Patient Intake Form
PLEASE ANSWER ALL QUESTIONS BELOW BEFORE SUBMITTING

IMPORTANT NOTE: If unable to submit, it is because there is a required question that has not been answered. You will have to scroll until you find one of the questions highlighted in RED.

Also, you do NOT need a GMAIL account to submit this form.
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电子邮件地址 *
Have you previously worked with one of our practitioners?
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If so, which practitioner did you see? 
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Are you seeing different Health Care Practitioner? *
Name of your Practitioner/Doctor:
Address of The Clinic:
Website and Phone Number of the Clinic:
How did you hear about us? Please be specific. If through referral, who may we thank? *
Do you have a Saturday or 7 AM  Appointment? *
If you clicked YES on a Saturday appointment, then please save link below to your desktop, and click the link for instructions for getting into the building.  The building is closed on Saturdays and before 7 AM, so it is important you know how to access the building. 
http://thermographycenter.com/wp-content/uploads/2021/01/How-To-Get-Into-The-Building.pdf
GENERAL INFORMATION
Full Name *
Email *
Phone Number *
Birthdate *
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Physical Address *
City *
State *
Zip Code *
Height *
Weight *
What is your Blood Type And Dominant Hand? *
Emergency Contact Person *
What is your relationship with this person? *
Emergency Contact Phone Number *
Emergency Contact Email
Have you worked with a holistic or functional practitioner before? *
Current Doctor - What type of Doctors are you currently working with? Please check all that apply: *
必填
What is your current profession? *
What is your previous profession(s)? *
What is your country of origin (genetically)? *
Where were you born? *
Where were you raised? *
STRESS/RELAXATION
What do you do for fun? *
When was your last vacation? *
Do you relax once a day? *
What do you do when you relax? *
What does your support system look like? *
Have you ever Smoked? (Y/N)  If YES, then what and for how long? *
How well do you sleep? *
Do you take any kind of sleep aid, and if so, what and how often? *
PERSONAL AND FAMILY HEALTH HISTORY
Please fill out in detail - having your history greatly helps your practitioner serve you better!  
Have you ever been Vaccinated? Which Ones? And When? *
Do you have  Children? *
If YES, then how many children do you have?
What is the Age of each child?
Have any of your children been Vaccinated? Which vaccines?
Do any of your children have any health symptoms or conditions? (e.g. ADD or Allergies or Asthma)
PERSONAL HEALTH HISTORY
Use this link to see an example of what types of information will be useful for the question below. https://249a90af-46cc-4d08-8d62-5074f27f11d4.filesusr.com/ugd/76edc2_f7c3d9bb4e134f67823b3e75fb4767ec.pdf
Give a complete chronological Personal  health history. *
Give a complete chronological Family health history. *
Any Other Relevant Family History? *
What does your typical daily diet pattern look like?  What do you typically eat for breakfast, lunch and dinner? Please include all beverages as well!
What time do you typically begin eating each day, and what time do you typically stop eating each day?
时间
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SYMPTOMOLOGY
Reasons/Symptoms that motivated you to seek our help: *
What concerns are your highest priority to address with your practitioner?
How often do your bowels move? *
Do you frequently experience hard stools and/or loose, watery stools? *
Have you experienced ANY of the following?​ *
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What have you done in the past to work on these health conditions and have any been effective? (Please include both alternative & traditional modalities.) *
What obstacles, challenges, and struggles have you encountered in making changes to your lifestyle to improve your health? *
Any Other Concerns or Formal Diagnosis
Do you take any antacids or acid blockers? If yes, then which medication are you taking, what is the dosage, frequency of use, and how long? *
Are you currently taking any prescription medications?    If yes, then which medication are you taking, what is the dosage, frequency of use, and how long?
Have you taken prescription medications in the past?  If so, please list each medication, for how long, and how long ago.
Are you taking any over the counter medications?   If yes, then which medication are you taking, what is the dosage, frequency of use, and how long?
Have any of the following been removed? *
必填
List Other Hospitalizations, Implants or Surgery (child births, C-section):
Have you had ANY cosmetic procedures? If so, then what have you had done? *
Have you had any Liposuction work done before? *
必填
Have you had botox? *
必填
If so, what condition did you have it for?
Have you ever had any motor vehicle or other accidents? *
STRESS/EMOTIONAL HEALTH
Have you had any emotional upsets or traumas in your life “recently”? *
If Yes, can you please share what happened and the emotion it evokes?
