sydneyrx2014.com Available ED Drugstore is an 1st. pharmacy providing a individual service to the society in Australia. Over 80,000 extremely satisfied buyers! We're your medication drug store kamagra australia and have provided trusted service to families in Australia for over 15 years.

Elissa v

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? _________________________________________________________ _________________________________________________________ _________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________

Source: http://www.healinginsideout.info/NewPatientIntakeForm9.12.13.pdf

svibrescia.it

peruanoclandestino@email.it / settembre2mila5 / newsletter #2______________________________(Distacchi) donde no nace, noNon troppo, ma è stata come una libera uscita, riappropriarsi di uno spazio; più mentalmenteche fisicamente. Ci fa bene all’anima avere gente attorno, altrimenti finiremmo sempre a parlaredel Progetto, a pensare di lavoro; ma non è bello dover far girare i Nirvana ogn

campingislas.ch

Bouillon mit Einlage (frische Flädli oder Ei) Hausgemachte Bündner Gerstensuppe Bruschetta mit einer hausgemachten, pikanten Tomatenvariation auf getoastetem Brot Cordon bleu (vom Schwein) ca. 380-400 gr. mit Vorderschinken, Bergkäse und Pommes frites Lady Cordon bleu (vom Schwein) ca.200-250 gr. mit Vorderschinken, Bergkäse und Pommes frites Schnitzel nach Wiene

Copyright © 2010-2014 Pdf Medical Search