Thermography
Patient History for Women
Sign in to Google to save your progress. Learn more
Email *
Emergency contact: Full name and mobile number.
Your Full Name
Date of Birth
MM
/
DD
/
YYYY
Age / Sex
Occupation
Mobile number
Current Address
HIPPA CLIENT CONFIDENTIALITY AND RELEASE FORM.  I understand this modality is not a replacement for medical care. The practitioner does not diagnose medical illness, disease or other physical or mental conditions unless specified under his/her professional scope of practice. As such, the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform spinal manipulations (unless specified under his/her professional scope of practice). The practitioner may recommend referral to a qualified health care professional for any physical or emotional conditions I may have. I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.  Confidentiality of medical and personal information obtained during the course of the practitioner’s work is of the utmost importance.  HIPAA regulations require all practitioners obtain a signed release form from their client before taking any information about them. The best way to be fully compliant is to obtain this release signature at the initial consultation.  Clients should receive a copy of the form they signed (upon request), and the practitioner maintains a copy for their records (Please sign and date below to confirm you have read the above HIPPA CLIENT CONFIDENTIALITY AND RELEASE).
Primary Care Provider
Who referred you to Thermography?
Clinical Concerns / Cheif Complaint
Current symptoms
Current treatment
Current pharmaceutical medications
Thermography History ~ Have you had thermography before?
Thermography Results (include dates and findings)
Surgical History (include dates and findings) *
Dental History (include dates and findings) *
General History (include dates and findings) *
Immediate Family History (Parents/Siblings) *
Other Diagnoses (include dates and findings) *
Skin Lesions and Physical Abnormalities  (include dates and findings) *
OB/GYN History: Have you had any Mammograms/Ultrasounds? (please include dates and findings) *
OB/GYN History: Have you had any Children, Miscarriages, Terminations?  (please include dates and details) *
OB/GYN History: Have you had any abnormal Pap tests or results? Any STDs?  (please include dates and details) *
OB/GYN History: Have you had any (sexually transmitted diseases) STDs?  (please include dates and details) *
OB/GYN History: Have you had any surgeries or procedures in the pelvic bowl?  (please include dates and details) *
Next
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms