Alternative Medicine-Patient Intake form

Patient Questionnaire
Date*

MonthDayYear
Full Name*

First NameMiddle NameLast Name
Prefferred Name
Birth Date*

MonthDayYear
Genetic Background*

African AmericanNative AmericanMediterraneanHispanicCaucasianNorthern EuropeanAsianOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Preferred Primary Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Fax

Area CodePhone Number
E-mail*
Best way to contact?*
Primary Physician*
Name
Physican
Email
Physican
Phone
Physican
City
Other Pertinent Provider
Name
Provider
Email
Provider
Phone
Provider
City
Referred By*

Physical Activity
Do you engage in moderate cardiovascular physical activity for a minumum duration of 20 minutes at least 3 days a week? For example: brisk walking, jogging, cardio exercise classes*

Please indicate the type of exercise you are currently engaging in.*

	Type/Intensity (low/mod/high)	# Day Per Week	Duration (mins)
Stretching/Yoga
Cardio/Aerobics
Strength Training
Sports or Leisure
Other

Note any problems that limit your physical activity:*

Authorization for the Release of Information
I, the patient, hereby authorize the use or disclosure of my health information from the listed Health Practitioner as described below to the requesting practitioner.
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PATIENT INFORMATION
Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
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HEALTH PRACTITIONER
Health Practitioner Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area Code
Fax Number

Area Code
I authorize Sheila L. Hall, CFMHC and/or*
to release and/or disclose the medical information as indicated below to the health care provider, entity, or person I have indicated above.
DURATION: This authorization shall become effective immediately and shall remain in effect until*
or for one year from the date of signature if no date entered.
REVOCATION: This authorization may be revoked in writing by the undersigned at any time prior to the release of information from the disclosing party. Written revocation will not affect any action taken in reliance on this authorization before the written revocation was recieved.
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INITIAL each line next to which type of information you approve to be released and/or disclosed & give the approriate range of dates for the information:
General Medical Information*
From

MonthDayYear
To

MonthDayYear
Laboratory Tests (serum, urine)*
From

MonthDayYear
To

MonthDayYear
Information regarding specific diagnosis or treatment*
From

MonthDayYear
To

MonthDayYear
Other Nutrition and Dental*
Requesting Practitioner Information

Sheila L. Hall, CFMHC
Patient Name*
Name

First NameLast Name
Should be Empty:

	5	4	3	2	1
Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (work demands, sleep habits, exercise)
Practice a relaxation technique
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress

Patient Questionnaire

Complaints / Concerns

Reflection

Self Love Care

Physical Activity

Daily Stressors

Lifestyle Information

Patient Narrative

ALL PATIENT INFORMATION IS HANDLED UNDER THE HIPPA PRIVACY ACT - CONFIDENTIAL / HIPPA APPROVED FORM

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Authorization for the Release of Information

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Requesting Practitioner Information