traditional medicine for modern times tm Laura Gabbé, LAc, MS Acupuncture & Herbs
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1 traditional medicine for modern times tm Laura Gabbé, LAc, MS Acupuncture & Herbs FIRST NAME LAST NAME ADDRESS CITY STATE ZIP HOME PHONE OTHER PHONE OCCUPATION INSURANCE CO. INSURER S NAME SELF SPOUSE DEPENDANT OF BIRTH AGE SEX WEIGHT PHYSICIAN S NAME PHYSICIAN S PH# PHYSICIAN S ADDRESS REFERRED BY PRIMARY COMPLAINT ACUTE HEALTH PROBLEMS CHRONIC HEALTH PROBLEMS (onset & frequency) CURRENT & PAST TREATMENTS (include medications, herbs, vitamins. dates used.) SURGERY (type and age) FREQUENT OR SERIOUS CHILD- HOOD ILLNESS (age of occurrence)
2 EXERCISE (type and frequency) RECREATION (type and frequency) SIGNIFICANT TRAUMA (include years] involved - falls, accidents, emotional or physical abuse) EMOTIONS (choose two that seem predominant in your life.) INDICATE WITH ONE CHECK ANY CONDITION THAT YOU SOMETIMES EXPERIENCE; USE TWO CHECKS FOR THOSE THAT OCCUR OFTEN; AND THREE CHECKS FOR SYMPTOMS THAT ARE A MAJOR CONCERN. WATER ELEMENT: HEARING LOSS DIZZINESS LOWER BACK ACHE/NECK PAIN SINUS CONGESTION EDEMA DARKNESS UNDER EYES EMOTIONAL INSTABILITY AVERSION TO COLD HAIR THINNING AND/OR LOSS PRE-MATURE AGING FREQUENT URINATION KIDNEY STONES PERSPIRE VERY EASILY WEAKNESS OF LEGS/KNEES ASTHMATIC COUGH RAPID WEIGHT CHANGE LOOSE TEETH REDUCED SEXUAL ENERGY THYROID PROBLEMS DIABETES EARTH ELEMENT: INDIGESTION FLATULENCE FOOD ALLERGY STOMACH ULCER DIARRHEA ANEMIA HALITOSIS SORES IN MOUTH HEARTBURN STRONG APPETITE WEAK APPETITE NAUSEA ABDOMINAL BLOATING LOW BODY WEIGHT WOOD ELEMENT: HEADACHES MIGRAINES RINGING IN THE EARS POOR EYESIGHT EYE INFECTION DRY EYES ECZEMA, ETC. SHINGLES HERPES SIMPLEX WARTS NERVOUSNESS CONVULSION, SPASMS IRRITABILITY CONSTIPATION HEMORRHOIDS HEPATITIS ULCER VOMITING GALLSTONES INDECISIVE FULLNESS BELOW RIBS SHOULDER/NECK TENSION INSOMNIA 11pm - 3am METAL ELEMENT: BRONCHITIS ASTHMA SHALLOW BREATHING COUGH SINUS CONGESTION NASAL INFECTIONS SPONTANEOUS SWEATING FIRE ELEMENT: OTHER: DRY SCALP SKIN ERUPTIONS, RASH CYSTS, TUMORS EAR INFECTION SORE THROAT, TONSILLITIS LUMP SWELLING HOT PALMS, SOLES HEART PALPITATION AVERSION TO HEAT BITTER TASTE IN TOUCH GUM PROBLEM NOSE BLEED FACIAL REDNESS ITCHING/BURNING SKIN HOT HANDS/FEET THIRST VIVID-DREAMING DARK URINE NIGHT SWEATS FATIGUE ARTHRALGIA SCIATICA NERVE PAIN COLD HANDS/FEET TENDONITIS BURSITIS
3 I TAKE THE FOLLOWING MEDICATIONS: MEDICATION DOSAGE PER DAY WEEKLY MONTHLY AS NEEDED I TAKE THE FOLLOWING VITAMINS AND/OR DIETARY SUPPLEMENTS: SUPPLEMENT DOSAGE PER DAY WEEKLY MONTHLY AS NEEDED I TAKE THE FOLLOWING HERBAL SUPPLEMENTS OR FORMULAS: HERBS DOSAGE PER DAY WEEKLY MONTHLY AS NEEDED SELF MEDICAL HISTORY: include dates CANCER DIABETES, HYPOGLYCEMIA HIGH BP/LOW BP HEART DISEASE HEPATITIS MONONUCLEOSIS GI PROBLEMS SEIZURES MOTHER/FATHER MEDICAL HISTORY: include dates CANCER DIABETES, HYPOGLYCEMIA HIGH BP/LOW BP HEART DISEASE HEPATITIS MONONUCLEOSIS GI PROBLEMS SEIZURES TENSION/ANXIETY ARTHRITIS URINARY TRACK INFECTION KIDNEY DISEASE VENEREAL DISEASE HERPES HPV (papilloma virus) CANDIDA TENSION/ANXIETY ARTHRITIS URINARY TRACK INFECTION KIDNEY DISEASE VENEREAL DISEASE HERPES HPV (papilloma virus) CANDIDA DRUG ADDICTION EATING DISORDER CIGARETTE ADDICTION ALCOHOLISM TB HIV AIDS PARASITES HYPO/HYPER THYROID DRUG ADDICTION EATING DISORDER CIGARETTE ADDICTION ALCOHOLISM TB HIV AIDS PARASITES HYPO/HYPER THYROID
