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