Welcome to our clinic! Here s a checklist to help get you ready for your first visit.

Similar documents
Health Intake Form. Name: Prefer Name: Date: City: State: Zip Code: Gender: M F. Telephone # (home): (work): (Cell):

Rockwood Natural Medicine Clinic

HILL PARK MEDICAL CENTER PATIENT REGISTRATION FORM

Medical History Form

New Patient Intake Form

NEW PATIENT INTAKE FORM

New Patient Intake Form

Adult Health History

Healthworks Nutrition Centre. Naturopathic Medical Questionnaire. Name Date of First Visit. Address. Province Postal Code. Telephone # (home) (work)

Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166

Signature: Today s date: (Parent or Guardian if a minor)

Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA

Dr. Keri Marshall 5415 W Cedar Ln, Suite 202a, Bethesda, MD 20814

Greg Garcia ND, LAc S.W. Watson Ave., Beaverton OR ~ Office: ~ Office Fax: ~

S u n s h i n e. Health Care Center N 94th Drive, Ste. C-4 Peoria, AZ ADULT INTAKE FORM

New Jersey Natural Medicine Dr. Jason Frigerio 4 Village Rd, New Vernon, NJ p (973) f (973) Address: City: State: Zip Code:

Naturopathic Intake Form PERSONAL MEDICAL HISTORY

Ageless Acupuncture Patient Health History

Patient Health History

Pure Health Natural Medicine

ADULT HEALTH HISTORY FORM. Patient Name: Address: City, State, Zipcode: Telephone (home):

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

Health History Questionnaire Date: / /.

55 S. Main Street, Driggs, ID (208)

Lisa Rosenberger, ND, LAc

Inner Balance Acupuncture

Bridges Family Wellness PC. New Patient Intake. Bridges Family Wellness Intake Form SE Lake Rd, Suite 102 Milwaukie, OR

Personal &Work Information Date: Patient Name: Age: City: State: Zip: Primary Care Physician: PCP Phone:

Headache Follow-up Visit Form

LAKES INTERNAL MEDICINE

Essential Wellness Of Illinois, LLC Health History Questionnaire Christine A. Renz L.Ac., Dipl OM, MSTOM

Holistic Health Care New Patient Intake Form

Application For Admission Jersey Shore Low Back Center DRX 9000 Severe Back Pain Solution Program

NEW PATIENT HEALTH HISTORY

Health History Questionnaire. Age Date of Birth Gender. Married Single Separated Divorced Widowed Partnership

Personal Information Name: Date of First Visit: MSP # Address: City, Province: Postal code: Telephone # (home): Telephone # (work):

Status Single Married Separated Live with Alone Spouse Partner Divorced Widowed Partnership Parents Children Friends

Eastern Body Therapy

Questionnaire for Lipedema Patients

PATIENT INTAKE FORM. Employer Name and Address:

Patient Information. Marital Status (Single, Married, Life Partner, Divorced, Widowed) CHIEF COMPLAINT

Patient History Form

ADULT INTAKE FORM - NATUROPATH Date:

Amarillo Surgical Group Doctor: Date:

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

Health History Questionnaire

Dr. Andrea Gri B.Kin, ND Doctor of Naturopathic Medicine Phone: Fax: Peter Robertson Blvd, Brampton ON L6R 1T4

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

I understand cancellation policy. OCCUPATIONAL INFORMATION PHYSCIAN INFORMATION INSURANCE INFORMATION

Acupuncture Patient Health History

Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Adult Intake Form. 411 N. 3 rd St. Suite A2 Elma, WA Phone:

REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL

Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?

stoneburner acupuncture

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

Camas Acupuncture & Nutrition Stephanie Meinhold, LAc 405 NE 6 th Avenue Camas, WA P F

Adult Health History Summary

MEDICAL DATA SHEET For Patients 18 years of age and older

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

Johanna M. Hoeller, DC PS

My Certification I certify that the above information is correct and I request services. X Signature of patient or person acting on patient's behalf

Patient Health History. Name: Date: First Middle Last. Street Address: City: State: Zip Code:

Ayurvedic Intake Form

RHEUMATOLOGY PATIENT HISTORY FORM

Welcome to About Women by Women

Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:

Medical History Form

New Patient Intake Form

Natalie Kilheeney L.Ac., Dipl. OM Licensed Acupuncturist & Herbalist

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

Placer Private Physicians: Patient Health Questionnaire [2]

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

MEDICAL HISTORY RECORD

Oriental Medicine Questionnaire

Address Street Address City State Zip Code. Address Street Address City State Zip Code

Avery Acupuncture & Natural Medicine New Patient Registration

New Patient Medical History Intake Form

Name Date of Birth. City Province Postal Code. Phone # home mobile Phone # (wk) Okay to leave a message re: appointments?

NEW PATIENT QUESTIONNAIRE

New Patient Specialty Intake Form Department of Surgery

New Patient Information

Medical Intake Form. Patient Name: Age : Date of Birth: Gender: Female Male Marital Status: #Children: Address: City: State: Zip:

Dr. Michelle Mackay Patel, ND

John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter

MEDICAL HISTORY (To be filled in by patient)

Naturopathic Medicine Intake Form Adults (16+)

PATIENT INFORMATION Please print clearly and complete all blanks

MEDICAL DATA SHEET For Patients 18 years of age and older

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).

ABUNDANT HEALTH CHIROPRACTIC New Patient Form PERSONAL INFORMATION. Name: Gender: M F Today's Date: / / Birth Date: / / Age: Social Security #: - -

Island Acupuncture. Patient General Information. Last Name First Name. Home Phone Cell Phone. Work Phone . Date of Birth Occupation

PATIENT HEALTH INFORMATION SHEET

Adult Intake Form. Full name: Address: Province: City: Postal Code: Telephone number: Home: ( ) -

Transcription:

Welcome to our clinic! Here s a checklist to help get you ready for your first visit. New patient paperwork filled out Bring all the supplements/medications that you are currently taking Women please wear pants (no skirts) to your visits Avoid wearing perfumes, essential oils, scented hair products, scented lotions The first visit will be approx one hour 30 minutes. - 1 -

Intake Form Name: Date: Address: City: State: Zip: Telephone (home): (work/cell): Email address: Age: Date of Birth: Gender: Female / Male Married Separated Divorced Widowed Single Partnership Live with: Spouse Partner Parents Children Friends Alone Occupation: Hours per week: Employer: How did you hear about this clinic? Emergency contact: Relationship: Phone: Health History Questionnaire What are your most important health problems? List in order of importance. 1) 2) 3) 4) 5) 6) Family History Do you have a family history of any of the following? (Please check) Cancer Kidney Disease Asthma Tuberculosis Diabetes Epilepsy Stroke Hay Fever Heart Disease Arthritis Anemia Hives High blood pressure Mental Illness Glaucoma Hypothyroidism Depression/Anxiety Alcoholism Hospitalizations /Surgery /Accidents What hospitalizations or surgeries have you had? List any accidents: List any broken bones and dislocations: Were you ever knocked unconscious? Have you ever had a lapse of memory Y N Y N - 2 -

Patient Evaluation Questionnaire 1. Please rate on scale how serious you are about getting well (circle number). 0 1 2 3 4 5 6 7 8 9 10 Not Serious Very Serious 2. Would you prefer: (Please Circle). A. Correction of Cause of Health Problems B. Temporary Symptom Relief 3. Are you willing to follow a treatment program designed to help you return to health? (Treating the Cause) 4. Are you willing to take nutritional and/or homeopathic supplements? 5. Are you willing to make dietary changes? 6. Are you willing to start a moderate exercise program? 7. Please rate on scale how serious you are about staying healthy after your initial intensive care. 0 1 2 3 4 5 6 7 8 9 10 Not Serious Very Serious 8. Are you familiar with Applied Kinesiology? C. Very little (somewhat) 9. Have you ever been treated by a Chiropractor or Naturopath? If yes, how were your results? 10. Please rate your stress on scale. 0 1 2 3 4 5 6 7 8 9 10 No Stress Total Stress 11. Are any doctors or practitioners currently treating you? If yes, please list - 3 -

Toxic Profession Past or Present (Artist, graphic designer, dental asst, gas station worker, painter, industry, cleaners, etc.) Age: Age: Age: Major Psychological Trauma Age: Serious Infections/Diseases (pneumonia, mono, TB, cancer, heart attack, stroke, hepatits, etc) Age: Long periods on prescriptions or street drugs Age: Long visits or lived in a foreign country like India, Mexico, Africa, etc. Age: Age: Treated for parasites, infection? Y N Allergies Are you hypersensitive or allergic to Any drugs? Any foods? Any environmentals? Current Medications Laxatives Cortisone Tranquilizers Pain relievers Appetite suppressants Thyroid medication Birth control pills Antacids Sleeping Pills Antibiotics Please list any prescription medications, over the counter medications, vitamins or other supplements you are taking: - 4 -

Typical Food Intake Breakfast: Lunch: Dinner Snacks: Drinks: Habits Main interests and hobbies Do you exercise? Y N If yes, what kind? How often? Average 7-8 hrs sleep? Y N Sleep Well? Y N Awaken rested? Y N When during the day is your energy the best? Worst? Have a supportive Relationship Y N Have a history of Abuse? Use Recreational drugs? Do you eat three meals a day? Y N Do you eat out often? Y N Do you drink coffee? Y N Do you drink black/green/herbal teas? Y N Enjoy your work? Y N Take vacations? Y N Spend time outside? Y N Watch television? Y N How many hours? Alcoholic beverages How many per week? Smoke? How much per day? How many years? Do you have a religious or spiritual practice? Y N If yes, what? How does your condition affect you? What do you think is happening? Why? What do you feel needs to happen for you to get better? How long do you think it will take for you to get better? - 5 -

Review of symptoms Y= a condition you have now N= never had P= a condition you have had before Appendicitis Polio Whooping cough Anemia Measles Mumps Chills Convulsions Fainting Fatigue Fever Have you had, or do you have any of the following conditions: Chicken Pox Alcoholism Epilepsy HIV Multiple Sclerosis General Loss of Sleep Loss of Weight Neuralgia Sweats Treated for emotional problems Mood swings Considered/Attempted suicide Poor concentration Mental/Emotional Depression Anxiety or nervousness Tension Memory problems Hypothyroid Hypoglycemia Excessive thirst Fatigue Heat or Cold intolerance Endocrine Diabetes Excessive hunger Seasonal depression Night sweats Chronic fatigue Syndrome Chronic swollen glands Seizures Muscle weakness Loss of Memory Vertigo or dizziness Paralysis Immune Neurologic Reactions to vaccinations Chronic infections Slow wound healing Numbness or tingling Easily stressed Loss of Balance Fainting - 6 -

Rashes Eczema or Hives Acne/Boils Color change Skin Lumps Itching Hair loss Bruises easily Headaches Migraines Head injury Jaw/TMJ problems Spots in Eyes Impaired vision Blurriness Colorblindness Double vision Cataracts Glasses or contacts Eye pain/strain Tearing or dryness Glaucoma Impaired hearing Earaches Ringing Dizziness Head Eyes Ears Nose Throat Frequent colds Stuffy nose Runny nose Sinus problems Nose bleeds Hay fever Loss of Smell Frequent sore throat Teeth grinding Gum problems Dental Cavities Sores on tongue or lips Hoarseness Difficulty Swallowing Goiter Swollen glands Cough Persistent Cough Spitting up blood Asthma Pneumonia Emphysema Pain on breathing Respiratory Shortness of breath Shortness of breath at night Tuberculosis Spitting up phlegm Wheezing Bronchitis Heart disease High blood pressure Low blood pressure Pain over heart Poor circulation Rapid heart Slow heart Stroke Cardiovascular Varicose veins Murmurs Blood clots Phlebitis Rheumatic fever Swelling in ankles Palpitations/fluttering - 7 -

Trouble swallowing Change in thirst Nausea Vomiting blood Blood in stool Abdominal pain/cramps Belching or passing gas Black stools Liver trouble Dr. Carlotta Watson Gastrointestinal Heart burn Change in appetite Constipation Diarrhea Gallbladder trouble Ulcer Hemorrhoids Poor appetite Poor digestion Bowel movements: How often? Is this a change? Pain on urination Frequency at night Frequent infections Increased frequency Inability to hold urine Urinary Kidney stones Blood in urine Kidney infection Prostate trouble Hernias Testicular pain Venereal disease Impotence Male reproduction Premature ejaculation Testicular masses Prostate disease Discharge or sores Female Reproduction/Breasts Age of first menses Age of last menses Length of cycle days Duration of menses days Discharge Herpes Venereal Disease IUD Painful menses Birth control? Heavy or excessive flow PMS If yes, what are your symptoms? Endometriosis Ovarian cysts Difficult conceiving Hot flashes Are cycles regular Lump in breast Bleeding between cycles Pain during intercourse Clotting What type? Number of pregnancies Number of live births Number of miscarriages Number of abortions Have you had a mammogram? Y N Last Pap smear date? Was it normal? Y N Backache Foot trouble Pain between shoulders Painful tail bone Muscles/Joints/Bones Stiff neck Swollen Joints Tremors/Twitching Arm Trouble - 8 -

If you have musculoskeletal pain, please complete the following: Please mark the intensity of your pain today: 0 = no pain, 10= intense pain. Area: Intensity: Area: Intensity: Area: Intensity: Area: Intensity: How long has this condition lasted? Is this condition: Getting worse The Same Improving Was this caused by an injury/accident? Y N If no, when did you first notice it? Pain came on: Gradually Suddenly The pain is: Occasional Frequent Constant Describe the pain: Sharp (knife-like) Dull (toothache) Burning (hot) Does the pain: Stay in one spot Radiate (shoots) Go up &down spine What time of day is the pain worst: Morning Afternoon Evening Night All the time Do you have pain in: Legs Feet Arms Hands Left Right Numbness or tingling in: Legs Feet Arms Hands Left Right What makes the pain worse? What makes the pain better? Does the pain affect your sleeping: No Occasionally Frequently Constantly Does your pain affect your work? No Occasionally Frequently Constantly Have you been hospitalized in the last five years? If yes, for what? Have you had major surgery in the last five years? If yes, for what? Have you seen other doctors for this condition? Y N If yes, doctor s name: - 9 -

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback