Greg Meyer MD (H) Meyer Homeopathy LLC. Registration Form
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1 Greg Meyer MD (H) Meyer Homeopathy LLC Phoenix, AZ Tel: Registration Form Name.. Address.. Tel. Home Tel. Cell.Tel. Work... address. Date of Birth.. Age. Marital status: Married Single Partnered Separated Divorced Widowed Occupations: Emergency Contact Contact for Primary Doctor... How did you obtain Dr. Meyer s name for a consultation?... Have you had any experience with homeopathy in the past? If so what?... Do you see other complementary or alternative therapists ( eg. Chiropractor, acupuncturist, naturopath, healer)? Medications please all drugs (including hormones, sleeping pills, inhalers, creams, lotions, etc.) that you take constantly or intermittently. Name Strength/dose How often
2 Medications continued. Please list all your symptoms/problems below, with the main ones first, providing for each: 1) the date of onset, and 2) an estimate of how severely it troubles you (10 = worse, 1= very trivial) Problem or Symptom Date of Onset Severity
3 Lifestyle Questionnaire Alcohol on how many days of the week do you drink?... How much do you consume per day / week?... Tobacco how much do you smoke?...since what age?... If you quit, between what ages did you smoke?...how much did you smoke?... Drugs do you take any other recreational drug, eg. Cannabis, cocaine, ecstasy, meth, etc now or in past? Which and how often?... Exercise how much do you take and in what form(s)?... Relaxation how much do you take and in what form(s)?... Sleep what time do you normally go to sleep?... and wake up?... Do you have any sleeping difficulties?... Occupation, school, college what hours and days do you normally work in an average week?... Are you happy with your work? if not, please detail:.... Relationships, Do you have any difficult ones? Interests, hobbies & pastimes what are the main ones..... Stresses what are the main ones in your life and how do they affect you?... Tiredness, fatigue, lack of energy do you suffer inappropriately from any of these?... If so, give details & since when?.. Childhood did you have any particularly stressful or unhappy times?....
4 Cravings please list all foods or drinks that you ever have or have had cravings for. When do they or have they occur(ed)?... Aversions please list everything that you can t stand the taste or smell of.. Allergies / intolerances / Sensitivities / Adverse Reactions Do you have or have you in the past had allergies, intolerances, sensitivities or adverse reactions to anything such as foods, additives, drugs, immunizations, fumes, dust, pollens, animals, soaps, detergents, lotions, metals, plants, insect bites, etc? please list:... Past medical History Please list in order all problems, diseases, traumas, operations, serious injuries including head injuries, details of mother s pregnancy if known, major life events, (eg. Marriages, separations, divorces, death of loved ones, adoptions, births, etc.) Year Age Event
5
6 MAIN COMPLAINT Please describe your main complaint(s) in as much detail as possible. Note when it started, what makes it better or worse and what treatments you have tried?
7 Which vaccinations have you had? Mark all that apply: Small pox Polio Mumps Measles Chicken pox Tetanus Hepatitis Flu. Have you had any vaccinations in the last year? Yes No If Yes, describe: Have you ever had any reactions to any vaccination? Yes No If Yes, describe: Section C: FAMILY HISTORY Please fill in the details of your family s medical history. If you are adopted and do not know your family s history please indicate so and leave out this section. Please fill in this section as best as you can. Many of you will not know all the details, and that is fine too. ILLNESS Self Father Mother Brothers Sisters Child#1 Child#2 Child#3 Grandparents ALLERGIES ANEMIA ARTHRITIS/GOUT ASTHMA BLEEDING PROBLEMS CANCER EPILEPSY DIABETES ALCHOHOL/DRUGS ECZEMA EMPHYSEMA HEARTH TROUBLE HEPATITIS HIGH BLOOD PRESSURE FREQUENT INFECTIONS KIDNEY PROBLEMS MENTAL ILLNESS MIGRANES ABNORMAL PERIODS PSORIASIS PNEUMONIA POLIO PROSTATE PROBLEMS RHEUMATIC FEVER STOMACH PROBLEMS STROKE THYROID PROBLEMS TUBERCULOSIS ULCERS VENEREAL DISEASE WEIGHT PROBLEMS Are there any illnesses that run in your family? Is there any family history of: Tuberculosis Cancer Gonorrhea Scabies
8 General Symptoms 1) Are you? Thirsty Thirstless Somewhere in between 2) What do you drink? 3) Do you prefer drinks that are? Ice cold Hot drinks Room temperature 4) Is your appetite? Ravenous Average Slightly Increased Decreased 5) Is your body temperature? Too hot Too cold Can t stand heat /cold Not significant 6) What weather are you best in? 7) Is there any weather or time of year that aggravates you? 8) How is your perspiration? Where do you perspire the most, any odor, color, etc? 9) Any problems regarding stools? Any difficulties passing stool, etc 10) How strong is your sexual desire?. Do you suffer from any sexual disturbance?... WOMEN ONLY: What symptoms do you experience premenstrual or during menstruation? Do you suffer in any way before, during or after menses? ) What is your favorite color(s)?... 10) Are nightmares a problem for you? Yes No Sometimes 11) Describe any important dreams? Any recurrent dreams now or in the past?....
