Elissa D. Viarengo, L.Ac BioFeedback Practitioner New Patient Intake Form
Name:____________________________________________________ If a minor, Name of Parents / Guardian: ___________________________ Address: __________________________________________________ City: ____________________ State: _________ Zip Code: __________ Home Telephone (with area code): _______________________________ Work Telephone (with area code): _______________________________ Cell Phone (with area code): ____________________________________ Email address (for newsletters / discounts): _______________________ Date of Birth (month/date/year): ______ Age: _____ Sex: __________ Occupation: ________________________________________________ Who referred you to Elissa V. Blesch? ____________________________ What is the main reason you are seeking care? ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ updated 9/12/13 Surgeries / Major Illnesses: __________________________________ ________________________________________________________ ________________________________________________________ Other Practitioners You See: M.D._________________________Chiropractor: __________________ Acupuncturist: ________________ Naturopath:___________________ Massage Therapist: _____________ Physical Therapist: ______________ Other: ___________________________________________________ Medications You Are Currently Taking Name Supplements/ Vitamins / Homeopathics / Herbs You Are Currently Taking Name
Health Habits Do you use…
Hours of Sleep _______ Do you feel rested upon waking? ___________ Do you exercise? ____________ What kind and Frequency? ___________________________________ _______________________________________________________
Please indicate the symptoms you are CURRENTLY having or have REGULARLY throughout the year ___ Absent Minded
___ Seizures ___ Shortness of Breath ___ Sinusitis ___ Skin Rash ___ Skin Itch ___ Skin Burning ___ Sleeping Problems ___ Sneezing ___ Sore Throat ___ Stomach Discomfort ___ Swol en Glands ___ Teeth Pain ___ Tongue Swelling ___ Throat Constriction ___ Tightness in Chest ___ Tires Easily ___ Urinary Tract Disorders ___ Urination Painful / Burning ___ Vomiting ___ Weight Loss / Gain ___ Yeast Infections Any other symptoms: _________________________________________ _________________________________________________________ _________________________________________________________ Is there anything else you would like Elissa to know about your health? _________________________________________________________ _________________________________________________________ _________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________
Presentación La Cámara de Comercio de Barrancabermeja a través del Observatorio Económico, entrega el Sondeo de Percepción Empresarial correspondiente al segundo semestre del año 2007, cuyo objetivo es orientar a empresarios y comunidad en general, sobre el comportamiento de la actividad empresarial en la ciudad de Barrancabermeja durante el segundo semestre de 2007. Para
SELF ASSESSMENT, EVALUATION, AND CREDIT APPLICATION FORM Let’s Talk MRSA: 20 Frequently Asked Questions Learning Module 3: Clinical Tactics for MRSA Infections PODCAST Release Date: November 29, 2010 Credit Expiration Date: January 10, 2012 Center Serial #: CV3123-3 INSTRUCTIONS FOR CREDIT 1. Review the entire CME/CE information including target audience, learning objectives, and