Thank you for taking the time to fil out this intake form. Please feel free to put question marks next to any sections that you have questions about, and answer only those areas you are comfortable answering. During the consultation we wil go over this form together. PLEASE PRINT CLEARLY Intake Form Name
Are you currently seeing another practitioner?
If yes, please provide the practitioners name
and the type of care you are currently under.
If yes, please provide the Doctor's name and any
medical care/treatment you are currently under.
Is your Doctor or healthcare provider aware you are seeking alternative treatments?
What would you like help with at this time?
Please describe any treatments you have tried or are currently trying and how they are working for you. Lifestyle Please circle or fil in the appropriate response. Your honest answers wil greatly help with the evaluation process.
What is your total time (minutes) per week?
Are you satisfied with your energy levels?
What would you describe as the two dominant emotions in your life at this time:
Do you use any of the fol owing on a regular basis?Laxatives
Symptom Checklist Please check any of these symptoms or diseases you have had either in the past or now. If they are in the past please write the letter P beside them, and any that are current please write the letter C. Family History Has anyone in your family had any of the fol owing? If so, please specify your relation to them. Head Do you often have headaches? If so, how often? Location/type of headaches? Is there a particular time they come on? (i.e. after you eat, afternoon, driving etc) Bowels Do you have regular bowel movements?
Do you ever have difficulty with your bowel movements?
Men Please answer only those questions you are comfortable answering. Do you experience any of the fol owing past or current? Please answer past with a P and current with a C.
Is it ever difficult to get your urine flowing?Do you have a steady or interrupted stream of urine?Do you often have trouble maintaining an erection?
Women Please answer only those questions you are comfortable answering. Do you experience any of the fol owing past or current? Please answer past with a P and current with a C. Women: Menstrual and Menopausal Birth Control Please check all that you have used in the last ten years. Health History Have you been hospitalized for anything? If yes, when and why?
Other than the above, have you had surgeries? When and why?
Transfusions? When and why?Broken bone(s)? Which one(s)? Date(s)?Head injuries/concussions? When?Traveled out of the country? When and where?
Please list any major events in the last ten years of your life and the dates they occurred, this includes births, deaths, marriage, divorce, accidents, moves, job changes, miscarriages, il ness and anything else you feel greatly impacted your life. Dates
List any prescription or non-prescription pharmaceuticals you take on a regular basis with amounts and howlong you have been taking them. Feel free to use a separate sheet if necessary.
List any herbs, supplements or vitamins you take now or took previously on a regular basis. Include dates andamounts. Please bring the bottles with you. Feel free to use a separate sheet if necessary.
Are you allergic, or have side effects to any herbs, pharmaceuticals or supplements?
Diet and Nutrition Your honest answers wil greatly help the evaluation process. Please list your typical meals including beverages: Breakfast: Time Client Consultations and Consent Form
I have accurately disclosed my health history and agree to inform my practitioner if any concerns ariseduring my session. I understand that this session is not intended to replace medical treatment. I haveinformed my doctor of my intention to seek and use alternative treatments alongside my regularmedical treatments provided by my family doctor.
The personal information that you provide on this Client Information and Consent form is being col ected under the authorityof the Freedom of Information and Protection of Privacy Act of Alberta. The information wil be used to provide you with theappropriate clinical consultation. This information wil be protected under the Act and wil be stored in a secure manner.
Enquiries concerning the col ection, use, disclosure and disposal of the personal informationprovided on this form, should be directed to the practitioner.
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PODER JUDICIÁRIO TRIBUNAL DE JUSTIÇA DO ESTADO DE SÃO PAULOVistos, relatados e discutidos estes autos do Apelação nº 0040338-57.2010.8.26.0554, da Comarca de Santo André, em que é apelante PREFEITURA MUNICIPAL DE SANTO ANDRÉ sendo apelado EDSON BELLO. ACORDAM, em 10ª Câmara de Direito Público do Tribunal de Justiça de São Paulo, proferir a seguinte decisão: "Deram pro