9 Circle if you experience any of the following: headaches chest colds loss or gain of weight annoyed by little things back pains rapid or skipped heart beats loss of appetite family problems neck lumps or swelling loss of balance dizzy spells blackouts or fainting wear glasses blurry vision eyesight worsening seeing double seeing halos or lights eye pains or itching watery eyes earaches ear discharge hearing difficulties noises in ears dental problems sore or bleeding gums sore tongue congested nose runny nose sneezing spells head colds nosebleeds sore throat difficulty swallowing hoarse voice wheezing or gasping coughing up phlegm coughing up blood chest pains shortness of breath swollen feet or ankles armpits or groin swelling difficulty sleeping motion sickness excessive sweating recurring indigestion frequent belching nausea vomiting pain in abdomen bloated abdomen constipation loose bowels black stools gray or whitish stools blood with stools pain in rectum itching in rectum frequent urination involuntary urination burning on urination black or bloody urination weak urine stream difficulty starting urine constant urge to urinate sexual difficulties change of sexual energy always hungry fatigue or weariness fever or chills night sweats motion sickness warmer/colder than others aching muscles or joints swollen joints back or shoulder pains weakness in arms or legs painful feet leg cramps painful feet trembling numbness skin problems scalp problems bruise easily nervousness or anxiety nervous with strangers difficulty relaxing worry a lot nail biting difficulty making decisions lack of confidence scary dreams or thoughts shy or sensitive dislike criticism angered easily problems at work (husband s) lack of concentration loss of memory hopeless outlook feeling of desperation lonely or depressed frequent crying considered suicide MEN ONLY penile burning or discharge swelling on/of testicles painful testicles WOMEN ONLY missed periods menstrual problems bleeding between periods heavy bleeding bearing down feelings vaginal discharge genital irritation pain on intercourse swelling of breasts hot flashes # of pregnancies # of births # of miscarriages # of premature births # of caesarean sections # of abortions
10 In your own words, describe your personality, both positive and negative aspects. Then, describe in detail any negative attitudes or moods you may experience. What triggers these moods, or attitudes? Whatever describes you, and how you feel about it is important. What motivates you and what interests you in life? What is important to you?
11 What would you like to change in yourself and your personality? What do you need to work on in yourself? Where do you feel blocked, tense or disharmonious with yourself or in which area of your life? Sit quietly and feel inside your body where does it feel tense, knotted or restricted? Write down any Fears or Worries that you have, including worries about others, shyness, fear of certain animals heights, closed places, crowds, being alone, rejected, public appearance, speeches, thunderstorms, injections, doctors, open spaces etc.
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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.
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
Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name
NP Hagans Walk-In Clinic * 9135 Piscataway Rd. # 320 Clinton, MD 20735 * (240)-412-5093 (Office) Patient Information Patient First Patient Middle Initial Patient Last Sex Marital Status Date of Birth Social
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
Allina Health United Lung and Sleep Clinic
Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
Adult Health History New Patient
Adult Health History New Patient Today s Date PREFERRED NAME DATE OF BIRTH Reason for visit: What are your health goals for the next year? Previous Primary care Provider? Last visit? Specialists (Past
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
ACUPUNCTURE QUESTIONNAIRE
ACUPUNCTURE QUESTIONNAIRE CHIEF COMPLAINT: PAIN EVALUATION Pain Scale: no pain 0 1 2 3 4 5 6 7 8 9 10 severe pain 1 Mark each area where you are having pain according to the pain scale above. HISTORY HEALTH
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
ACTIVE EDGE CHIROPRACTIC
ACTIVE EDGE CHIROPRACTIC HEALTH HISTORY QUESTIONNAIRE PERSONAL INFORMATION Name: Female Male Alberta Health Care# Address: City: Province: Postal Code: Telephone: Home: Work: Cell: Email: Occupation: Birth
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