Consultation - Ali Optimal Wellness | Acupuncture & Custom Herb Center

Patient's Name

First

Last

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Age

Birthdate

Home Address

Address Line 1

City

State / Province / Region

Postal Code

Country

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Cellphone Number

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Occupation

Employer

Business Phone Number

Business Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Spouse's Name

First

Last

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Spouse's Occupation

Spouse's Employer

Spouse's Business Phone Number

Business Address

Address Line 1

City

State / Province / Region

Postal Code

Country

If Patient is a minor, give name of the legal guardian

First

Last

Main Problem

When did this start

Secondary Problem

When did this start

Any other health issues in chronological order

How is your digestion? Please explain

Female History

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Age of first menses

Age of menopause

PMS

Ever take the birth control pill

Current medications and how long each

Past medical history? Surgeries/Accidents/Illness

Health Habits

Vitamin Supplements

Cigarettes

If yes, indicate year you started smoking and how many per day.

Coffee

Tea

Water intake daily

Alcohol and frequency

Recreational drugs

Sodas

When was the last time your teeth were cleaned?

Do you usually get them cleaned every 6 months?

Do you sleep well? Explain if necessary

How many hours/night?

Do you wake up in the middle of the night?

Allergies

Check all that apply

Medications

Penicillin or other antibiotic
Morphine, Codeine/narcotics
Novacain/anesthetics
Aspirin/pain remedies
Sulfa drugs
Tetanus Antitoxin
Adhesive tape
Cortisone
Anti-inflammatory
Anti-coagulants
Tranquilizers
Blood pressure medication
Others

Indicate here

Seasonal

Pollesn
Trees
Grasses
Flowers
Dust
Smog
Mold
Others

Indicate here

Foods

Dairy/Milk
Egg
Soy
Wheat
Tomatoes
Bell peppers
Peanuts
Nuts
Chocolate
Wine
Others

Indicate here

Please give us an emergency contact person

Name

First

Last

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Phone Number

We supply itemized statements for insurance purposes. Please let us know before you see Majid or Ahnjel if you will need a statement.

Please be considerate of other patients, Majid and Ahnjel, and notify us at least 24 hours in advance of any cancellation. This is a standard office policy to avoid being charged for the office visit if notification is not given.

I understand that total payment of the fees for service performed by Majid or Ahnjel Ali is my responsibility and not that of the insurance company.

I understand that if there is any legal issue with my treatment in this office that it will go to arbitration.

Name *

First

Last

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Date

Who referred you?

Ali Optimal Wellness

Consult with Majid & Ahnjel

Patient History Form

Female History

Health Habits

Allergies

Check all that apply

Please give us an emergency contact person

Contact

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