Treatment Intake Form
|
|
|
- Piers Lamb
- 5 years ago
- Views:
Transcription
1 Sally Valentine, PhD, LCSW 1 W. Camino Real, Suite 202, Boca Raton, FL drsallyvalentine@me.com Treatment Intake Form Please complete all information on this form and bring it to your first visit or scan and the completed form to me at drsallyvalentine@me.com. Couples should each complete a form. If I do not have a completed form for your first visit, we will need to complete it at that time. Name Date Age Date of Birth What are the problem(s) for which you are seeking help? What do you hope to get out of therapy? Who referred you? Medical history ( ) Thyroid disease ( ) Anemia ( ) Liver disease ( ) Chronic fatigue ( ) Kidney disease ( ) Diabetes ( ) Erectile dysfunction ( ) Delayed ejaculation ( ) Premature ejaculation ( ) Asthma or respiratory problems Please check all that apply. ( ) Stomach or intestinal problems ( ) Fibromyalgia ( ) Heart disease ( ) Epilepsy or seizures ( ) Chronic pain ( ) High cholesterol ( ) High blood pressure ( ) Head trauma ( ) Liver problems ( ) Cancer (type) ( ) Injury or trauma to genitals ( ) Endometriosis ( ) Transgender surgery ( ) Sexually transmitted diseases ( ) Skin problems ( ) Weight loss or gain ( ) Other Allergies Current weight Height Primary care provider name Date and place of last physical exam: 1
2 For women only Date of last menstrual period Are you currently pregnant or do you think you might be pregnant? ( ) Yes ( ) No Are you planning to get pregnant again? ( ) Yes ( ) No Birth control method How many times have you been pregnant? How many live births? List all current prescription medications, their dosage and frequency, and what you take them for. If you take more than five, please list the rest on a separate sheet. Name Dosage Frequency Purpose List all current over the counter medications and supplements, their dosage and frequency, and what you take them for. If you take more than five, please list the rest on a separate sheet. Name Dosage Frequency Purpose Emotional or behavioral issues ( ) Depressed mood ( ) Racing thoughts ( ) Excessive worry ( ) Unable to enjoy activities ( ) Impulsivity ( ) Anxiety attacks ( ) Sleep disturbance Suicide risk assessment Please check all that apply. ( ) Increased risky behavior ( ) Avoidance ( ) Increased libido ( ) Hallucinations ( ) Difficulty concentrating ( ) Forgetfulness ( ) Decreased need for sleep ( ) Suspiciousness ( ) Change in appetite ( ) Excessive energy ( ) Excessive guilt ( ) Increased irritability ( ) Fatigue ( ) Crying spells ( ) Decreased libido 2
3 Have you ever had feelings or thoughts that you didn't want to live? ( ) Yes ( ) No If yes, please answer the following questions. (If no, please skip to the next section.) Do you currently feel that you don't want to live? ( ) Yes ( ) No How often do you have these thoughts? Have you thought about how you would kill yourself? ( ) Yes ( ) No Have you ever tried to kill or harm yourself before? ( ) Yes ( ) No Do you have access to guns? ( ) Yes ( ) No If yes, please explain. Past mental health treatment Outpatient treatment ( ) Yes ( ) No If yes, please describe when, by whom, and for what you were being treated. Psychiatric hospitalization ( ) Yes ( ) No If yes, describe for what reason, when and where. Exercise level Do you exercise regularly? ( ) Yes ( ) No How many days a week do you get exercise? What kind of exercise do you do? Drug and alcohol use How many days per week do you drink any alcohol? What is the least number of drinks you will drink in a day? What is the most number of drinks you will drink in a day? In the past three months, what is the largest amount of alcoholic drinks you have consumed in one day? Have you ever felt you ought to cut down on your drinking or drug use? ( ) Yes ( ) No Have people annoyed you by criticizing your drinking or drug use? ( ) Yes ( ) No Have you ever felt bad or guilty about your drinking or drug use? ( ) Yes ( ) No Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover? ( ) Yes ( ) No Do you think you may have a problem with alcohol or drug use? ( ) Yes ( ) No Have you used any street drugs in the past 3 months? ( ) Yes ( ) No If yes, which ones? Have you ever abused prescription medication? ( ) Yes ( ) No If yes, which ones and for how long? Have you ever been treated for alcohol or drug use or abuse? ( ) Yes ( ) No If yes, for which substances, where and when? 3
4 Trauma history Do you have a history of neglect or emotional, sexual, or physical abuse? ( ) Yes ( ) No If yes, please describe when, where and by whom: Education and work history What is your highest educational level or degree attained? Are you currently: ( ) working ( ) student ( ) unemployed ( ) disabled ( ) retired How long in present position? What is/was your occupation? Where do you work? Relationship history Are you currently: ( ) married ( ) partnered ( ) divorced ( ) single ( ) widowed ( ) polyamorous How long? Are you sexually active? ( ) Yes ( ) No How would you identify your sexual orientation: ( ) heterosexual ( ) lesbian ( ) gay ( ) bisexual ( ) transgender MtF ( ) transgender FtM ( ) unsure/questioning ( ) asexual ( ) other (type) ( ) prefer not to answer What is your spouse or significant other's occupation? Describe your relationship with your spouse or significant other: Have you had any significant prior relationships? ( ) Yes ( ) No If yes, how many? How long? Do you have children? ( ) Yes ( ) No If yes, list ages and gender: Describe your relationship with your children: List everyone who currently lives with you: 4
5 Legal history Have you ever been arrested? ( ) Yes ( ) No If yes, what were you arrested for? Do you have any pending legal problems? ( ) Yes ( ) No If yes, what are they? Spirituality Do you belong to a religion or spiritual group? ( ) Yes ( ) No If yes, which one and what is your level of involvement? Is there anything else that you would like me to know about you? Signature Date 5
6
Yen Chiropractic, LLC Personal Injury Patient Intake Form Page 1
GENERAL INFORMATION: TODAY'S DATE: YEN CHIROPRACTIC DR. DANIEL D. YEN, D.C. 4528 W CRAIG RD, SUITE 190 NORTH LAS VEGAS, NV 89032 PATIENT NAME: SOCIAL SECURITY #: ADDRESS: CITY: STATE: ZIP: EMAIL: SEX:
East West Acupuncture & Wellness Center, Inc. Patient Intake Form
East West Acupuncture & Wellness Center, Inc. Patient Intake Form Date: / / How did you hear about us? ( )Ad ( ) Healthcare Referral ( ) Friend/Family Whom may we thank for the referral? Name DOB / / Age
ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message?
ADULT INTAKE FORM (13 and older) Name Date of First Visit Address City State Zip Code Telephone (home) (work) (cell) Is it ok to leave a message? Age Date of Birth Gender Identity Relationship: Single
Phone number: When and how did your pain begin? (a date is required for Medicare and some insurance policies) Date of onset:
C H I R O P R A C T I C O R T H O P E D I C S A N D R E H A B I L I T A T I O N ILJXAi Pain Relief Clinics Please complete all sections. Full Name: Nickname: Gender: M F Age: Race: Date of Birth: I I Family
Philip J Cimo DDS PA 650 West Bough Lane Ste #160 Houston TX
Philip J Cimo DDS PA 650 West Bough Lane Ste #160 Houston TX 770024 O: (713)464-1887 F: (713)461-0605 PATIENT INFORMATION Date: / / Patient Name: First MI Last Address: Date of Birth: Social Security #:
H E A LT H H I S T O RY
H E A LT H H I S T O RY Name: : List All Current Health Problems: List Any Other Doctors Seen, Treatments And Results Obtained: Your Current Physician(s)/Therapist(s): List All Surgeries And Their s: List
IKDC DEMOGRAPHIC FORM
IKDC DEMOGRAPHIC FORM Your Full Name Your Date of Birth / / Your Social Security Number - - Your Gender: q Male q Female Occupation Today s Date / / The following is a list of common health problems. Please
Address: City: State: Zip: Age: Birth Date: Marital Status: M S W D No. of Children. Your Employer: Occupation: Years on Job:
C O N F I D E N T I A L PAT I E N T I N F O R M AT I O N The following information is needed in order to better serve you. Please complete all questions. If you need help, please ask the receptionist.
Premier Pain Consultants
Premier Pain Consultants Advanced Solutions For Pain Relief Name: DOB: Who is your primary care physician/family doctor? What is the major reason you are coming to see the doctor (chief complaint): How
When Your Head is Hurt
INVISIBLE INJURIES When Your Head is Hurt 1855 E. Dublin Granville Road, Suite 301 Columbus, OH 43229 800-934-9840 www.odvn.org www.odvncares.com This booklet was produced by the Ohio Domestic Violence
Date of Birth Gender. List, in order of importance, your goals for working with your physician:
List, in order of importance, your goals for working with your physician: 1. 2. 3. 4. 5. Please list your allergies and what happens when you are exposed to the allergen: Drug Allergies: Food Allergies:
New Immigrant Survey Section D - Health
Section D: Health D1 {CP, IM, SP - Next I have some questions about your health. Would} {OS Would} you say your health is excellent, very good, good, fair, or poor? 1. EXCELLENT [D2; OS: E1a] 2. VERY GOOD
Detox Your Body Quickly and Easily With Super Zeolite Powder
Detox Your Body Quickly and Easily With Super Zeolite Powder Are you constantly unwell? Do you keep going down with ailments? It could be you re your body is chock full of toxins which you must get rid
SOUTH TEXAS BONE & JOINT
SOUTH TEXAS BONE & JOINT NEW PATIENT INFORMATION (PLEASE PRINT) DATE: PATIENT S NAME EMAIL DATE OF BIRTH AGE M/ F SOCIAL SECURITY # MAILING ADDRESS PERMANENT OR TEMPORARY CITY, STATE, ZIP CODE (AREA CODE)
BIRTH CHART XXXXXXXX. Date of Birth XXXXXXXX. Time of Birth XXXXXX, XXXXXX. Place of Birth. Scorpio (Vritchika) Lagna/Ascendant. Birth Star Rohini - 2
Vedic Astrology Report HEALTH REPORT Name Date of Birth Time of Birth Place of Birth Lagna/Ascendant XXXXXX, XXXXXX Scorpio (Vritchika) Birth Star Rohini - 2 Rasi (Moon Sign) Sun Sign Gender Marital status
What are you seeking treatment for? Have you ever had acupuncture before? If so, for what condition?
Name Date What are you seeking treatment for? Have you ever had acupuncture before? If so, for what condition? Do you bruise or bleed easily? q Yes q No Pain l r b = left, right, both past current q q
Charlotte, NC (980) Roanoke, VA (540)
New Patient Information NAME: SEX: / / AGE: (Last) (First) ADDRESS: CITY: STATE: ZIP: HOME PHONE:( ) CELL PHONE: ( ) WORK PHONE: ( ) EMAIL ADDRESS: SSN: Would you like to receive our email newsletter?
Non Prolotherapy Patient Intake Form
Non Prolotherapy Patient Intake Form Scottsdale Pain Rehabilitation & Wellness Fred G. Arnold, N.M.D. 7595 East McDonald Drive, Suite 100 Scottsdale, AZ 85250 (O) 602 292-2978 Fax: 480-219- 8132 www.prolotherapyphoenix.com
SONG OF NATURAL MEDICINE Dr. Crystal Song, NMD
Patient Intake Form DATE: Patient Name: List in Order of importance what your problems are: 1) 2) 3) DOB: Last time you had wellness checkup and with what physician: Family History Father Mother Siblings
Holly Zapf, ND -- Whole Family Health Clinic
Holly Zapf, ND -- Whole Family Health Clinic 2928 SE Hawthorne, Suite 106, Portland, OR 97214 phone: 503-460-0630 fax: 503-231-4003 wholefamily97214@gmail.com Name: Date: Address: City: State: Zip Code:
Natural Healing Family Medicine
Adult Intake Form Last Name: First Name: Date: Address: City: State Zip Telephone (Home): Telephone (Work): Email Address: Age: Date of Birth: Gender: Married: Separated: Divorced: Widowed: Single: Partnership:
M e d i c a l P s y c h o l o g y U n i t, D e p a r t m e nt of C l i n i c a l N e u r o s c i e n c e s a n d M e n t a l H e a l t h Fa c u l t y
R. Fonseca; M. Figueiredo-Braga M e d i c a l P s y c h o l o g y U n i t, D e p a r t m e nt of C l i n i c a l N e u r o s c i e n c e s a n d M e n t a l H e a l t h Fa c u l t y of M e d i c i n e,
Keeping well and healthy when it is really cold
Cold Weather Plan for England 2012 Keeping well and healthy when it is really cold Easy Read version of: Cold Weather Plan for England 2012: Protecting health and reducing harm from severe cold. What
(Work address): How did you hear about our clinic? Has any other family member already been a patient at the clinic?
Name: Date: Address: City: State: Zip Code: Telephone # (home): (work): E-mail address: Age: Date of Birth: Gender: female male Education: Married: Separated: Divorced: Widowed: Single:_ Partnership:_
Family History. Patient Name: DOB: List in Order of importance what your health concerns are: 1) 2) 3) 4) 5)
Naturopathic Heart Institute of Tucson, LLC June E. Stevens NMD Southwest Integrative Healthcare 2802 N. Alvernon Way, Suite 200 Tucson, AZ 85712 (520) 326-0850 (520) 326-0849 Patient Name: DOB: List in
Patient Intake Form. Name Date of birth Age Sex: Male Female
Patient Intake Form Today s date: Name Date of birth Age Sex: Male Female Health Concerns: Please list your main health concerns in order of importance. 1. Describe your primary concern When did it start?
BINF 702 SPRING Chapter 8 Hypothesis Testing: Two-Sample Inference. BINF702 SPRING 2014 Chapter 8 Hypothesis Testing: Two- Sample Inference 1
BINF 702 SPRING 2014 Chapter 8 Hypothesis Testing: Two-Sample Inference Two- Sample Inference 1 A Poster Child for two-sample hypothesis testing Ex 8.1 Obstetrics In the birthweight data in Example 7.2,
A.L. Struik Clinical Psychologist/Family Therapist
A.L. Struik Clinical Psychologist/Family Therapist } Book } Six tests form } Not a protocol } Age differences } www.amazon.com } www.ariannestruik.com } Chronically traumatized } PTSD, FASD, RAD, ODD,
COMPA SS L IGH T. Curriculum. A Serie s o n M en ta l H ea l th
COMPA SS & L IGH T A Serie s o n M en ta l H ea l th Curriculum Dear Viewers, Thank you for you interest in learning more about mental health through our Compass & Light film series. Our hope and prayer
Harrison Drury and Co Limited. IT/HR/other corporate
Survey: SRA Legal Diversity 2017 Submissions: 90 Completed: 49 Regulator Number: 534326 / 536043 Harrison Drury and Co Limited 1. Select one category which best describes your role in the firm. practitioner,
(PLEASE CIRCLE YES ANSWERS ONLY)
(PLEASE CIRCLE YES ANSWERS ONLY) Childhood Illnesses Scarlet Fever Y N Diphtheria Y N Rheumatic fever Y N Mumps Y N Measles Y N German Measles Y N Hospitalizations and Surgery What hospitalizations or
Spirit Relationships - Suffering Caused By Spirit Interaction. Introduction
Spirit Relationships - Suffering Caused By Spirit Interaction Introduction Questions to answer: Reminders about the soul and soul condition Reminders about the Law of Attraction What types of human suffering
DR.CRISTINA COLOMA, ND 2888 GARDNER COURT ABBOTSFORD, BC V2T 5H9 Phone/Fax (604)
DR.CRISTINA COLOMA, ND 2888 GARDNER COURT ABBOTSFORD, BC V2T 5H9 Phone/Fax (604) 556-4596 E-mail: abbynaturopath@gmail.com Name: Date: Address: City: Province/State: Zip/Postal Code: Telephone # (home):
ADULT INTAKE. Name: Date: Address: City: Prov: PC: Telephone (home): (work): Age: Date of Birth: Gender: Female / Male
ADULT INTAKE Name: Date: Address: City: Prov: PC: Telephone (home): (work): Age: Date of Birth: Gender: Female / Male Married: Separated: Divorced: Widowed: Single: Partnership: Live with: Spouse: Partner:
Keeping healthy when it is really hot
Heatwave Plan for England Keeping healthy when it is really hot Easy Read version of: The Heatwave Plan for England: To protect the health of people from the effects of hot weather What is in this plan
Divine Medicine NW Greenbrier Parkway, Suite 100 Beaverton, Oregon P F
Divine Medicine 15455 NW Greenbrier Parkway, Suite 100 Beaverton, Oregon 97006 P 503.466.2722 F 503.644.1293 Patient Demographic Information: Patient Name Street Address Last Name First Name Middle Initial
Dr. Roxie Strand, NMD
Dr. Roxie Strand, NMD Name: Date: Address: City: State: Zip Code: Telephone # home: work: cell: E-mail address: Age: Date of Birth: Gender: female male Education: Married: Separated: Divorced: Widowed:
Adaptive Play and Wellness. Miela Gruber Cooley ND Registration Form (Please Print)
KIDSPACE Adaptive Play and Wellness 469 Buckland Road South Windsor, CT 06074 phone (860) 432-9923 fax (860) 432-7553 Miela Gruber Cooley ND Registration Form (Please Print) Today s Date: PCP: Patient
SPIRITUAL GIFTS. ( ) ( ) 1. Would you describe yourself as an effective public speaker?
SPIRITUAL GIFTS QUESTIONNAIRE: SPIRITUAL GIFTS ( ) ( ) 1. Would you describe yourself as an effective public speaker? ( ) ( ) 2. Do you find it easy and enjoyable to spend time in intense study and research
Paranormal Investigations of Rockland County. New Investigator Brief and Application
Paranormal Investigations of Rockland County New Investigator Brief and Application V1-11.2014 Table of Contents 1. Introduction... 3 2. Starters... 3 3. About You... 4 4. Training Program Brief Description...
