ADULT PATIENT PROFILE

1. PATIENT INFORMATION
Date:

MonthDayYear
Date
Name:
DOB:

MonthDayYear
Date
MFOther
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Age:
Height:
Weight:
Blood Type (if known):
Occupation:
Full-TimePart-Time
SingleMarriedLong-Term PartnerSeparatedDivorcedWidowed
Emergency Contact:
Relationship:
Phone:
Format: (000) 000-0000.
Legal Guardian Name & Contact#:
Who can we thank for referring you to Longevity Health:
YesNo
2. PRIMARY HEALTH CONCERNS
Please list your top concerns in order of importance:

Please list your top 3 concerns in order of imporatance:

Rows	Concern	Onset	Frequency	Severity (mild/ moderate/severe)
1
2
3

Additional Health History
Did anything trigger your change in health?
What makes you feel better?
What makes you feel worse?

5. MEDICAL HISTORY
List all Diagnosed Medical Conditions (include year of diagnosis):
Surgeries / Hospitalizations (with approx. dates):
Do you have a pacemaker?
Have you had any organ transplants?
Organ?
Antibiotic Use (frequency):
Steroid Use (frequency):
ChildhoodFluShinglesPneumoniaOther
COVID#:
Birth Story: Vaginal
Cesarean
Breastfed
Date of last physical:
Date of last bloodwork:
6. MEDICATIONS & SUPPLEMENTS

6. MEDICATIONS & SUPPLEMENTS

Rows	Medication	Reason	How Long	Dose
1
2
3
4
5

Rows	Supplements	Reason	How Long	Dose
1
2
3
4
5

Authorization to Release Health Information
I authorize Longevity Health Center to disclose my protected past, present and future health information to the following people or entities:
This health information may be used by the person I authorize for health treatment or billing/payment purposes. This authorization will remain in effect until such time as I choose to revoke the authority in writing.
Signature

Clear
Date

MonthDayYear
Date
STATEMENT OF UNDERSTANDING
I acknowledge that the modalities utilized by Alice Honican, DTCM, ND, L.Ac., Cristina McMullen ND, Maria Jones, ND, and Janelle Bertler, ND, at Longevity Health Center are not approved for medical evaluation or diagnosis. The bio-energetic assessments performed may indicate "disturbance signals" related to microbial or environmental pollutants, but these are not to be interpreted as a medical diagnosis. The information gathered is intended solely to guide the development of a recommended protocol for holistic wellness. I also understand that none of the practitioners or staff members at Longevity Health Center are medical doctors. I voluntarily choose to undergo an evaluation and treatment based on oriental medical principles, including traditional and modern acupuncture techniques.
CANCELLATION POLICY - $50 Missed Appointment Fee
We strive to provide timely and quality care to all our patients. To ensure the availability of appointments, please be aware of the following policy:
- Late Cancellations: Appointments must be canceled at least 24 hours in advance. If you cancel with less than 24 hours' notice, it will be considered a late cancellation.
- No-Shows: A no-show occurs when a patient misses an appointment without prior notice.
In either case, a $50 missed appointment fee will be charged. When you book an appointment, you reserve a time slot that could have been offered to another patient. Timely cancellations allow us to accommodate other patients in need of care.
If you need to cancel your appointment, please call us at 770-642-4646 between 9:00 AM and 5:00 PM. If you call outside of business hours, please leave a detailed voicemail. We will return your call as soon as possible.
I have read and understand the above CANCELATION POLICY.
I have read and understand this STATEMENT OF UNDERSTANDING.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Rows	0	1	2	3	4	5	6	7	8	9	10
Brain Fog
Neck/Upper Back Pain
Joint/Muscle Pain
Headaches/Migraines
Tingling/Numbness in Extremeties
Blurry Vision/Floaters
Digestive Dysfuntion (Gas/Bloating, Indigestion/Reflux, Diarrhea/Constipation)
Insomnia/Sleep Disturbance
Fatigue/Exhaustion
Anxiety
Depression
Cardiovascular Issues
Sinus/Chest Congestion
Hormone/Endocrine Imbalance
Skin Rash/Irritation
Urinary Tract /Kidney Dysfunction

Rows	BREAKFAST	LUNCH	DINNER
1
2
3

1. PATIENT INFORMATION

2. PRIMARY HEALTH CONCERNS

3. CURRENT SYMPTOM SEVERITY (0 = none, 10 = worst)

4. HEALTH GOALS & READINESS

5. MEDICAL HISTORY

6. MEDICATIONS & SUPPLEMENTS

7. ALLERGIES / SENSITIVITIES

8. DIGESTION

9. DIET & NUTRITION

10. LIFESTYLE

11. ENVIRONMENTAL EXPOSURES

12. EMOTIONAL & SOCIAL HEALTH

13. FAMILY MEDICAL HISTORY

14. WOMEN ONLY (if applicable)

15. MEN ONLY (if applicable)

Authorization to Release Health Information

STATEMENT OF UNDERSTANDING

CANCELLATION POLICY - $50 Missed Appointment Fee