Applied Natural Health
Integrative Care Acupuncture Herbs
WHAT LANGUAGE DO YOU PREFER:
COMPLETE LEGAL NAME
First Name
Last Name
DATE OF BIRTH:
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Month
-
Day
Year
Date
SEX
M
F
Referred By:
ADDRESS (number, street, apt./unit)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone #:
Format: (000) 000-0000.
DRIVER'S LICENSE #
CITY, STATE, ZIP:
EMAIL ADDRESS:
SOCIAL SECURITY # (Veterans only):
PLEASE ANSWER ALL QUESTIONS. IF AN ANSWER IS YES, PLEASE DESCRIBE ON LINES BELOW.
PLEASE ANSWER ALL QUESTIONS. IF AN ANSWER IS YES, PLEASE DESCRIBE ON LINES BELOW.
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Rows
YES
NO
1. Are you allergic to any foods or medication? If so, describe below.
2. Are you currently taking any medication? If so, describe below.
3. Have you had any major illness or injury? If so, describe below.
4. Have you been hospitalized or had an operation? If so, describe below.
5. Have you ever had an occupational illness or injury? If so, describe below.
6. Have you ever been advised to have an operation? If so, describe below.
7. Have you ever filed a workman's compensation claim? Received an award?
8. Have you ever worked in a hazardous environment such as Asbestos, Lead, Dust, Noise, Chemicals?
9. Has your ability to work ever been restricted? Refused job because of health?
10. Smoke cigarettes or Drink Alcohol?
11. Has any blood relative had:
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Cancer
Diabetes
Heart Disease
High Blood Pressure
Tuberculosis
Mental Illness
Allergies or Asthma
DESCRIBE ANY YES ANSWERS GIVEN ABOVE:
HAVE YOU EVER HAD OR HAVE YOU NOW (Mark all boxes):
FOR FEMALE PATIENTS ONLY
(Mark all boxes that apply):
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Rows
YES
NO
1. Recent Gain or Weight Loss
2. Weakness, Fatigue, Loss of Appetite
3. Nervous Condition, Depression
4. Cancer, Tumor, Growth, Cyst
5. Rashes, Allergies, Hives
6. Skin Diseases or Cancer
7. Frequent or Severe Headaches
8. Head Injuries
9. Epilepsy, Fits, Convulsions
10. Dizziness/Fainting Spells
11. Eye Injury, Infection, Pain
12. Double Vision
13. Decreased Vision or Blindness
14. Ear Pain, Infection Discharge
15. Loss of Hearing
16. Broken Bones/Joint Dislocation
17. Arthritis/Rheumatism/Bursitis
18. Nose, Throat, Sinus Trouble
19. Voice Change/Hoarseness
20. Dental/Gum Disease
21. Recurrent Sore Throat
22. Chronic/Recurrent Cough/Cold
23. Asthma or Wheezing
24. Shortness of Breath
25. Coughing of Blood
26. Tuberculosis
27. Heart Trouble/Medications
28. High Blood Pressure
29. Chest Pain or Pressure
30. Palpitation/Pounding Heart
31. Swelling Feet/Ankles
32. Mid or Low Back Pain
33. Pain/Stiffness of Neck/Back
34. Pain in Shoulders/Arms/Hands
35. Varicose Veins
36. Vomiting of Blood
37. Frequent Indigestion
38. Frequent Use of Antacids
39. Ulcers
40. Change in Bowel Habits
41. Frequent Constipation/Diarrhea
42. Bleeding from Bowels/Black Stools
43. Hemorrhoids (Piles)/Rectal Disease
44. Rupture or Hernia
45. Jaundice
46. Diabetes/High Blood Sugar
47. Kidney/Bladder Infection/Stone
48. Venereal Disease
49. Blood/Sugar/Protein in Urine
50. Pain in Hips/Legs/Knees/Ankle
51. Foot Trouble
Rows
YES
NO
1. Vaginal Infection/Discharge
2. Female Disorder Treatment
3. Irregular Menstruation
4. Painful Menstruation
Complete the Following:
Rows
Number of
5. Interval Between Period:
6. Duration of Periods:
7. Date of Last Pap Smear:
8. Date of Last Period:
9. Number of Pregnancies:
10. Abortions/Miscarriages:
11. Abnormal Pregnancies:
12. Number of Living Children:
BRIEFLY DESCRIBE ANY YES ANSWERS GIVEN ABOVE:
"I hereby certify that to the best of my knowledge, the foregoing answers are complete and correct and I understand that any omission or falsification of this record is cause for termination"
PLEASE SIGN
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Date
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Month
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Day
Year
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