LAST NAME FIRST NAME MI SEX BIRTH DATE AGE ADDRESS CITY STATE ZIP ( ) - ( ) - PHONE CELL PHONE ADDRESS DRIVER S LICENSE NO.
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1 Cathryn Aiken, L.Ac. 530 Traffic Way Arroyo Grande, CA T: F: PLEASE PRINT LEGIBLY TODAY S DATE: M / F / / LAST NAME FIRST NAME MI SEX BIRTH DATE ADDRESS CITY STATE ZIP ( ) - ( ) - PHONE CELL PHONE ADDRESS DRIVER S LICENSE NO. CURRENT OCCUPATION - IF RETIRED, WHAT WAS YOUR PREVIOUS OCCUPATION? EMPLOYER ( ) - WORK PHONE EMPLOYER S ADDRESS SPOUSE or PARENT ADDRESS PHONE REFERRED BY: NAME OF PRIMARY HEALTH CARE PROVIDER AND PRACTICE (M.D., CHIROPRACTOR, ETC.) ARE YOU CURRENTLY UNDER THE CARE OF THIS HEALTH CARE PROVIDER? YES NO HAVE YOUR COMPLAINTS PREVIOUSLY BEEN GIVEN A PARTICULAR MEDICAL DIAGNOSIS? YES NO PLEASE EXPLAIN ARE YOU CURRENTLY TAKING ANY PRESCRIBED MEDICATIONS, VITAMINS, SUPPLEMENTS, HERBS? PLEASE LIST: PRESENT COMPLAINT / SYMPTOMS: WHEN AND HOW DID PROBLEM START? WHAT MAKES IT BETTER? WHAT MAKES IT WORSE? PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY: DIABETES HEPATITIS A B C HYPERTENSION PREGNANCY TB CHEM /RAD SEIZURES HEMOPHILIA PACEMAKER HIV / AIDS
2 DESCRIBE YOUR GENERAL ENERGY LEVEL: PLEASE RATE GENERAL ENERGY LEVEL ON SCALE OF 1-10: 1 = EXHAUSTED & 10 = GREAT: WHAT TIME OF DAY DO YOU FEEL BEST? WORST? HISTORY OF PARTICULAR EMOTIONAL EPISODES: HOBBIES / INTERESTS: WHAT ARE YOUR MOST COMMONLY EXPERIENCED EMOTIONS? PLEASE X ANGE R FRUSTRATION WORRY SADNESS FEAR EXCITEMENT JOY WHAT EMOTIONS DO YOU HAVE A DIFFICULT TIME EXPRESSING? PLEASE X ANGE R FRUSTRATION WORRY SADNESS FEAR EXCITEMENT JOY IF YOU COULD CHANGE 3 THINGS ABOUT YOUR LIFE / SELF, WHAT WOULD THEY BE? WHAT IS YOUR HISTORY FOR MAJOR ADULT ILLNESSES: SURGERI ES: CHILDHOOD ILLNESSES: PRESCRIBED MEDICATIONS:
3 PLEASE PROVIDE A BRIEF FAMILY HISTORY. INCLUDE ANY INCIDENCES OF ALCOHOLISM/SUBSTANCE ABUSE, ARTHRITIS, ASTHMA, CANCER, DIABETES, HEART DISEASE, HYPERTENSION, NERVOUS DISORDERS, SEIZURES, SKIN DISEASE, STROKE, TB, ETC. FATHER MOTHER SIBLING SIBLING SIBLING MATERNAL GRANDFATHER GRANDMOTHER PATERNAL GRANDFATHER GRANDMOTHER OTHER WOMEN OF FIRST PERIOD: LAST PAP: RESULTS: LENGTH of FULL MONTHLY CYCLE: DAYS DURATION of FLOW: DAYS IS CYCLE REGULAR? ANY SPOTTING? PAIN? PMS? VAGINAL DISCHARGE? OTHER? DIFFICULTIES DURING TEENS (PAIN, FLOW, REGULARITY, CRAMPS, HEADACHES, ETC.): BIRTH CONTROL HISTORY (METHOD & DURATION OF USE): OBSTETRIC HISTORY NO. OF PREGNANCIES: NO. OF BIRTHS: NO. OF MISCARRIS: NO. OF ABORTIONS: OTHER: MENOPAUSE? YES NO? STDs (HERPES, WARTS, ETC.): MEN HISTORY OF IMPOTENCE, PREMATURE EJACULATION, FERTILITY DIFFICULTIES, DISCHARGE FROM PENIS, VASECTOMY, ETC. STDs (HERPES, WARTS, ETC.) ANY CHILDREN? YEAR of BIRTH