Because I Care: Preventing and Dealing with Burnout, Compassion Fatigue, and Vicarious Trauma
Because I Care: Preventing and Dealing with Burnout, Compassion Fatigue, and Vicarious Trauma Presented by, Noé Vargas DBH, LPC, FT & Patrice Pooler MA, ADC At the Association for Addiction Professionals
What is your stress level(1- none 10- very stressful) Occupational Personal
Patient Information form (Please Print) Name: Date of Birth: How do you identify? Male Female Two-spirit Transgendered Intersexed Are you indigenous? If so, please identify Address Postal Code: Phone:
Childhood Nephrotic Syndrome
WORKSH EETS Childhood Nephrotic Syndrome Developed by Pediatric Nephrology Program British Columbia Children s Hospital British Columbia Provincial Renal Agency Vancouver, British Columbia, Canada RD EDITION
AQI Detectives. Learning Objective: Understand the Air Quality Index and learn how to find the daily air quality. Subjects
AQI Detectives 8 A C T I V I T Y Learning Objective: Understand the Index and learn how to find the daily air quality. Subjects Health Social Studies Materials Computer with internet access Crayons, colored
Objectives. Girls will be Girls 3/16/2015. Developmental Resources, May be reproduced by attendees of Mean Girls: Behind the Mask Webinar 1
Developmental Resources Presents Please Ask Questions Via Chat! Presented by: Steph Jensen, MS, LPC Objectives Understand the influence of biology and neurology on aggression. The Girl s World gender roles
ASSOCIATED PRESS-WEATHER UNDERGROUND WEATHER SURVEY CONDUCTED BY KNOWLEDGE NETWORKS January 28, 2011
1350 Willow Rd, Suite 102 Menlo Park, CA 94025 www.knowledgenetworks.com Interview dates: January 21 January 26, 2011 Interviews: 1,125 adults Sampling margin of error for a 50% statistic with 95% confidence
Portland Dental and Naturopathic Clinic
Portland Dental and Naturopathic Clinic Adult Intake Form Name Date of First Visit Address City State Zip Code Telephone # (home) (work) Cell Email address Age Date of Birth Gender: female male Education
Surrey Pay Offer non-schools 1 July 2017 to 30 June 2018 ADDITIONAL INFORMATION REQUESTED
Surrey Offer non-schools 1 July 2017 to 30 June 2018 ADDITIONAL INFORMATION REQUESTED Contents Table 1: Headcount across pay models for non-schools Table 2: 2016 pay bands for job family and leadership
Our approach to academics, as well as our classroom experience can greatly influence our mental, physical and emotional well-being.
Q1 CSG x Active Minds Classroom Climate Around Mental Health Student Survey Our approach to academics, as well as our classroom experience can greatly influence our mental, physical and emotional well-being.
AUBURN UNIVERSITY ATHLETIC DEPARTMENT MEDICAL HISTORY QUESTIONNAIRE
AUBURN UNIVERSITY ATHLETIC DEPARTMENT MEDICAL HISTORY QUESTIONNAIRE NAME: SPORT: SOCIAL SECURITY #: SEX: BIRTHDATE: / / Please circle any of the following that you have, have had, or are now undergoing
JOINT STRATEGIC NEEDS ASSESSMENT (JSNA) Key findings from the Leicestershire JSNA and Charnwood summary
JOINT STRATEGIC NEEDS ASSESSMENT (JSNA) Key findings from the Leicestershire JSNA and Charnwood summary 1 What is a JSNA? Joint Strategic Needs Assessment (JSNA) identifies the big picture in terms of
Protists and Humans. Section 12-3
Protists and Humans Section 12-3 Protists and Disease Key Idea: Protists cause a number of human diseases, including giardiasis, amebiasis, toxoplasmosis, trichomoniasis, cryptosporidiosis, Chagas disease,
Compassionate Care R E D U C I N G S T R E S S A N D D I S C O M F O R T D U R I N G N E E D L E P R O C E D U R E S
Compassionate Care R E D U C I N G S T R E S S A N D D I S C O M F O R T D U R I N G N E E D L E P R O C E D U R E S Guided Imagery Being Afraid Understanding Fear and Phobias M o s t c h i l d r e n a
Gender Recognition Act Survey ONLINE Fieldwork: 19th-21st October 2018
Recognition Act Survey ONLINE Fieldwork: thst October 0 Table Q. Do you think that those who wish to legally change their gender on official documentation (e.g. birth certificate, passport) should or should
Dr. Kevin Passero, N.D Lubrano Drive, Suite L 15, Annapolis, MD New Hampshire Ave Suite B4 NW Washington DC 20036
Dr. Kevin Passero, N.D. 443-433-5540 130 Lubrano Drive, Suite L 15, Annapolis, MD 21401 1330 New Hampshire Ave Suite B4 NW Washington DC 20036 Health History Form Name: Date: Address: City: State: Zip
Poole Hospital NHS Foundation Trust. Equality and Diversity Workforce Monitoring Report
Poole Hospital NHS Foundation Trust Equality and Diversity Workforce Monitoring Report 1. INTRODUCTION 1.1 This report provides workforce data relating to the diversity of Trust staff for the period 1
Chapter 3.2 The organisation of multicellular organisms
biology sample book.indd 25 28/06/2016 7:49:20 PM TOPIC 3 MULTICELLULAR ORGANISMS Chapter 3.2 The organisation of multicellular organisms Understanding Multicellular organisms have a hierarchical structural
Online supplement. Absolute Value of Lung Function (FEV 1 or FVC) Explains the Sex Difference in. Breathlessness in the General Population
Online supplement Absolute Value of Lung Function (FEV 1 or FVC) Explains the Sex Difference in Breathlessness in the General Population Table S1. Comparison between patients who were excluded or included
New Traditions and Tips for the Holidays
Tragedy assistance program for survivors New Traditions and Tips for the Holidays TRAGEDY ASSISTANCE PROGRAM FOR SURVIVORS 800-959-TAPS (8277) www.taps.org N e w T r a d i t i o n s a n d T i p s f o r
Middle Aged Men and Suicide
Middle Aged Men and Suicide C o m m u n i t y H e a l t h N e t w o r k 2 Table of Contents I. M i d d le Aged M e n and Suicide a. T h e S ilent Epidemi c II. D e a t h by Suicide Statistics a. L o c
Cold Weather Plan. This Plan is to be read in conjunction with: Winter Plan Escalation and Surge Business Continuity Plans Major Incident Plan
Cold Weather Plan This Plan is to be read in conjunction with: Winter Plan Escalation and Surge Business Continuity Plans Major Incident Plan This Plan can be accessed from the Staff Zone Authorising Manager
ENHANCEMENTS Lash Boost is only to be used as directed by one person. It is not to be shared with other people.
F R E Q U E N T L Y A S K E D Q U E S T I O N S RODAN + FIELDS ENHANCEMENTS LASH BOOST TM W H A T I S E N H A N C E M E N T S L A S H B O O S T? A nightly eyelash conditioning serum that pairs with any
Naturopathic Intake Paperwork
3500 Kensington Ave Suite B- 2 Richmond, VA 23221 T/F 804-977- 2634 Naturopathic Intake Paperwork 1) What led you to choosing this clinic? 2) What do you know about us and how we work? 3) What three expectations
Grading Scheme 2 nd, Semester Tests 30% Quizzes 15% Labs 10% Assignments 10% Exam 30% Participation 5%
San Pedro High School San Pedro Town Belize District Telefax: 226-2045 Email Address: esantizo@sphs.edu.bz 4 th Form BIOLOGY YEARLY CURRICULUM Text: BIOLOGY FOR CXC Credit Hours: 5 Teacher: Mr. Erick Santizo
RENCO ELECTRONICS, INC.
Directions: Complete sections 1, 2, and 3 for all accidents and incidents. Accidents or incidents that require medical attention or lost or restricted work require the signature of Human Resources. Attach
CHAPTER 8. Editors: Dr Omar Sulaiman Dr Hooi Lai Seong
CHAPTER 8 DECEASED (CADAVERIC) ORGAN Editors: Dr Omar Sulaiman Dr Hooi Lai Seong Expert Panel: Dr Omar Sulaiman (Chairperson) Dr Hooi Lai Seong Dr Rosnawati Yahya Dato' Dr Sharifah Suraya Syed Mohd Tahir
The following information is needed in order to better serve you. Please complete all questions.
C O N F I D E N T I A L PAT I E N T I N F O R M AT I O N The following information is needed in order to better serve you. Please complete all questions. If you need help, please ask the receptionist.
Supplementary Material
1 ORIGINAL RESEARCH ARTICLE Pharmacoeconomics 2008; 26 (1): Supplementary Material 1170-7690/08/001-0001/$48.00/0 2008 Adis Data Information BV. All rights reserved. Economic Burden of Bilateral Neovascular
I.LISTENING A. Listen to an interview about health and choose the correct answer. You will listen to the recording TWICE. (3x1=3 pts.
I.LISTENING A. Listen to an interview about health and choose the correct answer. You will listen to the recording TWICE. (3x1=3 pts.) 1. How does the woman being interviewed feel about psychiatric drugs?
