Sample Page

This is an example page. It’s different from a blog post because it will stay in one place and will show up in your site navigation (in most themes). Most people start with an About page that introduces them to potential site visitors. It might say something like this:

Hi there! I’m a bike messenger by day, aspiring actor by night, and this is my website. I live in Los Angeles, have a great dog named Jack, and I like piña coladas. (And gettin’ caught in the rain.)

…or something like this:

The XYZ Doohickey Company was founded in 1971, and has been providing quality doohickeys to the public ever since. Located in Gotham City, XYZ employs over 2,000 people and does all kinds of awesome things for the Gotham community.

As a new WordPress user, you should go to your dashboard to delete this page and create new pages for your content. Have fun!

    Step1

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    Personal Informatiom
    Date:















    Primary person to be notified in case of an emergency:









    Step2

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    Insurance Information







    PLEASE BE ADVISED THAT WEARE UNABLE TO BILL ANY INSURANCE ACCEPTED BY OUR OFFICE WITHOUT A COPY OF THE CURRENT INSURANCE CARD. Also, in the event your insurance company denies the claim for ANY reason, youwill be personally responsible for the charges incurred.

    Assignment of Benefits: I authorize assignment of all medical insurance benefits to the named provider for the medical services rendered.


    [signature* signatureofPatient color:#000000 backcolor:#dddddd width:300 height:200 id:signatureofPatient class:form-control]

    Assignment to pay for Services: I agree to pay Green Health Clinic for all charges for services rendered to the patient today, or any future date of service in the office. I understand payment in full and/or co-pay and/or co-insurance is expected at the time of services rendered. I further understand, in the event this account is referred to an agency or attorney for collection, I will be responsible for all collection fees, attorneys’ fees and/or court costs.


    [signature signatureofall id:signatureall cols:300 rows:137 placeholder "Sign Here"]

    Please list all doctors you have seen in the last 5 years

    Doctor’s Name Address Phone Reason for visits

    Medications: List all medications currently taking:

    Medication Dosage Times per day Reason for taking

    List any to which you are allergic:

    Medication Type of reaction
    Food allergies Type of reaction
    Environmental allergies Type of reaction

    Step3

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    Social History

    Has this or any job put you around strong chemicals or smoke?










    Past Surgical History:



    List year performed next to surgery. Fill in those not listed at the end.


    Past Medical History: **please check all that apply fill in any not listed at the end**


    Please check any symptoms or concerns you have now.


    Activities of Daily Living Assessment:

    Please check if any of the following activities are substantially limited (i.e., pain/weakness/impaired strength or ability) by the medical condition for which you seek medical attention?



    Family Medical History:

    To the best of your knowledge, have any blood relatives been diagnosed with the following (Please state the family member(s) in the space provided):




    Step4

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    Spiritual Life:

    Having an active spiritualor religious life is an important part of overall health.
    Describe your current religious practice (please provide details as to how often and what you do. For example, do you attend church or other ceremony? Any small group studies?)

    Client Two Day Food Diary

    Green Health Clinic believes very strongly that the food you put in your body plays a large role in your health; both positively and negatively. A food diary is a very valuable resource fordeterminingyourcurrentlevelofnutrition.Itwillallowustomakerecommendationsfor improvement, as well as consider the possibility of some groups of foods that may be causing symptoms.

    Please choose two days to record all of your intake. These days should be considered "normal", don't choose days where your foods are drastically different from usual. Try to record intake for at least one weekday and one weekend day, because food choices can be different. This is preferred but not necessary.

    Meal Day 1 Day 2
    Goals:

    Please list the reasons you have come to Green Health Clinic

    Please list all doctors you have seen in the last 5 years