand smoke. Total Points Well-being I feel useful. I deal well with problems. I am interested in other people. I feel loved. I feel good about myself. I feel close to others I lead a purposeful and meaningful life. I am engaged and interested in my daily activities. I am able to make my mind up about things. _ I feel optimistic about the future. _ Total Points List all current medications List all known allergies
4 Daily Food Intake List Your Daily Breakfast Meals _ List Your Daily Lunch Meals What Do You Eat For dinner? List your daily snacks Dining Out How often to you eat out per week? List some restaurants you go to and what do you normally order to eat?
5 Symptoms / Toxicity Section The toxicity and symptoms section identifies symptoms that help to identify the root cause of illness and symptoms and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past 30 days. If you are taking this for any other time besides the first time, record your symptoms for the last 48 hours ONLY. NAME: Date: POINT SCALE 0 = No Symptoms 1= Mild Symptoms 2= Moderate Symptoms 3= Severe Symptoms DIGESTIVE TRACT Nausea or vomiting NOSE LUNGS Diarrhea / Constipation Stuffy Chest Congestion Reflux / Heartburn Sinus problems Asthma, bronchitis Bloated / Gas Hay fever Shortness of breath Heartburn Sneezing attacks Difficult breathing GI upset from certain foods Excessive mucous recent appetite change EMOTIONS MIND HEAD Mood swings Poor memory Faintness Anxiety, fear, nervousness Confusion Dizziness Anger, irritability, aggressive Poor concentration Insomnia Depression Poor physical coordination Headaches Difficulty w decisions Learning disabilities slurred speech MOUTH/ THROAT JOINTS/MUSCLES Chronic coughing Pain or aches in joints WEIGHT Gagging, frequent needs to clear throat Arthritis Underweight Sore throat, hoarseness, loss of voice Stiffness, movement limited binge eating Swollen / discolored tongue, gum, lips Muscles aches or pains binge eating Canker sores Weak / Tired muscles Craving certain foods Inability to lose weight EARS SKIN OTHER Itchy ears, Acne frequent illness Earaches, ear infections Hives, rashes, dry skin Frequent auto immune Drainage from ear Eczema / Psoriasis Ringing in ears, hearing loss Flushing, hot flashes / sweats NEURO / ENDOCRINE Excessive sweating Abdominal fat Dry skin Thyroid issues HEART Low libodo Irregular or skipped heartbeat ENERGY / ACTIVITY Cold body temp Rapid or pounding heartbeat Fatigue, sluggishness Too warm Chest pain Apathy, lethargy difficulty sleeping High blood pressure Hyperactivity hair loss/ thinning High cholesterol Restlessness Low strength / endurance EYES GENITAL / URINARY Watery or itchy eyes Bladder Pain / irritation Swollen, red, sticky eyelids EMOTIONAL / MENTAL Frequent UTIs Bags, dark circles under eyes Depression Yeast infections Blurred or tunnel vision Anxiety Increased urination Change in vision Mood swings Incontinence Irritability Poor memory
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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
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
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
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?
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
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
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
Patient Health History Form
Thomas S. Burgoon, M.D. West Chester, PA 19382 Patient Health History Form Successful health care and preventative medicine are only possible when the practitioner has a complete understanding of the patient