Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR
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1 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 name * Page 1
2 Emergency Contact Phone number * Insurance information. Please include Company, company phone number, ID number, Group number, name of insured and birthday of insured: * Referred By: * Primary Physician * Preferred Pharmacy: Please list address including zip code and phone number. * Do you currently smoke? Have you been a smoker in the past? * What is your Main Concern? How long has this been a problem? Are you currently receiving any treatments for this issue? * When and where did you last receive medical care? For what purpose? * Page 2
3 Have you had any surgeries? If so, please list them: * Have you had any hospitalizations or prolonged periods of immobility? If so, please list them: * Have you had any major illnesses? If so, please list them. Examples: Cancer, Diabetes, High Blood pressure, Heart Disease, Hepatitis, Rheumatic Fever, Thyroid Disease, Seizures, etc. * Do you have any current diagnoses? If so, please list them below: * Do you have any allergies? If so, please list them: * Have you had any significant Traumas? If so, please list them: * Are you currently taking any medications? If so, please list the names and dosages: * Are you taking any over the counter supplements including herbs and homeopathics? If so, please list Page 3
4 them along with their doses: * Are you up to date on your vaccinations? If an adult, have you had a tetanus shot in the past 10 years? Do you choose to receive annual flu shots? * Do you have any job or hobby related stresses (chemical, physical, psychological, etc.) * Are there any illnesses such as cancer, heart disease, diabetes, thyroid disease, hypertension, high cholesterol, or mental health disorders that run in your family? If so, please list them below: * What type of exercise do you engage in and how often? * Do you partake of any of the following substances: Coffee, Tea, Cola, Alcohol, Drugs, Sugar, Salt, Other. If so which and how often? * What did you eat in the last 24 hours? * Do you have any of the following issues? * Poor appetite Heavy appetite Change in appetite Poor Sleep Insomnia Sudden energy drop at a particular time Cravings Heavy Sleep Fatigue Tremors Page 4
5 Vertigo Fever night sweats Localized weakness Bleeding or Bruising easily Coldness of the hands, feet, back, or abdomen chills easy sweating Poor coordination Do you have any of the following issues? * Rashes Ulcerations Hives Eczema Dandruff loss of hair Itching Pimples Changes in hair or skin texture purpura (tiny bruises) Do you have any of the following issues? * Dizziness Concussions Migraines Eye pain spots in eyes color blindness blurry vision Earaches poor hearing sinus problems Dry throat copious saliva jaw clicks Recurrent sore throats sores on lips or tongue Headaches Eye strain Poor vision night blindness cataracts wear glasses or contacts ringing in ears Nose bleeds mucus dry mouth teeth problems grinding teeth Gum problems Facial pain Do you have any of the following issues? * High blood pressure Low blood pressure Chest Pain Dizziness Swelling in hands or feet Phlebitis (inflammation of veins) Irregular Heartbeat Fainting Blood Clots Difficulty Breathing Do you have any of the following issues? * Cough Coughing blood Page 5
6 Asthma Pneumonia Tight chest Bronchitis Do you have any of the following issues? * Nausea Vomiting Diarrhea Belching Bad breath Hemorrhoids Bloody stools Pain or Cramps none of the above Difficulty Breathing when lying down Production of phlegm Gas Black stools Rectal pain Constipation Sensitive abdomen Do you use laxatives Do you have any of the following issues? * Pain on urination Frequent urination Blood in Urine Unable to hold urine Sexually transmitted infection Erectile Dysfunction none of the above Urgency to urinate Kidney stones Do you practice safer sex waking to urinate Please answer these questions regarding female bodies: * These Questions do not apply to me as I do not have a female body. Do you use birth control Are you experiencing breast tenderness Are you experiencing vaginal discharge Have you ever been pregnant Are you experiencing menopausal symptoms Are you experiencing breast lumps Are you experiencing vaginal sores Do you experience any of the following: * Seizures Areas of Numbness Poor memory Depression Bad temper Treated for emotional problems Have you considered or attempted suicide Concussion Anxiety Easily stressed Treated for other neurological problems none of the above Page 6
7 What is your preferred season, which do you least prefer? * What types of taste do you prefer (e.g.. sweet/salty), what is your least favorite? * What type of climate do you enjoy, what type do you try to avoid? * What are your best and worst times of the day? * Do you prefer hot or cold temperatures? * Page 7
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Advanced Acupuncture Inc. II Dr. Nikki N. Medghalchy, DAOM, L.Ac., M.Ac., Dip (NCCA) O.M Natalie Lehmann, L.Ac, MAcOM 17704 Jean Way Ste. 105, Lake Oswego, Oregon 97035 Tel: (503) 908-0157 Fax: (503) 908-0187
Joseph S. Weiner, MD, PC Patient History Form
Date: / / NAME: Last First M. I. Age: Sex: q F q M Birthdate: / / What specific questions or goals do you have for this appointment? Please list the names of other clinicians you have seen for this problem:
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY: