New Patient Packet Please bring with you to your first appointment.

Similar documents
Welcome to Our Community!

NE COMMUNITY ACUPUNCTURE & Wellness Center

TEMPE COMMUNITY ACUPUNCTURE (480)

WELCOME TO STREAMS OF GRACE CLASSICAL CHINESE ACUPUNCTURE!

Welcome to Our Community!

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

PATIENT INFORMATION Please print clearly and complete all blanks

PATIENT INTRODUCTION

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

Reason forappointment:

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

Johanna M. Hoeller, DC PS

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

Emotional Relationships Social Life Sexually Recreation

CHRISTOPHER BROWN D.O. - TRADITIONAL OSTEOPATHY

New Patient Information

Phoenix Community Acupuncture s Fine Print -Please initial each section, then sign and date the back. Thank you.-

New Adult Intake Form

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

CHIROPRACTIC ASSOCIATES CLINIC

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

Chiropractic Applied Kinesiology Vitamins Herbs Homeopathy Health Education Classes PATIENT REGISTRATION

KEY TO LIFE CHIROPRACTIC

INFORMATION/APPLICATION FOR CARE

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

Rachel Beth Dorfman, L.Ac., C.M.T.

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

Allan Warshowsky MD,FACOG, ABIHM. New Patient Questionnaire Date of appointment :

Dr. Brett A. Morgan PATIENT INFORMATION TRUE HEALTH Chiropractic Physician Applied Kinesiologist So. Charleston, WV PERSONAL INFORMATION

CHIROPRACTIC ASSOCIATES CLINIC

Inner Balance Acupuncture

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

If you have any questions, feel free to contact us at 475- WLNS (9567) or

Avery Acupuncture & Natural Medicine New Patient Registration

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

CHIROPRACTIC INTAKE FORM

NEW PATIENT HEALTH HISTORY

Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History

Patient History (Please Print)

Medical History Form

Patient Health History Questionnaire

Acupuncture & Herbal Therapies

CONSULTATION ADMITTANCE FORM

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

Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.

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

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

MEDICAL DATA SHEET For Patients 18 years of age and older

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

Laser Vein Center Thomas Wright MD RVT Page 1 of 4

TOMBALL REGIONAL INTERNAL MEDICINE ASSOCIATES Medical Complex Drive, Suite 6 Tomball, TX

Pure Health Natural Medicine

Patient Intake Form Please Write Legibly

Laser Vein Center Thomas Wright MD Page 1 of 4

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

Dear Valued Patient, Revised 09/24/2018 UC Health Integrative Medicine Page 1 of 5

Thank you for choosing Therapy Works to assist you with your current condition.

Medical History Form

ACUPUNCTURE QUESTIONNAIRE

KEY TO LIFE CHIROPRACTIC

Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:

Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy

Gentle Chiropractic, LLC Dr. Amy Richard 7919 Big Bend Blvd. Suite B Webster Groves, MO Phone: Patient Data Sheet:

PERSONAL INJURY QUESTIONNAIRE

NEW PATIENT INTAKE FORM

ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address

**PLEASE NOTE OUR NEW ADDRESS** The Spine Center 159 Wells Ave, Newton, MA Ph: Fax:

Questionnaire for Lipedema Patients

Patient First Name Patient Middle Initial Patient Last Name. Primary Care Physician Primary Care Physician Phone Pharmacy Name

Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code

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

Hospital he hospital is located near the interchange of highway 217 and (US 26).

MICHAEL J. SUNDINE, M.D., F.A.C.S., F.A.A.P.

Vanessa Schulte, CCMA Practice Administrator Huntsville Hospital Pediatric Neurology

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy

Eastern Body Therapy

Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone

LAKES INTERNAL MEDICINE

Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)

Patient Interview Form

Gender: M F Race: Caucasian African American Hispanic Other

Last Name First Name Middle Name MRN

ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:

New Patient Medical History Intake Form

Amarillo Surgical Group Doctor: Date:

New Patient Intake Form. Personal Information. Name Date. Address City State Zip. Occupation Referred by. I prefer to be contacted by: Phone ( )

PATIENT MEDICAL HISTORY INTAKE FORM

CompassionMassage.com. Client Intake Form

Welcome to the Kentucky Neuroscience Institute at the University of Kentucky!

New Patient Information

NEW PATIENT REGISTRATION FORM

Margie Petersen Breast Center

Date: SSN: Birthday: First Name: Middle Name: Last Name: Sex: Male Female Height: Weight: Married/Single: Spouse Name: Home # Cell # Work #

ACTIVE EDGE CHIROPRACTIC

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

Health History Questionnaire Date: / /.

PATIENT INTAKE SHEET 2016

Transcription:

New Patient Packet Please bring with you to your first appointment. Welcome to Hollywood Community Acupuncture! Gentle, Effective, Affordable Health Care for All of Us! Located in the Heart of Hollywood: 1535 NE 41st Avenue, Portland, Oregon 97232 (Between NE Halsey & Broadway; across the street from Trader Joe s!) Online Scheduling: HollywoodCommunityAcupuncture.com (Click red Book Now! button) Information & Appointments: Call 503-282- 9777 during clinic hours, or leave a voice message. Email: HollywoodCommAcupuncture@gmail.com Sliding Scale: $15 - $40 per treatment in a comfortable group setting. Plus, $10 Initial Intake fee for New Patients on first visit only. Visit our website for more detail: HollywoodCommunityAcupuncture.com Welcome to our community! Thank you for scheduling your New Patient appointment with us. We look forward to meeting you and becoming your partner in health care. In this New Patient Packet, you will find: - Welcome Letter from HCA - Patient Health History & Contact Information form - Location Map with parking suggestions Please, complete the provided Health History form and bring it with you to your first appointment...or, arrive 15 minutes early to complete your paperwork before your scheduled time. Welcome 6-22- 15, 1 of 2

A few things to know before your first appointment: Please allow 90 minutes for your first visit: Plan to be at the clinic for about 90 minutes. This allows time to complete and process your paperwork, review your health issues with the acupuncturist, and get a treatment. Follow- up appointments for returning patients are generally 30-60 minutes. Arriving on time: We realize your time is valuable and we want you to get the most out of each visit. Therefore, we ask that you arrive at least 5 minutes before your appointments. If you arrive late and other patients are waiting, you may need to reschedule. (A $15 missed appointment fee may also apply.) Payments: You will pay $15 to $40 (you decide) when you sign in at the front desk. There is an additional $10 Initial Intake fee on your first visit only. We take cash, check, and 4 major credit cards. Insurance billing: We do not process insurance claims. However, upon request, we will gladly issue a super- bill that you can submit to your insurer. What to wear: Wear loose, comfortable clothing with sleeves you can roll up to the elbows and pants you can pull up to the knees. You'll need to remove your shoes and stockings, but nothing else. Fragrance Free Zone: Many of our patients are sensitive to smells. Please avoid wearing any perfume, cologne, or scented lotions to your appointment. No strong- smelling food brought into the clinic, please. Cell phones and other electronics: Out of consideration for others, and to get the most out of your own treatment, please completely turn OFF your cell phone, etc., before entering the treatment room. Non- urgent scheduling & cancellations: To schedule or cancel an appointment (one, or more days in advance), you may use our online schedule system, or call during clinic hours. Last- minute cancellations: Please note that we may charge a $15 fee for appointments that are cancelled with less than a 24- hour notice. Call us at 503-282- 9777 as soon as possible, so we can offer your slot to someone else. Walk- ins are welcome: We will fit you in, if we can but that may not always be possible. Scheduling ahead assures you a space. Parking: Parking can be a challenge at peak hours. Please allow extra time to get to your appointment if you are driving. Do not park in the Trader Joe s lot. We have a few spaces in the lot behind our clinic that you may use, if you cannot find street parking. Client responsibility: Hollywood Community Acupuncture does not provide primary care medicine. Acupuncture is a wonderful complement to Western medicine, but it is not a substitute for it. If you think you have a serious, undiagnosed problem, you need to see a primary care physician (MD or ND). Clinic responsibility: We at HCA whole- heartedly believe in the healing, compassionate properties of ancient Chinese medicine. And we believe everyone has a right to quality health care. Whatever your financial or social status, whatever your age, gender, sexual orientation, ethnicity, or belief system, we treat you with respect, and are honored to be a part of your health care community. We look forward to meeting you! Sincerely, Jeanine Office Manager HollywoodCommunityAcupuncture.com 503-282- 9777 Welcome 6-22- 15, 2 of 2