Do you have regular practices for alleviating/managing your stress, and if so, what are they?
TOXIN EXPOSURE
Please list any known toxic exposures (chemicals, molds, etc.), and how long ago? *
Have you received Chemotherapy? (Y/N) If YES, then when? *
Have you received Radiation Therapy? (Y/N) If YES, then when? *
If YES on either question, then what condition did you receive it for?
Have you had any of the following medical imaging procedures? Please check all that apply: *
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Date of last medical imaging
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DENTAL WORK
Have you had any dental work in the past 3 weeks (including cleanings)? *
When was your last dental visit? *
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Name of current dentist? *
Is your dentist holistic? *
Do you have:
Have you ever had any mercury/gold fillings? *
Have your amalgam fillings been removed?  *
If so, when, and by whom?
Do you have your wisdom teeth? *
Were your wisdom teeth removed? *
Have you been diagnosed with gum disease?
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What kind of toothpaste do you use? *
Do you use a tongue cleaner? *
Do you floss? *
WATER
What kind of water do you currently drink?  If filtered, what kind of filtration? *
 Do you drink tap water from restaurants? *
Do you drink tap water at work? *
Do you shower in unpurified city water? *
FEMALE ONLY QUESTIONS
Age of first menses?
Are you currently in Menopause or Perimenopause?
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Length of monthly cycle, counting from first day of period to first day of following period?
What day of your cycle are you in, counting from the first day of your period? 
Are your cycles regular?
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If cycles are irregular, then how irregular?
The number of pregnancies?
The number of live births?
The number number of C-Sections?
Are you currently nursing your child?
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Have you experienced ANY of the following:
MALE ONLY
Have you experienced ANY of the following:
24 HOURS prior to your appointment, HAVE YOU: *
必填
Please Read and by clicking submit you acknowledge, understand and agree with the information below.
I understand that Computerized Regulation Thermography (CRT) is not a primary diagnostic device as deemed by the U.S. Food and Drug Administration and is not to exclude other methodologies of cancer detection. Its purpose is to add information to the physician or practitioner to aid in the integration of other tests and results in order to achieve treatment outcomes, and not intended as diagnostic of any disease or dysfunction in itself. I agree to not hold the Thermography Report Writing Services responsible for any decision I or my doctor make based on the results obtained. I am ultimately responsible for payment to the Thermography Center and accept that the Center does not bill insurance companies.  Payment is due at the time of service.  You will be given a receipt for your visit, which you can submit to your insurance company for reimbursement.  If the insurance company does not pay for the services, The Thermography Center assumes no responsibility for reimbursement.  
Please Read and by clicking submit you acknowledge, understand and agree with the information below.
I have requested and do hereby authorize The Thermography Center (“The Center”) or any qualified and certified agents, independent contractors, or trainees of the Computerized Regulation Thermography (Alfa Sight 9000) System to perform adjunctive diagnostic screening test with the Alfa Sight 9000 for the sole purpose of information only. I understand that The Center is not a medical facility and will not be treating me or diagnosing any medical condition. I understand that the test data or readings from this procedure will be classified and categorized by an independent party familiar with the Alfa Sight 9000 and the data will be forwarded to my chosen medical professional for interpretation and medical care intervention. Regulation Thermography is an adjunctive NOT primary diagnostic tool. I am responsible for following up with my medical care with my physician and should not rely on this procedure for the diagnosis or treatment of any medical condition.  I further understand all services of the Thermography Center of Dallas operates under the umbrella of a health ministry called Abundant Grace Ministry.

I certify that I have consulted with a representative of the Thermography Center of Dallas and have read all applicable literature given to me. I have read and fully understand all of the information presented in this Patient Consent and Release form for Diagnostic Screening. I certify that I am eighteen (18) years of age or older, of sound mind, and I am fully capable of executing this Patient Consent and Release form for Diagnostic Screening myself.
Confirm Today's Date and that you are Agreeing to ALL Terms Above *
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Do you agree to all Terms Above? *This agreement of a yes is the same as a signature. *
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