Alternative Medicine-Patient Intake form

Patient Questionnaire
Date *

Month Day Year Date Picker Icon
Full Name *

First Name Middle Name Last Name
Prefferred Name
Birth Date *

Month Day Year
Genetic Background *

African American Native American Mediterranean Hispanic Caucasian Northern European Asian

Address *

Physical Activity
Do you engage in moderate cardiovascular physical activity for a minumum duration of 20 minutes at least 3 days a week? For example: brisk walking, jogging, cardio exercise classes *

Please indicate the type of exercise you are currently engaging in. *

Authorization for the Release of Information
I, the patient, hereby authorize the use or disclosure of my health information from the listed Health Practitioner as described below to the requesting practitioner.
Unique Scripts

PATIENT INFORMATION
Full Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year

Address *

Address *

Phone Number *

Area Code
Fax Number

Area Code
I authorize Sheila L. Hall, CFMHC and/or *
to release and/or disclose the medical information as indicated below to the health care provider, entity, or person I have indicated above.
DURATION: This authorization shall become effective immediately and shall remain in effect until *
or for one year from the date of signature if no date entered.
REVOCATION: This authorization may be revoked in writing by the undersigned at any time prior to the release of information from the disclosing party. Written revocation will not affect any action taken in reliance on this authorization before the written revocation was recieved.
Unique Scripts

INITIAL each line next to which type of information you approve to be released and/or disclosed & give the approriate range of dates for the information:
General Medical Information *
From

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To

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Laboratory Tests (serum, urine) *
From

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To

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Information regarding specific diagnosis or treatment *
From

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To

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Other Nutrition and Dental *
Requesting Practitioner Information

Sheila L. Hall, CFMHC
Patient Name *
Name

First Name Last Name
Should be Empty:

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Significantly modify your diet
Take nutritional supplements each day
Keep a record of everything you eat each day
Modify your lifestyle (work demands, sleep habits, exercise)
Practice a relaxation technique
Engage in regular exercise/physical activity
Have periodic lab tests to assess your progress

Patient Questionnaire