Family Relationship Alive/Deceased Present Health/ Cause of Death Father Mother. # Alive Health #Deceased Cause of Death Brother Sisters Children/Ages

Similar documents
Riverwalk Physical Therapy, L.L.C. ACUPUNCTURE HEALTH HISTORY QUESTIONNAIRE

Mary R. Hunter, RN, BSN, LMT Clinical Herbalist Certified Nutritionist

71 Spit Brook Road, Suite 407 Nashua, NH 03060

PATIENT INFORMATION INSURANCE PHONE NUMBERS ACCIDENT INFORMATION GENERAL INFORMATION. Sex: M F Age Birthdate. Date. Name. Relationship to Patient

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

General Internal Medicine Clinic New Patient Questionnaire

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

Workman s Compensation

MEDICAL HISTORY AND SCREENING FORM

Full name DOB Age Address Phone numbers (H) (W) (C) Emergency contact Phone

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

PATIENT HISTORY FORM

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach

Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX Phone-214) Fax-214)

JAMES PETROS, M.D., INC. PHONE: (408) FAX: (408)

Women s Continence and Pelvic Health Center

Emory Eye Center New Patient Questionnaire

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE Schoenherr Road, Suite 230 Shelby Township, MI (586)

PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )

412 Holistic Health, LLC Maura Schuster, L.OM Practitioner of Oriental Medicine NEW PATIENT INTAKE

NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH Phone: Fax:

Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD

Surgery Health Survey

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Primary Care Physician: Pharmacy: Pharmacy Phone #:

PATIENT INFORMATION INSURANCE INFORMATION

Southwestern Foot & Ankle Associates, P.C Parkwood Blvd, Suite 602 Frisco, TX Phone: Fax: Dr. Thomas H.

Relation Address City State Zip Code

New Patient Intake Form

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico (575) Fax: (575)

NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone address

1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU

CAMARILLO AQUATICS AND REHABILITATION SERVICES

The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il Tel: Fax:

Lighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY.

PATIENT DEMOGRAPHICS

PATIENT REGISTRATION FORM

CLINIC APPLICATION. Client Information

PATIENT HEALTH QUESTIONNAIRE: Urology

INITIAL PATIENT QUESTIONNAIRE-

For the Patient: Dasatinib Other names: SPRYCEL

PATIENT SELF-ASSESSMENT FORM

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

Rehabilitation Medicine Clinic. New Patient Questionnaire

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

Cervical Spine. New Patient Form

PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION

Plano Heart Center, P.A.

REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:

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

RETINA CARE CENTER, P.C. PATIENT INFORMATION

Rheumatology Associates of North Jersey New Data Sheet

Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL Phone (727) FAX (727)

that will be helpful to you in your interaction with our office. Please read this prior to your visit.

PATIENT REGISTRATION FORM

Dear Patient, Sincerely, Gastroenterology Associates of North Jersey

PATIENT DEMOGRAPHICS:

Gemcitabine and Cisplatin

THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History

PLEASE PRINT LEGIBLY

NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute

Patient Intake Form. Patient Information. How did you find out about our office?

Pulmonary Associates of Richmond

CARY ORTHOPAEDIC SPORTS/SPINE SPECIALISTS/PERFORMANCE PHYSICAL THERAPY NEW PATIENT INFORMATION RECORD

Patient Medical History & Intake Form

Interventional Spine Pain Consultants, P.A. Initial Consultation Information

Patient Information Form Pain Management Center at Phoebe

Infant / Child New Patient Information Package Dr. Anne M. Desneiges - Chiropractor

NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet

PAST MEDICAL HISTORY REVIEW OF SYSTEMS

Kalpana Patankar MD; M.Ac; Dipl. OM

New England Pain Management Consultants At New England Baptist Hospital

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)

(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas NAME: Today s Date:

OrthoVirginia Registration Information 2016

Addiction Medical Clinic LLC

For the Patient: Paclitaxel injection Other names: TAXOL

319 Airport Road Hackettstown, NJ Ph: / FAX:

Duke Medicine Division of Pulmonary, Allergy & Critical Care Medicine New Patient History Evaluation. Today s Date:

How To Get A Medical Checkup From A Doctor

FAIRBANKS PHYSICAL THERAPY

MEDICAL HISTORY INFORMATION

NEW PATIENT INFORMATION FORM

Disclosure Form. Memberships: National Certification Commission for Acupuncture and Oriental Medicine (Dipl. Acup.)

