Paul Kempisty L.Ac. Acupuncture. Chinese herbs. Reiki. Aromatherapy. Patient Information. Please answer questions to the best of your knowledge
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1 Paul Kempisty L.Ac. Acupuncture. Chinese herbs. Reiki. Aromatherapy. Patient Information Please answer questions to the best of your knowledge Name Date Address_ City State Zip Home Phone Other Phone Fax Sex: male ( ) female ( ) Height Weight Birthdate / / Age Emergency Contact: Name Phone Referred by Have you received acupuncture before? Yes ( ) No ( ) Your primary biomedical doctor s contact information: Name Address_ Phone Fax Please indicate any significant illness you or a blood relative have had: Cancer Hepatitis High blood pressure Infectious diseases Diabetes You Relative When ( ) ( ) High cholesterol Seizures Emotional disorders Tuberculosis HIV/AIDS l d d d You Relative When ( ) ( )
2 Acupuncture. Chinese herbs. Reiki. Aromatherapy. Please list any medications and supplements you are currently taking: (Continue on back if necessary) Medicine Dosage Reason How long Prescribed by Last check up Please check if any of the following statements are true for you. ( ) I have known allergies ( ) I am taking anticoagulants ( ) I have a pacemaker ( ) I am pregnant Please indicate the use and frequency of the following: yes no how much yes no how much yes no how much Coffee/Black tea Water intake Soda pop Non-medical drugs Alcohol Tobacco How do you FEEL about the following areas of your life: Good Average Poor Your comments: Significant other ( ) Family ( ) Diet ( ) Sex ( ) Self ( ) Work ( ) Exercise ( ) Spirituality ( ) What are the main health problems for which you are seeking treatment? What other forms of treatment have you sought? Please list any other health problems you now have: Please list any allergies or food sensitivities you may have: Please list any accidents, surgeries or hospitalizations (including date): Please list any special considerations or circumstances you would like your practitioner to be aware of:
3 Acupuncture. Chinese herbs. Reiki. Aromatherapy. For Men Date of last prostate checkup / / PSA results Manual prostate exam results Frequency of urination: Daytime Night time Color of urine: Clear ( ). Cloudy ( ). Red ( ). Odor ( ) Symptoms related to prostate: Delayed stream ( ). Dribbling ( ). Incontinence ( ). Retention of urine ( ). Rectal dysfunction ( ). Increased libido ( ). Decreased libido ( ). Premature ejaculation ( ). Impotence ( ). Groin pain ( ). Testicular pain ( ). Back pain ( ). Other: ( ): For Women Age of first period (menarche) Are you pregnant? yes ( ). no ( ) Age of last period (menopause) Number of days between periods Number of days of flow Number of pads/tampons on heaviest day Color of flow: Red ( ). Purple ( ). Dark ( ). Brown ( ). Clots: yes ( ) no ( ) Number of pregnancies Number of live births Number of abortions Number of miscarriages Date of last: Gynecological exam Pap smear Mammogram Results: Have you been diagnosed with: Fibroids( ). Fibrocystic breasts ( ). Endometriosis ( ). PID ( ). Ovarian cysts ( ). Other ( ): Symptoms associated with menses: Pain ( ). Nature of pain: Cramping ( ). Stabbing ( ). Burning ( ). Aching/dull ( ). Constant ( ). Intermittent ( ). Bearing down sensation ( ). Discharge ( ). Nature of discharge: Clear ( ). White ( ). Yellow ( ). Other color ( ). Thick ( ). Thin ( ). Scanty ( ). Copious ( ). Headache ( ). Swollen breasts ( ). Increased libido ( ). Constipation ( ). Ravenous appetite ( ). Mood swings ( ). Irritability ( ). Nausea ( ) Vaginal Dryness ( ). Poor appetite ( ). Decreased libido ( ). Hot flashes ( ). Diarrhea ( ). Night sweats ( ). Insomnia ( ). Other: ( ):
4 Acupuncture. Chinese herbs. Reiki. Aromatherapy. General Symptom Survey ( for everyone ) Please check the symptoms you have experienced recently: ( ) Poor appetite ( ) Insomnia/difficult sleeping ( ) Abdominal pain ( ) Eye problems ( ) Excessive appetite ( ) Heart palpitations ( ) Chest pain ( ) Jaundice ( ) Digestive problems ( ) Cold hands & feet ( ) Sciatic pain ( ) Difficult to ( ) Loose stools/diarrhea ( ) Nightmares ( ) Headaches digest oily foods ( ) Nausea ( ) Mentally restless ( ) Gall stones ( ) Vomit ( ) Frequently laughing ( ) Soft brittle nails ( ) Belching/burping ( ) Chest pains ( ) Low back pain ( ) Easily irritated ( ) Heartburn/reflux ( ) Knee problems ( ) Easy to faint ( ) Food sitting in stomach ( ) Hearing impairment ( ) Tendonitis ( ) Gas or bloating ( ) Cough ( ) Ear ringing ( ) Muscles spasms ( ) Constipation ( ) Asthma ( ) Kidney stones or twitches ( ) Tired after meals ( ) Hay fever ( ) Bone spurs ( ) Dry skin ( ) Easily bruised ( ) Frequently catching colds ( ) Decreased sex drive ( ) Dizziness ( ) Sudden weight loss ( ) Shortness of breath ( ) Infertility ( ) Poor ( ) Hemorrhoids ( ) Intolerant to weather changes ( ) Sexual dysfunction concentration ( ) Colitis or Diverticulitis ( ) Bronchitis ( ) Hair loss ( ) Frequent sighing ( ) Blood in stool ( ) Allergies ( ) Urinary problems ( ) Pasty taste in mouth ( ) Nasal problems ( ) Edema ( ) Skin problems ( ) Decreased sense of smell ( ) Depression ( ) Frequent yawning ( ) Worrying a lot ( ) Recent use of antibiotics ( ) Anxiety ( ) Easily frightened ( ) Difficulty in making decisions ( ) Fatigue ( ) Often sad ( ) Often too cold ( ) Often angry ( ) Often too hot ( ) Often crying ( ) Very thirsty ( ) Thinking a lot ( ) Bitter taste in mouth
5 Paul Kempisty L.Ac. Acupuncture. Chinese herbs. Reiki. Aromatherapy. Informed Consent to Acupuncture Treatment This signed form indicates that the patient named below has been informed of and has consented to acupuncture treatment and other associated and complimentary procedures. The methods of treatment include but are not limited to Acupuncture, moxibustion, cupping, guasha, Electro-acupuncture, laser stimulation, Tui Na (Chinese massage), Shiatsu (Japanese massage), essential oil application, Reiki, herbal medicine and nutritional counselling. The patient has been informed that acupuncture is a safe method of treatment and side effects are generally uncommon. Potential side effects of acupuncture include bruising, numbness or tingling near the needling site that may last a few days. Occasionally dizziness or fainting may occur. The patient is encouraged to actively and openly communicate with the practitioner about their treatment experience so as to allow adjustments to be made which aim to maximize patient comfort. Single-use, sterile and disposable needles are used to avoid infection. When moxibustion is applied to acupoints, some burning and/or scarring may occur, depending on the technique used. This form lists the most common risks of acupuncture, but each person may experience different effects. The herbs and nutritional supplements (derived from plant, animal and mineral sources) which may be recommended are traditionally considered safe, although some may be toxic at high doses. Some herbs are inappropriate for pregnant women. Some possible side effects of herbs include nausea, gas, stomach ache, vomiting, diarrhea, rashes, hives or tingling of the tongue. Please inform the practitioner if these or any other side effects are experienced after taking herbs so that appropriate modifications can be made to the formula. These side effects can generally be avoided when herbs are administered by a properly trained herbalist. The patient has also been advised to inform the practitioner if she becomes pregnant. Patient Advisory to Consult a Physician In order to gain the best of both worlds, the patient named below has been advised that for whatever medical conditions they are seeking treatment for by acupuncture and other alternative modalities, they have been advised to check in and consult with their biomedical doctor(s). In compliance with Article 160, Section (b) of NYS Education Law.. Print Patient Name has been advised by Paul Kempisty L.Ac. to consult a physician regarding the condition(s) for which they are seeking acupuncture treatment. Patient Signature Date L.Ac Signature Date
6 Paul Kempisty L.Ac. Acupuncture. Chinese herbs. Reiki. Aromatherapy. New York State Licensed Acupuncturist 73 Spring Street. Suite 201. New York, New York, Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your medical information is important to us. You may be aware that U.S. government regulations established under HIPAA (Health Information Portability and Accountability Act) govern the protection of health information. This notice describes how it may be used, as well as certain rights you have as a patient. Use And Disclosure Of Protected Information All information regarding patients, their treatments, diagnosis and appointments is kept strictly confidential. Patient chart and financial data will be seen only by the practitioner. There is no electronic transfer of your medical data. For treatment purposes, private information will be provided to another practitioner only after your written consent is given. Your medical information may be used, without further notice to you, or specific authorization by you, where required by law: for public health purposes; to report child abuse; in judicial or administrative proceedings; by a health oversight agency for oversight activities authorized by law; under law enforcement purposes; by a coroner or medical examiner; to avert serious threat to health or safety; under military authorites if you are a member of the armed forces of the United States. New York State law provides additional protection for information regarding HIV/AIDS. We will continue to follow New York State law with respect to such information. We may contact you by mail or telephone, at your residence, to remind you of appointment(s). No reference to medical service will be made. Occasionally, we may call to give instructions or to notify you that herbs or supplements are in the office. If you wish for us to make use of alternative methods of communicating with you, please provide that information on the signature sheet. Rights That You Have You have the right to inspect and obtain copies of your