Adult Intake. (Please print clearly) Name Date. Address. Address. Home Telephone Number. Emergency contact: Name
Adult Intake (Please print clearly) Name Date Date of birth (M/D/Y) Sex M F Address E-mail Address Home Telephone Number Work _ May we leave messages relating to your visits? Y / N Which Phone Number?
My. is married and settled in. Dear,
DateOfBirth : 12/ /19 TimeOfBirth : 13. PlaceOfBirth : City : State : Country : INDIA Query : I have done my My parents are looking for a suitable match for me. Initially. I was looking for only but did
18 : :(26-33) «- - -» ( ( ( (3 «- - -» ( ( ( (4-3 -( : ) -( : ) -( : ) -( : ) -( : ) -( :
12 1 94 18 25 1 20 50 26 17 75 51 20 100 76 75 : 25 25 25 25 100 : 18 : :(26-33) «- - -» -1 - - - (2 - - - (4 - - - (1 - - - (3 «- - -» -2 - - - (1 - - - (2 - - - (3 - - - (4-3 -( : ) -( : ) -( : ) -(
Announcements. Topics: To Do:
Announcements Topics: In the Probability and Statistics module: - Sections 1 + 2: Introduction to Stochastic Models - Section 3: Basics of Probability Theory - Section 4: Conditional Probability; Law of
Spiritual H U S B U N D / W I F E S. Christiaan Coetzee
Spiritual H U S B U N D / W I F E S Christiaan Coetzee www.mathetes.co.za What is a Spiritual Spouse A spiritual husband or wife is when there is a evil spirit or demon that have a relationship with a
Thank You. Instructors 2/9/2018. Crossing The Client / Therapist Boundary with Cherie Sohnen-Moe & Ben Benjamin. World Massage Conference Presents:
World Massage Conference Presents: Crossing The Client / Therapist Boundary with Cherie Sohnen-Moe & Ben Benjamin Instructors Cherie Sohnen-Moe Ben Benjamin, PhD 2 Thank You 3 1 Goal Improve the therapeutic
HEAT ACCLIMATIZATION GUIDE
HEAT ACCLIMATIZATION GUIDE H E AT A C C L I M AT I Z AT I O N G U I D E 2003 RANGER & AIRBORNE SCHOOL STUDENTS u Should you be concerned about hot weather? u How fast can you become heat acclimatized?
Placement Test English for Academic Purposes
Placement Test English for Academic Purposes DATE: NAME: NATIONALITY: AGENT/CONTACT: This test is a provisional placement test only. Students will require further testing on arrival. The test should be
= MOTION. Yang (+) Yin (-)
DEATH = STILLNESS LIFE = MOTION Figure 8 Above is the characteristic of life and death described throughout the course. MOTION Modern Language Yang (+) Yin (-) Figure 9 Ancient Language (penis) (vagina)
Examples of frequentist probability include games of chance, sample surveys, and randomized experiments. We will focus on frequentist probability sinc
FPPA-Chapters 13,14 and parts of 16,17, and 18 STATISTICS 50 Richard A. Berk Spring, 1997 May 30, 1997 1 Thinking about Chance People talk about \chance" and \probability" all the time. There are many
Pig organ transplants within 5 years
www.breaking News English.com Ready-to-use ESL / EFL Lessons Pig organ transplants within 5 years URL: http://www.breakingnewsenglish.com/0509/050911-xenotransplant.html Today s contents The Article 2
NEW PATIENT APPLICATION
NEW PATIENT APPLICATION WHOM MAY WE THANK FOR REFFERING YOU TO OUR OFFICE: TODAYS DATE: PATIENT DEMOGRAPHICS: Name: Birth : - - Age: q M q F Address: City: State: Zip: Social Security: Email: Mobile#:
c u l t i v a t e w e l l n e s s
Patient Information Name Age Date of birth Sex: Male Female Amy Bader, ND n atu r o p a t h i c d o c t o r Date Address City State Zip Telephone (Home) (Work) (Cell) Email Emergency Contact Relationship
EGD (Upper Endoscopy)
Gastroenterology EGD (Upper Endoscopy) REMINDER FOR: ON THE DAY OF YOUR PROCEDURE Bring a list of all your medications (over-the-counter and prescription) You must have a driver to take you home following
HEALTH HISTORY FORM. Patient Name: Birth Date: / / Supportive relationship(s)? Yes No Spiritual Practice? Yes No If yes,
HEALTH HISTORY FORM PERSONAL INFORMATION: Today s Date: Patient Name: Birth Date: / / Supportive relationship(s)? Yes No Spiritual Practice? Yes No If yes, Any pets/farm animals? Yes No If yes, Have you
