trinitynaturalhealthky.com - Trinary Natural Health Application

Application For Care
Name:

First NameLast Name
Birth Date:

MonthDayYear
Date
Age:
Date:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address for Doctor Correspondence:
example@example.com
Phone Number:
Please enter a valid phone number.
Number of children and ages:
Employer/Occupation:
Name & Number of Emergency Contact:
Relationship:
REFERRAL:
Please, let us know who referred you for help or how you heard about our clinic.
Have you ever been under functional nutrition care?
RATE the IMPORTANCE OF YOUR HEALTH on scales of 1-10:

1

2

3

4

5

6

7

8

9

10

1 is Least, 10 is Most
RATE the QUALITY OF YOUR LIFESTYLE choices (diet, exercise, etc.) on a scale of 1-10:

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Great
Are there any hobbies or interests that you would like to be able to do again?
Your Top 3 Health Concerns, Goals or Problems
Primary:
Secondary:
Third:
Mark on the body where you experience symptoms
With 10 being the most severe and 0 being normal, rate your above concerns by selecting the number:
Primary or chief complaint is:

0

1

2

3

4

5

6

7

8

9

10

0 is , 10 is
Second complaint is:

0

1

2

3

4

5

6

7

8

9

10

0 is , 10 is
Third complaint is:

0

1

2

3

4

5

6

7

8

9

10

0 is , 10 is
When did the problem(s) begin?
When is the problem at its worst?

AMPMMid-dayLate PM
How long does it last?

It is constantI experience it on and off during the dayIt comes and goes throughout the week
Has this condition ever been treated by anyone in the past?

YesNo
If yes, when and by whom?
How long were you under care:
What were the results?
What relieves your symptoms?
What makes your symptoms feel worse?
YOUR PAST HISTORY
Identify all jobs you have had in the past:
Identify mental trauma or emotional stress you have experienced (divorce, infidelity, death of a family member, assault, self-esteem, etc.)

If you have ever been diagnosed with any of the following conditions, please indicate wit Past, Currently have or Never have had:

	Past	Currently	Never
Broken Bone
Dislocations
Tumors
Rheumatoid Arthritis
Fracture
Disability
Cancer
Heart Attack
Osteo Arthritis
Diabetes
Cerebral Vascular

Other serious conditions:

PLEASE identify ALL PAST and any CURRENT:

	HOW LONG AGO	TYPE OF CARE	RECEIVED BY WHOM
INJURIES or SURGERIES
SCARS ON BODY
ALL DISEASES IN LIFE

SOCIAL HISTORY
1. Smoking

cigarspipecigarettes
How often?

DailyWeekendsOccasionallyNever
2. Alcoholic Beverage: consumption occurs

DailyWeekendsOccasionallyNever
3. Recreational Drug use:

DailyWeekendsOccasionallyNever
4. Hobbies -Recreational Activities- Exercise Regime: How does your present problem affect?
FAMILY HISTORY:
1. Does anyone in your family suffer with the same condition(s)?

YesNo
If yes whom:

grandmothergrandfathermotherfathersister(sbrother(s)son(s)daughter(s)
Have they ever been treated for their condition?

YesNoDon't Know
2. Any other hereditary conditions the doctor should be aware of?

YesNo
If yes, please explain:
I acknowledge the value and office-time-commitment required for my appointments; should I need to cancel (within 24hrs) or no-show for any appointment I am responsible for the fee associated with that appointment in its entirety. Initial here

I consent and agree to allow this office to treat me, or my child, and use their Patient Health Information for the purpose of treatment, payment, healthcare operations, sharing of testimonials and coordination of care. (Initial)
BLOOD TYPE:

ABABOUnsure
atient or Authorized Person’s Signature

Clear
Date Completed

MonthDayYear
Date
Should be Empty:

Application For Care

REFERRAL:

Your Top 3 Health Concerns, Goals or Problems

YOUR PAST HISTORY

SOCIAL HISTORY

FAMILY HISTORY: