Elissa D. Viarengo, L.Ac BioFeedback Practitioner New Patient Intake Form
Name:____________________________________________________ If a minor, Name of Parents / Guardian: ___________________________ Address: __________________________________________________ City: ____________________ State: _________ Zip Code: __________ Home Telephone (with area code): _______________________________ Work Telephone (with area code): _______________________________ Cell Phone (with area code): ____________________________________ Email address (for newsletters / discounts): _______________________ Date of Birth (month/date/year): ______ Age: _____ Sex: __________ Occupation: ________________________________________________ Who referred you to Elissa V. Blesch? ____________________________ What is the main reason you are seeking care? ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ updated 9/12/13 Surgeries / Major Illnesses: __________________________________ ________________________________________________________ ________________________________________________________ Other Practitioners You See: M.D._________________________Chiropractor: __________________ Acupuncturist: ________________ Naturopath:___________________ Massage Therapist: _____________ Physical Therapist: ______________ Other: ___________________________________________________ Medications You Are Currently Taking Name Supplements/ Vitamins / Homeopathics / Herbs You Are Currently Taking Name
Health Habits Do you use…
Hours of Sleep _______ Do you feel rested upon waking? ___________ Do you exercise? ____________ What kind and Frequency? ___________________________________ _______________________________________________________
Please indicate the symptoms you are CURRENTLY having or have REGULARLY throughout the year ___ Absent Minded
___ Seizures ___ Shortness of Breath ___ Sinusitis ___ Skin Rash ___ Skin Itch ___ Skin Burning ___ Sleeping Problems ___ Sneezing ___ Sore Throat ___ Stomach Discomfort ___ Swol en Glands ___ Teeth Pain ___ Tongue Swelling ___ Throat Constriction ___ Tightness in Chest ___ Tires Easily ___ Urinary Tract Disorders ___ Urination Painful / Burning ___ Vomiting ___ Weight Loss / Gain ___ Yeast Infections Any other symptoms: _________________________________________ _________________________________________________________ _________________________________________________________ Is there anything else you would like Elissa to know about your health? _________________________________________________________ _________________________________________________________ _________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________
Summary of the Types of Flip-flop Behaviour Since memory elements in sequential circuits are usually flip-flops, it is worth summarising the behaviour of various flip-flop types before proceeding further. All flip-flops can be divided into four basic types: SR , JK , D and T . They differ in the number of inputs and in the response invoked by different value of input signals. The four