Dr. Ella Woods, DAOM, LA, Dipl. OM Acupuncture & Herbal Medicine PERSONAL INFORMATION TODAY'S DATE:
HEIGHT: WEIGHT: DATE OF BIRTH: AGE: GENDER: OCCUPATIONAL INFORMATION
OCCUPATIONAL STRESS (PHYSICAL/CHEMICAL/PSYCHOLOGICAL)
PHYSCIAN INFORMATION
PRIMARY DOCTOR: PHONE: INSURANCE INFORMATION MISSED APPOINTMENT POLICY If you need to change or cancel your appointment please do so with 24 hours notice. Failure to do so will result in being charged full price for missed appointment. Dr. Ella Woods, DAOM, LA, Dipl. OM Acupuncture & Herbal Medicine GENERAL HEALTH INFORMATION
WHAT IS YOUR INTENTION FOR THIS TREATMENT?
WHAT ARE YOUR GOALS FOR YOUR HEALTH IN GENERAL?
ARE YOU CURRENTLY BEING TREATED FOR A MEDICAL CONDITION?
WHAT CONDITION (S) OR ISSUE(S) WOULD YOU LIKE HELP WITH AT THIS OFFICE?:
PLEASE DESCRIBE ANY OTHER HEALTH CONCERNS:
ARE YOU CURRENTLY EXPERIENCING ANY ACUTE OR CHRONIC PAIN? YES NO IF YES, PLEASE DESCRIBE THE LOCATION, QUALITY AND DURATION OF THE PAIN (S) PLEASE LIST ANY SURGERIES OR HOSPITALIZATIONS (INCLUDE DATES): PLEASE DESCRIBE YOUR EXERCISE ROUTINE: PLEASE DESCRIBE ANY SIGNIFICANT TRAUMAS OR ACCIDENTS (PHYSICAL OR EMOTIONAL): WHAT MEDICATIONS ARE YOU CURRENTLY TAKING? (PLEASE MARK BOTH PAST & PRESENT ONGOING USE)
PLEASE LIST ANY OTHERS MEDICATIONS: DO YOU HAVE ANY DRUG OR FOOD ALLERGIES?
PLEASE LIST ANY HERBS OR SUPPLEMENTS YOU ARE CURRENTLY TAKING (not already listed above): PLEASE LIST THE FOODS THAT YOU AVOID OR TRY TO REDUCE AND WHY: PLEASE DESCRIBE YOUR TYPICAL DAILY FOOD & DRINK INTAKE BELOW: BREAKFAST LUNCH Dr. Ella Woods, DAOM, LA, Dipl. OM Acupuncture & Herbal Medicine FAMILY HISTORY: (PLEASE MARK EACH BOX THAT APPLIES FOR A FAMILY MEMBER OR YOURSELF) CONDITION CONDITION PERSONAL HABITS (PLEASE MARK ANY USE OF THE FOLLOWING NOW OR IN THE PAST) Dr. Ella Woods, DAOM, LA, Dipl. OM Acupuncture & Herbal Medicine HAVE YOU HAD ANY OF THE FOLLOWING SYPTOMS OR CONDITIONS? (PLEASE CHECK ALL THAT APPLY) Digestive Respiratory Skin / Hair Cardiovascular Musculoskeletal Shoulder pain Head & Neck Joint / bone problems Genito-urinary Nose/Throat Neurological Infection Screening Dr. Ella Woods, DAOM, LA, Dipl. OM Acupuncture & Herbal Medicine Psychological / Behavioral Gynecological (cont) Gynecological (cont) Gynecological
Pre-operative Instructions: Do not eat or drink anything after midnight the night before your surgery. Please discontinue aspirin five days prior to your surgery when possible to minimize Please discontinue the use of anti-inflammatory medicines such as Motrin®, Aleve®, Advil®, and Ibuprofen 10 days before your surgery, if possible, to minimize bleeding. You may take
September 2009 Dear Parents/Carers Welcome back to the start of another school year. We thought we would give you some reassurance over swine flu. As you are aware, the numbers of cases of swine flu dropped considerably over the summer but with the start of the new academic year cases may start increasing again. NHS advice is that the best way to prevent the spread of infection is to remember the
Dr. Ella Woods, DAOM, LA, Dipl. OM 
Dr. Ella Woods, DAOM, LA, Dipl. OM 
Dr. Ella Woods, DAOM, LA, Dipl. OM