Hollywood Community Acupuncture PATIENT INFORMATION CONTACT INFORMATION Date Name Best contact phone Email Age Birth Date Sex: F M Preferred Gender: F M Address Primary physician Physician phone number City, State, Zip Occupation Employer How did you hear about us? Another person we may contact, if needed: Name Relationship Have you had acupuncture before? Yes No Preferred Phone HEALTH HISTORY What are your primary reasons for coming in? 1. 2. 3. How is your sleep? How is your digestion? Are you currently taking pain medication or blood thinners? (incl. aspirin) Yes No Medications and food supplements you take: List serious illnesses, traumas, accidents, surgeries: List known allergies: Date of last complete medical exam? Symptoms you have experienced in the last year? Depression Difficulty focusing Dizziness Easily startled Excessive worry or fear Excessive anger or irritability Fatigue/tiredness Headaches Loss of sleep/poor sleep Loss or gain of weight Overwhelmed by life Conditions you have (or have had): Allergies Head trauma Anemia Hepatitis (type ) Arthritis HIV/AIDS Bleeding disorder Migraines Breast lump Heart condition Cancer Seizure Diabetes Stroke

HEALTH HISTORY continued Symptoms you have (or have had) in the last year: MUSCLES/JOINTS/BONES Tremors Swollen joints Cramps Pain, weakness, numbness in: (indicate side of body) Neck Shoulder Back Arm Hip Elbow Leg Wrist Knee Hand Ankle Other EYES/EARS/NOSE/THROAT/RESPIRATORY Asthma/wheezing Earache Difficulty breathing Loss of hearing Persistent cough Ringing in ears Hoarseness Eye pain Hay fever Blurred/failing vision Sinus problems Nose bleeds Frequent colds Gum trouble Enlarged glands Other SKIN Boils Bruise easily Dry Sensitive Itchy Sore won t heal Sweats Other GENITO/URINARY Bladder or urinary tract infection Blood/pus in urine Frequent urination Inability to control urine Kidney infection/stones Lowered libido Other CARDIOVASCULAR Chest pain Hardening of arteries Pain over heart Previous heart attack Poor circulation Rapid/irregular heart beat Swelling of ankles High or low blood pressure Other GASTROINTESTINAL Nausea Belching, gas, bloating Poor appetite Excessive hunger or thirst Indigestion Difficulty swallowing Constipation Diarrhea Vomiting Pain over stomach Colon trouble Gall bladder trouble Hemorrhoids (piles) Other MALE ISSUES Male infertility Prostate trouble Erection difficulties Other FEMALE ISSUES Irregular cycle Bleeding between periods Scanty menstrual flow Excessive menstrual flow Clots in menses PMS Severe menstrual pain Menopausal symptoms Infertility Previous miscarriage Could you be pregnant? Yes No Please let us know if this changes. If yes, how many weeks? Due date Physician/midwife Phone number The information on this form is correct to the best of my knowledge. Signature Date HollywoodCommunityAcupuncture.com 503-282- 9777 HH 6-3- 2015, 2 of 2

Hollywood Community Acupuncture Location and Parking Map 1535 NE 41st Avenue, Portland, OR 97232 503-282-9777 HollywoodCommunityAcupuncture.com You may park in the small lot behind the clinic, but we can only accommodate 4-6 cars. Additional parking may be available along NE 41st Avenue or NE Broadway. A word about parking: Parking can be a challenge at peak hours. Please allow extra time to get to your appointment if you are driving. Remember, parking at the Trader Joe s lot carries huge financial risk. You could probably get a lifetime supply of acupuncture for the cost of one towing charge.

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