Registro de pacientes

Información del paciente

Dirección

Si el paciente es menor de edad or incapacitated, who is their tutor legal or representative?

Contacto de emergencia

Dirección

MOTIVO PRINCIPAL DE CONSULTA (por prioridad)

OTRAS MOLESTIAS

por prioridad

Describa su dolor from 0 up to 10 (0 sin dolor , 10 insoportable)

Otras enfermedades:(problems)

Describa su dolor from 0 up to 10 (0 sin dolor , 10 insoportable)

COSAS QUE DEBE TRAER CONSIGO TO YOUR FIRST APPOINTMENT:
1. "Información del paciente" form filled out completely.
2. Bring X-rays, laboratory reports, blood tests, doctor's reports etc.
3. Bring (in their original containers) all medications you are currently taking.
4. Bring (in their original containers) all supplements, herbs, etc. you are currently taking.

Nutrición y estilo de vida

Historial Médico

encuesta de síntomas del paciente

The information you provide is estrictamente confidencial.
Please check any condition you Now have Now (N),or have had in the Pasado (more than 12 months) past(P) Now and Pasado (N and P).

Family History

Has any member of your family had any of the above conditions?

If yes - Which family member and what did they have?

Accidents, Falls , Broken bones

Have you been in any car accidents, fallen and/or broken bones, or suffered other traumas resulting in injuries? Please list the fecha and event, starting with the most recent.

Surgeries, Medical Procedures

Please list them, along with the fechas, starting with the most recent. Have you been advised to undergo surgical procedures that you have not had?

Medicamentos,Drugs,Herbs or supplements

Please list the Medication by Name / dosage in mg./mcg., etc. / how often (AM-Noon-PM) as 1-0-1, etc. / how long taking (# weeks, or # months, # years, etc.)

Mental, Emocional and neurological

Femenino Reproductive system

Masculino reproductive system

Nutrición y estilo de vida

A menudo las personas tienen preocupaciones about their health but are too embarrassed or afraid to ask.

¿Tiene alguna pregunta or concerns about:

¿Cómo se siente con respecto a las siguientes áreas areas of your life?: Please tick the space that applies.

External/skeletal Exam

Head

Eyes

Nose

Ears

Neck/Throat

Shoulders

Brazos, codos, muñecas y manos

Por favor seleccione "R" (right), "L" (left) or "A" (both)

Back

Chest

Hips

Legs and knees

Ankles, feet and toes

Examen de órganos internos

Pulmones, Corazón

Hígado y vesícula biliar

Riñón y vejiga urinaria

Estómago, digestión y apetito

Intestino delgado, intestino grueso y recto

Piel y sudoración

SOLICITUD DE TRATAMIENTO DE ACUPUNTURA

Entiendo que los métodos de tratamiento methods may include (but are not limited to) acupuncture, electrical stimulation, chiropractic, Tui Na (Chinese massage), Swedish massage, Chinese herbal medicine, and supplements, nutrition and lifestyle advice. This clinic uses agujas estériles desechables (de un solo uso).

Notificaré al acupunturista if I am or become pregnant; if there is any change in my health condition or medications or if I have any adverse reaction to the treatments.

I understand all my los registros se mantendrán confidenciales and will not be disclosed without my written consent.

Mi intención es recibir and complete the course of treatment for my current condition and for any future condition(s) for which I seek treatment.

Usted ha terminado el ?Paciente Information? form for Passport To Health. Below please enter your name, your email address, and then select the button where the form is to be sent. A la Clínica