medical information. A reasonable fee will be charged for copying. You have the right to request amendments to your medical information. Such requests must be in writing and must state the reason for the requested amendment. If we disagree with requested amendment, we will notify you of such disagreement, and we will further notify you of your rights. You have the right of request an accounting of any disclosures we make of your medical information, except for: disclosures we make directly to you, or to carry out treatment, payment or health care operations, or as requested by your written authorization, or for emergency or notification purposes. Obligations That We Have We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices. We are required to abide by the terms of this notice as long as it currently is in effect. Please sign the attached acknowledgement of receipt as we are required under law to show that we gave you this information.
7 Acknowledgement of Receipt of Notice of Privacy Practices By signing below, I acknowledge that I have read and understand the Notice of Privacy Practices and have therefore been advised of how medical information may be used and disclosed in the office, and have also been informed of how I may gain access to and control this medical information. Signature of Patient or Personal Representative Print name of Patient or Personal Representative Relationship of Personal Representative to Patient Date If you wish for us to make use of alternative methods of communicating with you, please provide that information below:
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SLEEP DISORDER ADULT QUESTIONNAIRE
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Houston Primary Care REGISTRATION FORM (Please Print)
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Steven G. Trostel, M.D., P.A.
NAME: / / FIRST MIDDLE LAST DATE OF BIRTH ADDRESS: STREET CITY STATE ZIP PHONE (PLACE CHECK WHERE WE MAY LEAVE A MESSAGE, YOU CAN PICK MORE THAN ONE) HOME WORK CELL MARITAL STATUS: SINGLE MARRIED DIVORCED
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
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Relation Address City State Zip Code
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LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
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Mary R. Hunter, RN, BSN, LMT Clinical Herbalist Certified Nutritionist
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AGREEMENT AND INFORMATION
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Insurance (Let us make a copy of your insurance card and you can skip this section)
Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:
It is important that you tell your family and the people closest to you of this increased sensitivity to opioids and the risk of overdose.
MEDICATION GUIDE VIVITROL (viv-i-trol) (naltrexone for extended-release injectable suspension) Read this Medication Guide before you start receiving VIVITROL injections and each time you receive an injection.
Pulmonary Associates of Richmond
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PATIENT REGISTRATION
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BREAST HEALTH HISTORY FORM
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BHRT HEALTH HISTORY - Female
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PEDIATRIC MEDICAL HISTORY FORM
Patient s First and Last Name / / PEDIATRIC MEDICAL HISTORY FORM PRESENT HEALTH CONCERN (Reason for today s visit.) ALLERGIES List all allergies to medications, foods and/or other agents. Medication/Food/Other
Copayment Is Due At Time Of Visit. Self-pay (payment due at time of service)
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TC: Docetaxel and Cyclophosphamide
PATIENT EDUCATION patienteducation.osumc.edu What is TC? It is the short name for the drugs used for this chemotherapy treatment. The two drugs you will receive during this treatment are Docetaxel (Taxotere
that will be helpful to you in your interaction with our office. Please read this prior to your visit.
.) We look forward to your visit with us. We would like to provide you with infonnation that will be helpful to you in your interaction with our office. Please read this prior to your visit. OFFICE HOURS:
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
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Acupuncture & Natural Healing Center
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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 Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
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
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 Information Form Pain Management Center at Phoebe
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UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM
UNIVERSITY OF WISCONSIN MADISON BADGER SPORTS CAMP HEALTH FORM Event Name: Dates: Participant Name: Participant cell phone with area code: Custodial Parent/Guardian Name: Phone number: Cell phone: Home