4 OTHER MEDICAL HISTORY: include dates of other family members ALLERGIES (include medication,food, environment and chemicals) CANCER DIABETES, HYPOGLYCEMIA HIGH BP/LOW BP HEART DISEASE HEPATITIS MONONUCLEOSIS GI PROBLEMS SEIZURES TENSION/ANXIETY ARTHRITIS URINARY TRACK INFECTION KIDNEY DISEASE VENEREAL DISEASE HERPES HPV (papilloma virus) CANDIDA DRUG ADDICTION EATING DISORDER CIGARETTE ADDICTION ALCOHOLISM TB HIV AIDS PARASITES HYPO/HYPER THYROID DIET: please note foods you eat with frequency. One check- occasionally. Two checks- daily. Also note foods you avoid with an A COFFEE/TEAS SODA/SELTZER ALCOHOL MILK/CHEESE YOGURT CHICKEN RED MEATS FISH LEGUMES SOY PRODUCTS NUTS NUTS BUTTERS GRAINS VEGETABLES VEG. JUICES FRUITS FRUITS JUICES SEAWEED SWEETS PREPARED FOODS BREADS SPICY FOODS COLD FOODS I generally eat: IRREGULAR MEALS REGULAR MEALS OUT IN PAIN: if pain is involved, describe and indicate where, use illustration below COME ON GRADUALLY CAME ON SUDDENLY SLIGHT OR DULL SHARP OR STABBING MOVES FROM PLACE TO PLACE FIXED IN ONE LOCATION ALLEVIATED WITH HEAT ALLEVIATED WITH COLD RELIEVED WITH TOUCH AGGRAVATED BY TOUCH WORSE WITH FATIGUE BETTER AFTER EXERCISE
5 URINATION: NIGHT VOIDING: DAY FREQUENCY: AMOUNT: BLOOD: DIFFICULTY TO START: UNUSUAL DISCHARGE: RETENTION: COLOR: PAIN: DIFFICULTY TO PASS: BOWELS: DRIBBLING AFTER URINATION: FREQUENCY: COLOR: HEMORRHOIDS: PAIN/DIFFICULTY IN PASSING: TEXTURE/FORM: BLOOD: MUCOUS IN STOOL: MALES ONLY: DIFFICULTY TO START: OF LAST PROSTATE EXAM: PLEASE INDICATE YOUR EXPERIENCES OF THE FOLLOWING: PROSTATE: BLADDER INFECTIONS: HPV (warts): BURNING URINATION: URINARY TRACT INFECTION: INCOMPLETE EJACULATION: PAIN AFTER EJACULATION: AMOUNT OF EJACULATION: KIDNEY INFECTIONS: PAIN/ITCHING IN GENITAL AREA: GENITAL HERPES: FREQUENT URINATION: NOCTURNAL EJACULATION: PREMATURE EJACULATION: COLOR OF EJACULATION: IMPOTENCE: NOTES: INCOMPLETE ERECTION:
6 FEMALES ONLY: PLEASE INDICATE YOUR EXPERIENCES OF THE FOLLOWING: URINARY TRACT INFECTION: VENEREAL DISEASE: YEAST INFECTION: INFERTILITY: BLADDER INFECTION: HERPES SIMPLEX: PID: FIBROIDS: OVARIAN CYSTS: VAGINAL DISCHARGE COLOR: CONSISTENCY: ODOR: WHEN: GYN SURGERIES: NUMBER OF PREGNANCIES: NUMBER OF ABORTIONS: NUMBER OF MISCARRIAGES: OF LAST PAP: POSITIVE PAP : PERIODS: AGE OF ONSET: CRAMPING: BLOATING: EDEMA: DESCRIBE AMOUNT, COLOR AND ODOR (IF ANY) OF MENSTRUAL FLOW: DAY 1: DAY 2: DAY 3: DAY 4: DAY 5: DAY 6: PRESENT AND PAST BIRTH CONTROL METHODS: NOTES:
7 FEMALES ONLY: GRADING OF SYMPTOMS: 1: NONE 2: MILD 3: MODERATE 4: SEVERE SYMPTOMS NERVOUS TENSION: WEEK AFTER PERIOD: WEEK BEFORE PERIOD: MOOD SWINGS: PMT-A IRRITABILITY: ANXIETY WEIGHT GAIN: SWELLING OF EXTREMITIES: PMT-H BREAST TENDERNESS: ABDOMINAL BLOATING: HEADACHE: CRAVING FOR SWEETS: PMT-C INCREASED APPETITE: HEART POUNDING: FATIGUE: DIZZINESS OR FAINTING: DEPRESSION: FORGETFULNESS: PMT-C CRYING: CONFUSION INSOMNIA OTHER OILY SKIN ACNE: MENSTRUAL CRAMPS: MENSTRUAL BACKACHE
