Insured Date of Birth Soc Sec of insured Medical Insurance Subscriber NumberProvider to determine if you have any conditions that indicate you should not engage in any of the foregoingI a ID: 898394
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1 -06-25 website files:Working files:Intak
-06-25 website files:Working files:Intake form Health Atlast LB Double sided 06 25 18.docx HEALTH ATLAST LONG BEACH 2221 Palo Verde Ave #1J Insured Date of Birth: Soc. Sec # of insured: Medi
2 cal Insurance __________________________
cal Insurance ________________________________ Subscriber Number: (ÒProviderÓ) to determine if you have any conditions that indicate you should not engage in any of the foregoing.I am granting permission
3 to review my medication history online.
to review my medication history online. How many years? _____ How many packs per day?____ REVIEW OF SYSTEMS (circle which ones you have at this time or in the last few days) Fevers, Chills
4 , Night Sweats, Unintentional Weight los
, Night Sweats, Unintentional Weight loss? Poor endurance, wheezing, cough after exercise? New rashes or psoriasis or skin lesions? Bruise easily? Nausea, vomiting, black stools, loss of contr
5 ol of stools? Loss of control of urine,
ol of stools? Loss of control of urine, urinary urgency? Recent Kidney stones, Urine infection? Vision change, double vision, change in taste? Numbness, tingling, Intolerant to heat/c
6 old? Headaches, Ringing in ears, hearing
old? Headaches, Ringing in ears, hearing loss, vertigo? Depressed mood, sleep problems, anxiety? Chest pain, shortness of breath? Weakness, Loss of a jointÕs range of motion MASSAGE
7 , TRIGGER POINT THERAPY, EXERCISES, STRE
, TRIGGER POINT THERAPY, EXERCISES, STRETCHING Trigger Point Injections (TPI) are used to If you are signing this acknowledgement on behalf of the Individual named above, please sign your name on this l