4 DAILY HABITS (HOW MUCH OF EACH OF THE FOLLOWING DO YOU CONSUME DAILY?) CIGARETTES / TOBACCO: ALCOHOL / IN WHAT FORM: COFFEE / TEA/ CAFFEINATED BEVERS: DAIRY PRODUCTS (MILK, CHEESE, BUTTER, YOGURT, ICE CREAM, ETC.): MEAT / FISH / POULTRY: BREADS / GRAINS: COOKED VEGETABLES: RAW FRUITS / RAW VEGETABLES: SPECIFIC FOOD / FLAVOR CRAVINGS: TYPICAL DAY S MENU (INCLUDE CONTENT AND TIME YOU NORMALLY EAT) TIME CONTENT BREAKFAST: LUNCH: DINNER: SNACKS: EXERCISE (TYPE, DURATION, NUMBER OF TIMES PER WEEK): WHICH OF THE FOLLOWING MAKE YOU FEEL BAD / WORSE? COLD HEAT DAMP DRY WIND HUMIDITY FOG WHICH OF THE FOLLOWING MAKE YOU FEEL GOOD / BETTER? COLD HEAT DAMP DRY WIND HUMIDITY FOG DO YOU HAVE ANY INTOLERANCE TO HEAT OR COLD (FOOD, DRINKS) OR AREAS OF THE BODY THAT ARE HOT OR COLD? PLEASE TELL ME ABOUT ANY PREVIOUS TREATMENTS YOU HAVE TRIED FOR YOUR CONDITION (ACUPUNCTURE, HOMEOPATHY, MASS, NUTRITION, M.D., ETC.) AND THE RESULTS:
5 PLEASE X ANY THAT ARE LONG TERM SYMPTOMS or THAT YOU HAVE EXPERIENCED IN LAST 3-6 MONTHS ( )ACID REGURGITATION ( )HAIR DRY /DULL ( )SKIN - YELLOWING ( )ALLERGIES ( )HAIR LOSS ( )SLEEP - ALWAYS SLEEPY ( )ALTERNATING FEVER / CHILLS ( )HAIR PREMATURE GRAY ( )SLEEP - CAN T FALL ASLEEP ( )APPETITE - ALWAYS HUNGRY ( )HEART ATTACKS ( )SLEEP - CAN T STAY ASLEEP ( )APPETITE - POOR ( )HEAVINESS OF BODY ( )SLEEP - EXCESSIVE DREAMING ( )ASTHMA ( )HEAVINESS OF LIMBS ( )SNEEZING ( )BAD BREATH ( )HEMORRHOIDS ( )SPASMS - WHERE ( )BEARING-DOWN IN GROIN / SCROTUM ( )INDIGESTION ( )STIFFNESS - WHERE ( )BELCHING or HICCUPS ( )INFERTILITY ( )STOOL - BURNING ( )BLADDER or KIDNEY STONES ( )IRREGULAR HEARTBEAT ( )STOOL - CONSTIPATION ( )BLOATING of ABDOMEN ( )LUMPS / MASSES / TUMORS ( )STOOL - DIARRHEA - ACUTE ( )BLOOD CLOTS ( )MEMORY FORGETFULNESS ( )STOOL - DIARRHEA - CHRONIC ( )BREATH DIFFICULT TO INHALE ( )MEMORY - LOSS OF MEMORY ( )STOOL - DIFFICULT TO PASS ( )BREATH SHORTNESS OF BREATH ( )MEMORY - POOR MEMORY ( )STOOL - DRY STOOL ( )BREATH SIGHING ( )MENSES CLOTS ( )STOOL - INCONTINENCE ( )BREATH WHEEZING ( )MENSES CRAMPING DURING ( )STOOL - LOOSE STOOL ( )BRITTLE NAILS ( )MENSES HEAVY FLOW ( )STOOL - UNDIGESTED ( )BRONCHITIS ( )MENSES HEADACHES: ( )STROKE ( )BRUISE EASILY ( )MOUTH BLEEDING GUMS ( )SWEAT - EASILY WITH EXERTION ( )BURNING RECTUM / ANUS ( )MOUTH PAINFUL GUMS ( )SWEAT - NIGHT SWEATS ( )CHEST / ARM PAIN ( )MOUTH - SORES ON GUMS ( )SWEAT - SPONTANEOUS DAY SWEAT ( )CHEST FULLNESS ( )MOUTH - SORES ON LIPS ( )TEMPERATURE - ALWAYS COLD ( )CHILLS AND FEVER ( )MOUTH - SORES ON TONGUE ( )TEMPERATURE - ALWAYS HOT ( )CLEARING THROAT OFTEN ( )MOUTH - TOOTH LOSS ( )TEMPERATURE - BETTER WITH COLD ( )CONVULSIONS ( )NASAL DISCHARGE COLOR ( )TEMPERATURE - BETTER WITH HEAT ( )COUGH ( )NASAL - DRY NOSE ( )COLD AREAS ( )COUGHING MUCUS: COLOR ( )NAUSEA ( )HOT AREAS ( )CRAMPING ( )NUMBNESS WHERE ( )TEMPERATURE - HOT AT NIGHT ( )DESCENDING / SINKING in AB ( )PAIN ABDOMINAL ( )TEMPERATURE - HOT PALMS / SOLES ( )DISCHARGE CLEAR ( )PAIN - BODY ACHES ( )TEMPERATURE - OTHER ( )DISCHARGE MILKY ( )PAIN - DULL ACHE ( )THIRST - ALWAYS THIRSTY ( )DIZZINESS / VERTIGO ( )PAIN HEADACHES ( )THIRST - FOR HOT? ( ) FOR COLD? ( ) ( )EAR DEAFNESS ( )PAIN INTERMITTENT ( )THIRST - NO THIRST ( )EAR - LOW-HUMMING ( )PAIN - JOINT PAIN ( )THROAT - CHRONIC HOARSENESS ( )EAR RINGING ( )PAIN - LOW BACK AND / OR KNEES ( )THROAT - FREQUENT SORE THROAT ( )EMOTIONS ANXIETY ( )PAIN HEADACHES - MIGRAINE ( )SENSATION OF OBJECT STUCK IN THROAT ( )EMOTIONS DEPRESSION ( )PAIN - MUSCLE PAIN ( )ULCERS - ( )EMOTIONS EASILY STARTLED ( )PAIN - OTHER ( )ULCERS - STOMACH ( )EMOTIONS FEAR ( )PAIN - BACK WHERE ( )URINE - BLOOD IN URINE ( )EMOTIONS GRIEF / SADNESS ( )PAIN SHARP ( )URINE - BURNING URINE ( )EMOTIONS HYSTERIA ( )PALPITATIONS ( )URINE - CLOUDY URINE ( )EMOTIONS INDECISIVENESS ( )PARALYSIS ( )URINE - DARK URINE ( )EMOTIONS IRRITABLE ( )PMS ABDOMINAL DISTENTION ( )URINE - DIFFICULT URINE ( )ENERGY CAN T STOP GOING ( )PMS - BREAST TENDER / SWOLLEN ( )URINE - DRIBBLING URINE ( )ENERGY EASILY FATIGUED ( )PMS CRAMPING ( )URINE - INCONTINENCE ( )EYES - DRY EYES ( )PMS - EMOTIONAL ( )URINE - SCANT URINE ( )EYES EXCESSIVE TEARING ( )PMS - HEADACHES ( )URINE - URGENT ( )EYES FLOATERS ( )PNEUMONIA ( )URINE - AWAKE TO URINATE ( )EYES BLURRY VISION ( )PROLAPSE - WHERE? NO of TIMES PER NIGHT ( )EYES - POOR VISION ( )SEIZURES WHAT TIME? ( )EYES - RED / PAINFUL ( )SEXUAL - IMPOTENCE ( )VOICE - HARD TO PROJECT ( )FACE FLUSHED CHEEKS ( )SEXUAL - LOW SEX DRIVE ( )VOICE - HOARSENESS ( )FACE - PALE COMPLEXION ( )SEXUAL - NIGHT TIME EMISSIONS ( )VOMITING ( )FACE - PALE LIPS ( )SEXUAL - PREMATURE EJACULATION ( )VOMITING CLEAR FLUIDS ( )FACE - RED FACE ( )SKIN - DRY / ITCHING ( )WATER RETENTION ( )FEVERISH AT NIGHT ( )SKIN - LARGE RED PATCHES ( )WEIGHT GAIN ( )FEVERISH DURING DAY ( )SKIN - OTHER ( )WEIGHT LOSS ( )FREQUENT COLDS ( )SKIN - RED PAINFUL RASH
6 Cathryn Aiken, L.Ac. 530 Traffic Way Arroyo Grande, CA T: F: PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below: INSURED OR AUTHORIZED PERSON S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services rendered. I understand that cancellations made without 24 hours notice and appointments missed without notice of cancellation will be billed for the amount of the appointment. I understand that my insurance does not cover this amount. Payment is required at the time of treatment. For patients with insurance the insured should verify benefits available for the patient, as well as co-payments, deductibles and remaining benefits for the plan s year. Co-pays and deductibles are due at the time of treatment. Benefits are not guarantee of payment. Many insurance companies only pay for a portion of the total fee. Your insurance will be billed as a courtesy, however fees due are your responsibility. Your insurance will be billed for a period of three months after services are rendered. After this time, you will be responsible for payment. SIGNED: DATE:
Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist
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Mayflower Acupuncture LLC
Welcome to Mayflower Acupuncture. To help us provide you with the best possible care, please fill out this form as completely as you can. All information provided here will be held in strictest confidence.
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
Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042
Mimi Tagher, LAc, LMT Synergy Holistic Health Center 7413 US 42 Suite 3, Florence, KY 41042 Date: Name: Sex: M F Date of Birth: Drug Allergies: Address: City: State: Zip: Phone Numbers ( ) ( ) ( ) Home
CURRENT MEDICAL HISTORY
Patient name Please print, and check the appropriate items CURRENT MEDICAL HISTORY Date of birth Age Today s Date Who referred you? Family Physician Address of family physician Skim through entire form
Health History Questionnaire
CLINICAL ACUPUNCTURE SERVICES Cathy D. Adelman, RN, LAc PO Box 91451 Tucson, AZ 85752-1451 (520) 822-6844 cdarnlac@hughes.net www.clinicalacupunctureservices.com Health History Questionnaire I. GENERAL
New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:
Pamela A. Pappas MD, MD(H) Classical Homeopathy for Mind, Body, and Soul 8114 E. Cactus Rd., Suite #240 Scottsdale, Arizona 85260 Phone: 480.656.9218 Fax: 602.626.3695 E-mail drpam@drpampappas.com New
DATE OF FIRST INJURY OR ILLNESS NAME DATE OF BIRTH ADDRESS M F AGE MARITAL STATUS CITY STATE ZIP CODE HOME PHONE NUMBER ( ) WORK PHONE NUMBER ( )
Tri-Valley Oncology / Hematology Ashwin Kashyap, M.D. Martin Palmer, M.D. E. Lynn Meyering, M.D. 555 Marin St., Suite 200, Thousand Oaks, CA 91360 & 2045 Royal Ave # 208, Simi Valley, CA 93065 DATE DATE
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
Heartland Chiropractic Clinic, P.C. Sandra Kreber, L.Ac Cornhusker Road Bellevue, NE Date.
Heartland Chiropractic Clinic, P.C. Sandra Kreber, L.Ac. Number 2418 Cornhusker Road Bellevue, NE 68123 402-291-2121 Date Name Referred by Address City State ZIP Date of birth Marital Status: Single Married
What do you believe is causing your most important health concern?
Intake form Name Today s Date Date of Birth Address City Phone Postal Code Email Primary Health Care Provider Emergency Contact Phone Note: By providing your email address you are giving us consent to
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
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
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Patient History (Please Print)
Patient History (Please Print) Date: Name: Email: Phone: (Home) (Mobile) (Work) Address: City: Zip: Birth Date: / / Male Female Spouse/Parent Name: # of Children: Married Single Divorced Widowed Are you
WELCOME TO LING S ACUPUNCTURE
WELCOME TO LING S ACUPUNCTURE Thank you for choosing Ling s Acupuncture for your healthcare needs. We would like to implement a few office policies that are fair and simple which revolve around the care
(city) (State) (zip)
ACUPUNCTURE PATIENT INTAKE FORM DATE: / / NAME: DATE OF BIRTH: / / AGE SEX: M F HEIGHT: WEIGHT: ADDRESS: (street) (city) (State) (zip) PHONE: / / (Home) (Work) (Cell) E-MAIL: EMERGENCY CONTACT: Name: Address:
Patient Intake Form. Relationship. Contact information
Acupuncture & Massage Therapy 895 rue St. Francois, Florissant 314 921-3366 Mary S. Wallis, L.Ac, L.M.T. National Board Certified in Acupuncture (NCCAOM) MO License No. 2007002923 Patient Intake Form Today
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.
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status
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
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire
Emory Clinic Department of Neurological Surgery Second Opinion Questionnaire First Name: M.I. Last Name: Date of Birth: Phone: Marital Status: Married Divorced Separated Widowed Single Work Status: Employed
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Welcome to About Women by Women
Welcome to About Women by Women Today s Date New Patient Questionnaire Name: Birth Date: / / Home Phone: Address: Cell Phone: Work Phone: Occupation: Employer: Marital Status: Married Living w/ Partner
Ayurvedic Intake Form
Ayurvedic Intake Form Name: Today s Date Date of birth: Time of birth: Place of birth: Place of childhood: Other Places lived: Current address: Home phone: Work phone: Email address: Occupation: Age: Sex:
Condition #2: What is the next important condition you would like help with, and how long ago did it begin?:
NAME _ Please take the time to fill this form out completely. The more information we have, the better we can assist you, and will make better use of your initial visit. What is the main problem you would
ACUPUNCTURE INTAKE FORM
, ND ACUPUNCTURE INTAKE FORM Thank you for taking the time to complete the following new patient forms. Given this form is extensive, it plays an integral role in achieving our mutual goal of your optimal
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
Minister Medical ^Acupuncture
Minister Medical ^Acupuncture t^wellness Clinic What is acupuncture? Acupuncture is a therapy in which fine needles are inserted into specific points on the body. Is acupuncture safe? Acupuncture is generally
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
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
Creve Coeur Family Medicine, LLC
Creve Coeur Family Medicine, LLC Patient Name: Date of Birth: Medication List Medication Name (Over the counter medications too) Strength/ Dose (mg) Number of pills per dose Number of times per day Personal
CONSULTATION & CONSENT FORMS p. 1 of 5
CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your