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ 85282 480-284- 8155 Female Health History Patient Name: Date: DOB: Age: Street Address: City: State: Zip: Home phone: Work Phone:
H I D D E N W O M E N : T H E I M P A C T O F P O V E R T Y O N A B O R T I O N A C C E S S
H I D D E N W O M E N : T H E I M P A C T O F P O V E R T Y O N A B O R T I O N A C C E S S S E L I N A U T T I N G, R E S O U R C E M A N A G E R S U S A N S T A R K, S E N I O R C O U N S E L L O R N
NEW PATIENT INTAKE. Name: Date: Address: Preferred Phone: ( ) Alternate Phone:( ) Leaving Voice Message OK: Y N Preferred method of contact:
NEW PATIENT INTAKE Patient Information: Name: Date: Address: Preferred Phone: ( ) Alternate Phone:( ) Leaving Voice Message OK: Y N Preferred method of contact: E-mail address: Age: Date of Birth: / /
Calorimeter Design Project HASPI Medical Chemistry Lab 6a
Name(s): Period: Date: Calorimeter Design Project HASPI Medical Chemistry Lab 6a Background Engineering in Medicine Although you are in a science class, you might not realize that everything you are learning
Lecture 4 Scatterplots, Association, and Correlation
Lecture 4 Scatterplots, Association, and Correlation Previously, we looked at Single variables on their own One or more categorical variable In this lecture: We shall look at two quantitative variables.
Lecture 4 Scatterplots, Association, and Correlation
Lecture 4 Scatterplots, Association, and Correlation Previously, we looked at Single variables on their own One or more categorical variables In this lecture: We shall look at two quantitative variables.
Chemical Sensitivity By Sherry Rogers M.D.
Chemical Sensitivity By Sherry Rogers M.D. Chemical Sensitivity Foundation - Official Site - The primary goal of the Chemical Sensitivity Foundation, a 501(c)3 nonprofit corporation, is to raise public
15 Sapium Rd, Southport, 4215 ph: e:
15 Sapium Rd, Southport, 4215 ph: 07 5597 3844 e: info@benowaearlylearning.com.au www.benowaearlylearning.com.au Office Use Only: Class Required: Date of Commencement: ENROLMENT FORM 2017 Enrolled Formal
ASTROLOGY HUB FULL MOON. Essentials. A 7 Step Guide for Managing Emotions, Stress & Overwhelm. By Donna Woodwell
ASTROLOGY HUB FULL MOON Essentials A 7 Step Guide for Managing Emotions, Stress & Overwhelm By Donna Woodwell Are you feeling anxious? Overly emotional? Spaced-out? Overwhelmed? Headache-y? Have trouble
Adult Intake - Prenatal
Du La, ND# 1135 Jonah Lusis, ND# 1248 T: 416 598 8898 Adult Intake - Prenatal Date: Name: Age: D.O.B.: Address: City: Postal Code: Telephone: (home) (work) (mobile) E-mail: Emergency contact: Relationship:
QUANTUM TOUCH BY RICHARD GORDON DOWNLOAD EBOOK : QUANTUM TOUCH BY RICHARD GORDON PDF
Read Online and Download Ebook QUANTUM TOUCH BY RICHARD GORDON DOWNLOAD EBOOK : QUANTUM TOUCH BY RICHARD GORDON PDF Click link bellow and free register to download ebook: QUANTUM TOUCH BY RICHARD GORDON
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ
Arizona Integrative Medical Solutions 4657 S. Lakeshore Dr, Ste #1 Tempe, AZ 85282 480-284-8155 Diabetic Health History Patient Name: Date: DOB: Age: Street Address: City: State: Zip: Home phone: Work
Unit 1: Cells, Tissues, Organs, and Systems
Unit 1: Cells, Tissues, Organs, and Systems Big Ideas The cell is the basic scientific unit of all living things. Cells must interact with the external environment to meet their basic needs. Your health
Mental Health Program C O N S U L A T E G E N E R A L O F M E X I C O I N L O S Á N G E L E S, C A L I F O R N I A
Mental Health Program C O N S U L A T E G E N E R A L O F M E X I C O I N L O S Á N G E L E S, C A L I F O R N I A BACKGROUND M e n t a l H e a l t h H u b I r e l a n d ( M a y 2 0 1 4 ) U n i t e d K
INTAKE FORM ADULT. Contact Information. Date
INTAKE FORM ADULT Basic Information Dr Aoife M Earls, BSc, MSc Naturopathic Doctor Suite 212, 345 Lakeshore Rd E, Oakville, ON L6H 6K7 1.905.849.6730 draoife.com Date Name Date of Birth YYYY-MM-DD Sex