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On line health intake form

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Personal Information

Today's Date *

First Name *

Middle Initial

Last Name *

Date of Birth *

Gender *

Street Address 1 *

Street Addrss 2

City/Town

Zip Code

Home Phone

Cell Phone

Work Phone

Email Address *

Marital Status

Name of Spouse

Name of Employer

Number of Children

Age Range of Children

To whom we may thank for referring you:

If referred by other(internet, search engine). Please indicate

General Health Questions

Please rate your current state of health from 1 to 10

Please answer the following in number of 8 ounce servings per day.

Water

Coffee

Tea (caffinated)

Soda

Juices

Milk

Please answer the following lifestyle questions.

Number of hours of sleep (average) per night

Do have any of the following trouble with sleep

Position you sleep in

Do you smoke

How long have you been a smoker?

Current health complaints today

Please describe your current complaints, areas of concern or injuries.

Rate severity of injuries from 1-10 (10 is the worst pain ever)

When and how did the condition start?

What makes it feel better?

What makes it feel worse?

Since the problem(s) started have they gotten:

Does the condition(s) interfere with:

* If Other

Any other comments please describe:

Personal Health History

Please list any and all surgeries and date of occurance:

Please list any broken bones and date of occurance:

Please list any minor accidents, injuries or falls and date of occurance:

Please list any major accidents, injuries or falls and date of occurance:

Ear infections as a child?

Have you had recent X-rays?:

Date of last physical exam:

Is there a chance you are preganat?:

Have you ever been hospitalized?

If yes, please describe reason, place and date of hospitalization:

Please list ALL medications currently taking (both prescribed

What vitamins, minerals, or herbs do you currently take? (Please list for what condition, dosage, and frequency).

Have you ever been involved in an auto accident?

If yes, please describe:

Do you currently wear orthotics in your shoes or sneakers?:

Family History

Family members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.) -Dating back as far a back as grandparents:

Review of Systems

Check all conditions that you have suffered from within the past 5 years:

Acid Reflux Alcoholism Allergies Anemia Anxiety Arteriosclerosis Arthritis Asthma Back Pain Breast Lump Bronchitis Bruise Easily Cancer Chest Pain Cold Extremities Constipation Cramps Depression Diabetes Digestion Problems Dizziness Ears Ring Excessive Menstruation Eye Pain Fatigue Frequent Urination Headache Hemorrhoids High Blood Pressure Hot Flashes Irregular Heart Beat Irregular Cycle Irritable Bowel Syndrome Kidney Infection Kidney Stones Loss of memory Loss of balance Loss of smell Loss of taste Lumps In Breast Neck Pain or Stiffness Mood SwingsNervousness Nosebleeds Pacemaker Polio Poor Posture Prostate Trouble Sciatica Shortness of breath Sinus Infection Sleep problems or Insomnia Loss of Spinal Curvatures Stroke Swelling of ankles Swollen Joints Thyroid Condition Tuberculosis Ulcers Varicose Veins Venereal Disease Other

If other, please explain:

Goals for Health and Wellness

Please rate your level of stress in the following areas. (1-low, 10-very high):

Home

Work

Personal

On a scale of 1-10 (1 poor and 10 excellent) please rate the following Daily habits:

Eating

Exercise

Sleep

Overall Health

At Waldman Center for Wellness our goal is to help your overall health. Check the areas that are of interest to you and your long term health:

I would like to learn and pursue the areas of:

Relief Care/ Pain Care Corrective/Restorative Care Nutritional Care utilizing: NRT, AK and Brimhall techniques Nutritional Cleansing Weight Loss

Health Insurance Information

Name of party responsible for payment:

Phone number:

Do you have health insurance

YesNo

Name of health insurance company(please note we don't accept all insurances):

Health insurance ID number:

Do you have a deductible

Name of primary care physician

Is it ok to communicate with your doctor if necessary

YesNo

Signatures

Name of the insured:

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature_________________________________________________________Date____

Spouce's or Gaurdian's signature________________________________________________Date____________

Enter the verification code in the box below.

Verification Code: *

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On line health intake form

Personal Information

General Health Questions

Current health complaints today

Personal Health History

Family History

Review of Systems

Goals for Health and Wellness

Health Insurance Information

Signatures

Contact Us

Newsletter Sign Up

3D Spine Simulator

Now offering DOT Physicals

CDL License Requirement

Visit:

MassDOTPhysical.com

Social Networking

Community Content

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On line health intake form

Personal Information

General Health Questions

Current health complaints today

Personal Health History

Family History

Review of Systems

Goals for Health and Wellness

Health Insurance Information

Signatures

Contact Us

Newsletter Sign Up

3D Spine Simulator

Now offering DOT Physicals CDL License Requirement Visit: MassDOTPhysical.com

Social Networking

Community Content

Now offering DOT Physicals

CDL License Requirement

Visit:

MassDOTPhysical.com