PATIENT INFORMATION PATIENT INFORMATION INSURANCE
Who is responsible for this account?___________________
Relationship to Patient________________________
Is patient covered by additional insurance?
Relationship to Patient________________________
ASSIGNMENT AND RELEASE
I, the undersigned, certify that I(or my dependent) have insurance
coverage with ________________________and assign directly to
__________________________all insurance benefits, if any,
otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance. I hereby authorize the provider to release all
information necessary to secure the payment of benefits. I
authorize the use of this signature on all insurance submissions.
PHONE NUMBERS ACCIDENT INFORMATION
Best time & place to reach you__________________
IN CASE OF EMERGENCY, CONTACT
To whom have you made a report of your accident?
Attorney Name (if applicable)_____________________
Home phone____________Work phone__________
GENERAL INFORMATION Have you had acupuncture before?
Are you currently under the care of a physician?
No If Yes, for what?___________________________
ORIENTAL MEDICINE INTAKE FORM
Name:______________________________________ Date:_______________________ PRESENT HEALTH CONCERNS: Please list your most important health concerns in order of their significance. 1. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your:
2. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your:
3. ________________________________________ Approx. Date of Onset:____________________________ Does it interfere with your:
Please list all medications that you are currently taking (or have used in the past two months), with dosages: 1.________________________________________
Please list any vitamins, minerals, herbs, or homeopathic remedies that you are presently taking: 1.________________________________________
Please list allergies that you have to any of the following: Drugs:_________________________________ Foods:_______________________________________________ Other (i.e. pollen, paint, etc.):____________________________________________________________________ HEALTH HISTORY Past Medical History: Please list past injuries, broken bones, surgeries and hospitalizations, with approx. dates. ___________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Personal Habits: Work Activity: Exercise:
Do you follow any diet regimens/restrictions?
If Yes, describe:_____________________________
Do you have children?
No If Yes, how many?__________Ages______________________
Are you, or could you be currently pregnant?
Please check if you have had (in the last three months) GENERAL Poor appetite
Other hair or skin concerns: HEAD, EYES, EARS, NOSE, AND THROAT Concussions
Headaches (location, triggers, severity)? Other head & neck concerns: CARDIOVASCULAR High blood pressure
Other heart or blood vessel concerns: RESPIRATORY Cough
Production of phlegm - color?________
Pneumonia Other lung related concerns:
History of chronic laxative use? Other concerns with your general digestion: GENTIO-URINARY Pain on urination
If you wake to urinate, how often? Other concerns with genitals or urinary system: MUSCULOSKELETAL Neck pain
Other muscle, joint or bone concerns: NEUROPSYCHOLOGICAL Seizures
Have you ever been treated for emotional problems? Have you ever considered or attempted suicide? Other neurological or psychological concerns: GYNECOLOGY Age of first menses______ If no longer menstruating, approximate date ceased____________
First day of last menses______ Length between menses:______days Duration of period:_____days Unusual flow (
GYNECOLOGY (continued) Changes in body or psyche prior to menstruation (“PMS”): Date of last PAP:________________ Results were:
If you use birth control, what type & for how long? Have you ever used hormonal methods for contraception or period regulation? (i.e. the pill, Depo-Provera, etc.) Other gynecological concerns: PREGNANCY HISTORY Number of pregnancies______
Were your births relatively normal? Explain: Other related concerns: COMMENTS Please let us know of any other concerns you would like to address: Family History: Please fill in the boxes for each condition that applies to one of your family members. Comments
St John Ambulance Australia (NT) Inc Purpose The purpose of this policy is to provide details of the processes and standards which must be achieved by Paramedics who wish to advance through the various Advanced Care levels within St John Ambulance Australia (NT) Inc.; and to provide guidelines for the use of advanced care skills. Scope This policy applies to Paramedics of
Sengupta, M. and Dalwani, R. (Editors). 2008 Proceedings of Taal2007: The 12th World Lake Conference: 918-922 Use of Polyphosphate Accumulating Organisms (Pao) For Treatment Of Phosphate Sludge Shyam S. Bajekal and Neelam S. Dharmadhikari Department of Microbiology, Yashwantrao Chavan College of Science, Karad, Vidyanagar, KARAD – 415 124. (Maharashtra, India) E-mail: ABST