Fainting - Syncope. This reference summary explains fainting. It discusses the causes and treatment options for the condition.

Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1

PATIENT REGISTRATION

Name Home phone Work phone. Address. address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by

Get the Facts About Tuberculosis Disease

BREAST HEALTH HISTORY FORM

E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.)

Breast Cancer. Breast Cancer Page 1

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE

PATIENT REGISTRATION

Transcription:

Have you ever been treated with Acupuncture or Oriental Medicine? Chief Complaint Main problem/s you would like help with: How long ago did this problem begin? Does anything make it better or worse (e.g. heat, cold, massage, rest, fatigue, etc)? Have you been given a diagnosis for this problem? If so, what? What other kinds of treatment have you tried? Family Relationship Alive/Deceased Present Health/ Cause of Death Father Mother # Alive Health #Deceased Cause of Death Brother Sisters Children/Ages Check Illnesses which have occurred in any of your blood relatives: Diabetes Cancer Bleeding Tendency Kidney Disease Tuberculosis Heart Disease Stroke High Blood Pressure Nervous Illness Allergy Other Past Medical History Dates of significant illness or surgeries: Significant illnesses (please circle): Cancer Diabetes Hepatitis High Blood Pressure Seizures HIV/AIDS

Significant traumas (e.g. auto accident, falls, etc): Birth history: Allergies: Family medical history: Head, ears, eyes, nose, throat: Dizziness Concussions Migraine Glasses Eye strain Eye pain Poor vision Night blindness Color blindness Cataracts Blurry vision Earaches Ringing in the ears Poor hearing Grinding teeth Spots in front of eyes Facial pain Lip or tongue sores Teeth problems Jaw clicks Headaches Any other problems in this area? Cardiovascular: High blood pressure Low blood pressure Chest pain Irregular heartbeat Dizziness Fainting Cold hands or feet Swelling of the hands Swelling of the feet Blood clots Phlebitis Difficulty breathing

Any other problems with your heart or vascular system? Respiratory: Cough Coughing up blood Asthma Bronchitis Pneumonia Pain with deep breath Phlegm Any other problems with your lungs or respiration? Gastrointestinal: Nausea Vomiting Diarrhea Constipation Gas Belching Black stools Blood in stools Indigestion Bad breath Rectal pain Hemorrhoids Abdominal pain or cramps Chronic laxative use Any other problems with your stomach or intestines? Lifestyle Medicines, vitamins, herbs taken regularly within the last month? Occupation: Occupational stresses:

Do you follow a regular exercise program? Please describe: Have you ever been on a restricted diet? Please describe: Please describe your average daily diet: Morning: Afternoon: Night: Do you smoke? How many per day? How much coffee, tea or soda do you drink per week? How much alcohol do you drink per week? Please describe any drug use for non medical purposes: General (please check if you have had in the last three months): Poor appetite Poor sleeping Fatigue Fevers Chills Night sweats Sweat easily Tremors Cravings Localized weakness Poor balance Change in appetite Bleed or bruise easily Weight loss Weight gain Peculiar tastes or smells Strong thirst Sudden energy drop

Skin and Hair: Rashes Ulcerations Hives Itching Eczema Pimples Dandruff Loss of hair Recent moles Changes in hair or skin texture Any other skin problems? Uro Genital Painful urination Frequent urination Blood in urine Urgency to urinate Unable to hold urine Kidney stones Decrease in flow Impotency Sores on genitals Do you wake up to urinate? How often? Any particular color to urine? Any other problems with your urinary system or genitals? Pregnancy Number of pregnancies Number of births Premature births Miscarriages/abortions Age at first menses Number of days between menses Duration of menses Date of last menses Yeast infections Heavy or light period Painful periods Clots with flow Irregular periods Last Pap smear Vaginal discharge Vaginal sores Breast lumps PMS Do you use birth control? If so, what type and for how long?

Any other problems in this area? Musculoskeletal: Neck pain Muscle pains Knee pain Back pain Muscle weakness Foot/ankle pain Hand/wrist pains Shoulder pains Hip pain Any other joint or bone pain? Neuropsychological: Seizures Dizziness Loss of balance Areas of numbness Lack of coordination Poor memory Concussion Depression Anxiety Bad temper Easily susceptible to stress Any other neurological, psychological or mood problems? Comments: Please mention any other problems you would like help with or anything else you feel needs to be mentioned: Signature Date

2024 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information