8 INFORMED CONSENT FOR ACUPUNCTURE TREATMENT I, the undersigned, hereby assume full responsibility for any acupuncture energetic therapies engaged in by myself or with the therapist, as well as any self-help suggestions I may choose to follow. All therapies are a result of conclusions as a result of what I have learned from the above energetic assessment and are not treatments administered to me for medical and psychiatric disorders. The goal of the above therapies is to restore energetic integrity or my body and should any medical or psychiatric problem arise, I assume full responsibility to consult with the appropriate physicians and seek whatever treatment is indicated. I am aware that acupuncture/moxabustion is a form of treatment based on the principles and theories of Traditional Chinese Medicine. I am aware that acupuncture therapy involves the insertion of special acupuncture needles into specific acupuncture points on the human body. I have been made aware of the possibility of bruising, bleeding, faintness, nausea, areas of anesthesia, organ puncture, needle breakage and/or retention that may result, although unlikely, from the above procedure. I hereby certify that I understand that the above authorization and conditions. I have read, or have had read to me, the above consent. I have had an opportunity to ask questions about its content. I hereby give my voluntary consent for the administration of acupuncture or moxabustion to me. I am aware that I may stop acupuncture treatment at any time. SIGNATURE OF PATIENT SIGNATURE OF PARENT OR GUARDIAN IF PATIENT IS A MINOR SIGNATURE OF LICENSED ACUPUNCTURIST We, the undersigned, do affirm that, has been advised by Laura Gabbe, LAc., to consult a physician regarding the condition or conditions for which such patient seeks acupuncture. PRINT PATIENT NAME SIGNATURE OF PATIENT SIGNATURE OF PARENT OR GUARDIAN IF PATIENT IS A MINOR SIGNATURE OF LICENSED ACUPUNCTURIST
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The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
Patient Questionnaire for Men
Patient Questionnaire for Men Please fill out the following questionnaire to the best of your ability prior to your first appointment. Your physical therapist will review your responses during your initial
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
Infant / Child New Patient Information Package Dr. Anne M. Desneiges - Chiropractor
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SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
FAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
Name Last First Middle. (Complete Mailing) Address ** Street Apt# City State Zip. Work Phone # ( ) ** Emergency Contact Relationship Phone# ( )
Today s Date NEW PATIENT REGISTRATION Name Last First Middle (Complete Mailing) Address ** Street Apt# City State Zip Social Security # Home Phone # ( ) ** Date of Birth Work Phone # ( ) ** Cell Phone
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
CAMARILLO AQUATICS AND REHABILITATION SERVICES
CAMARILLO AQUATICS AND REHABILITATION SERVICES Last Name First M.I. Address Apt.# City State Zip Code Phone # SS# Date of Birth Sex M F Driver s License # Marital Status: S M D W Spouse s Name How did
Aspen Chiropractic & Wellness
WELCOME TO OUR OFFICE We are committed to providing you the best of care and are pleased to discuss our professional fees with you at any time. Please ask any questions you may have regarding our fees
Welcome! Please fill out this Patient Registration
Welcome! Please fill out this Patient Registration Personal: (Please Print Clearly, Sign ALL pages and be Complete) Last Name First Name Middle Street City State Zip Home Phone #: ( ) Work / Cell Phone
Pregnancy True Not True Can't Say
Child's Name Date of Birth Date form filled out The information obtained from the following checklists will assist us in our evaluations of your child. Please try to answer all the questions, even though
PATIENT DEMOGRAPHICS:
PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?
Patient Information. If Patient is child, Parent s Name. City State Zip Cell# SS# of Patient Driver s License #
Patient Information Patient Name Date of Birth If Patient is child, Parent s Name Street Address Male or Female City State Zip Cell# Home# Work# Name of Employer Email Address SS# of Patient Driver s License
FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST
Review of Systems. Eye/Ear/Nose/Throat. hard to empty bladder. palpitations/irregular heartbeat. persistent cough, wheezing. feelings of depression
Name: Review of Systems DOB: / / For staff: place patient label here. Check here if no symptoms. Check concerns below only if you have experienced symptoms recently. General loss of appetite abnormal weight
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
PATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
Mountain View Natural Medicine PATIENT REGISTRATION FORM PATIENT INFORMATION
Mountain View Natural Medicine Lorilee Schoenbeck ND, PC Jessica Stadtmauer ND Dana Dabransky ND Sara Norris ND 185 Tilley Dr. Suite 51 S. Burlington, VT 05403 Phone: (802) 860-3366 Fax: (866) 440-8220
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
SPINE PATIENT HISTORY FORM
Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print
PATIENT REGISTRATION FORM
GENERAL INFORMATION PATIENT REGISTRATION FORM All forms must be completed and signed prior to treatment. Account #: Patient Name: Address: Home Phone No: Cell Phone No: First Middle Last Work Phone No:
NEW PATIENT INFORMATION FORM
Woosik M. Chung, M.D. Timothy R. Kuklo, M.D., J.D. 303-762-DISC (3472) NEW PATIENT INFORMATION FORM Please print all information. By fully completing this form, you allow us to serve you quickly and efficiently.
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
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MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
Leader's Resource. Note: Both men and women can have an STD without physical symptoms.
Leader's Resource Information on Sexually Transmitted Diseases (STDs) Signs and Symptoms of STDs Note: Both men and women can have an STD without physical symptoms. Any of the following can indicate to
Relation Address City State Zip Code
To enable us to provide you with the best possible care, please complete the following: Date: Name Social Security # First Full Middle Last Address City Zip Code_ Telephone (home) (work) Date of Birth