Get the free ORIENTAL MEDICINE INTAKE FORM - Finger Lakes School of - aom nycc

PATIENT INFORMATION INSURANCE Date Who is responsible for this account? Name Relationship to Patient Address Insurance Co. Group # City State Zip Yes Is patient covered by additional insurance? Sex:

How to fill out oriental medicine intake form

How to fill out an Oriental medicine intake form:

1. Begin by filling out your personal information, including your full name, date of birth, address, phone number, and email address. This will help the practitioner identify you and stay in contact with you if needed.
2. Provide details about your medical history. This may include any past or current medical conditions, surgeries, medications you are taking, allergies, and any family history of illnesses. Be as thorough and accurate as possible to help the practitioner understand your health background.
3. Describe your current symptoms or concerns that you want to address through Oriental medicine. Explain when the symptoms started, how they affect your daily life, and any triggers or aggravating factors. The more specific and detailed you are, the better the practitioner can tailor their treatment plan.
4. Discuss your lifestyle habits, such as your diet, exercise routine, sleep patterns, and stress levels. These factors can greatly impact your overall health and well-being, so including this information will help the practitioner develop a comprehensive treatment approach.
5. Indicate any medications, supplements, or alternative therapies you are currently using. This includes both prescription and over-the-counter medications. It is important to inform the practitioner about all substances you are ingesting or applying to your body to ensure any potential interactions or contraindications are considered.
6. Answer questions related to your mental and emotional well-being. Oriental medicine takes into account the mind-body connection, so sharing information about your stress levels, emotional state, and any mental health conditions can contribute to a more holistic treatment approach.
7. Provide information about your menstrual cycle if applicable, including the regularity, duration, and any associated symptoms. This is particularly important for female patients seeking treatment for reproductive health issues.
8. Lastly, read through the entire form and double-check that all the information you provided is accurate and complete. Make sure you sign and date the form before submitting it to the practitioner.

Who needs an Oriental medicine intake form?

1. Patients seeking treatment from an Oriental medicine practitioner.
2. Individuals with a specific health concern, whether physical, mental, or emotional, that they believe Oriental medicine can address.
3. Anyone interested in taking a holistic approach to their healthcare and considering Oriental medicine as a potential treatment option.

For pdfFiller’s FAQs

What is oriental medicine intake form?

The oriental medicine intake form is a document used to gather information about a patient's medical history, current health status, and goals for treatment in the practice of oriental medicine.

Who is required to file oriental medicine intake form?

Patients seeking treatment from a practitioner of oriental medicine are typically required to fill out and file the oriental medicine intake form.

How to fill out oriental medicine intake form?

Patients can fill out the oriental medicine intake form by providing accurate and detailed information about their medical history, current health issues, and any specific goals they have for treatment.

What is the purpose of oriental medicine intake form?

The purpose of the oriental medicine intake form is to help the practitioner of oriental medicine understand the patient's health needs and develop an appropriate treatment plan.

What information must be reported on oriental medicine intake form?

Information such as medical history, current health concerns, any medications or supplements being taken, lifestyle habits, and treatment goals must be reported on the oriental medicine intake form.

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