Living Springs Natural Health (LSNH) & Living Springs Health & Wellness (LSHW), PLLC are members under the:

TURTLE ISLAND PROVIDER NETWORK Licensed & Registered by: Tribal Health Programs & Clinics

A Private Tribal Membership Facility NOT OPEN TO THE PUBLIC

Name: Type Name: Last, First Middle Date: Select Today’s Date
Date of Birth: Select D.O.B. Age: Age Occupation: Occupation
Home Address: Enter Street Address City: Enter City State: Enter State Zip: Enter Zip
Email Address: Enter Email Address
Home Phone: Enter Home Phone # Cell Phone: Enter Cell Phone # Work: Enter Work Phone #
In Case of Emergency Contact: Emergency Contact Relationship: Relationship Phone: Enter Phone #
How did you hear about Us: Enter Text
Please list all the providers you are seeing: List Providers

PATIENT QUESTIONNAIRE

MEDICAL HISTORY

Weight: Enter Weight

Have you ever had any issues with anesthesia? ☐ Yes ☐ No

Do you smoke? ☐ Yes ☐ No ☐ Quit How much? How Much How often? How Often Age started? Enter Age
Do you drink alcohol? ☐ Yes ☐ No ☐ Quit How much? How Much How often? How Often Age started? Enter Age
Any known drug allergies: ☐ Yes ☐ No If yes please explain: Enter Any Known Drug Allergies

Current Medications and dosage: List Current Medications and Dosage

Nutritional/Vitamin Supplements: List Supplements

Current Hormone Replacement Therapy: Enter Text Past HRT: Enter Text

Surgeries, list all and when: List Surgeries and Dates

Other Pertinent Information: Please provide any additional medical history information we should be aware of

Do you have a family history of? ☐ Heart Disease ☐ Cancer ☐ Diabetes ☐ Other Enter Text

Medical Illnesses:	Females Only:
☐ High blood pressure	☐ Heart bypass	Last Menstrual Period: Select Date.
☐ Blood clot and/or a pulmonary embolus	☐ High cholesterol	☐ Pregnant
☐ Arrhythmia	☐ Hypertension	☐ Menopause
☐ Any form of Hepatitis or HIV	☐ Heart Disease	☐ Hysterectomy - Full ☐ Partial ☐
☐ Lupus or other auto immune disease	☐ Pacemaker	☐ Tubal Ligation
☐ Fibromyalgia	☐ Heparin Allergy	☐ Mammogram in the last 6 months.
☐ Dark Urine	☐ Anemia	☐ Birth Control Pills.
☐ Chronic liver disease (hepatitis, fatty liver, cirrhosis)	☐ Fever	☐ Other: Enter text.
☐ Diabetes	☐ Abdominal/back pain
☐ Thyroid disease.	☐ Fatigue	Males ONLY:
☐ Arthritis	☐ Hemochromatosis.	☐ Elevated PSA
☐ Depression/anxiety	☐ G6PD	☐ Prostate Enlargement
☐ Psychiatric Disorder	☐ Cancer Type: Enter Type Year: Enter Year	☐ Vasectomy
☐ Stroke and/or heart attack	☐ Receiving Chemo or Radiation	☐ Other: Enter text.

*** Please Note: We do not file with insurance at this office & will not provide codes. The alternative therapies/suggestions we provide are not intended to diagnose, treat, cure or prevent any disease ***

I understand, agree & provide my consent that the submission of this form electronically requires the use of a digital signature. By signing, I agree that my digital signature on this form has the same legal affect as my manual signature (in accordance with the ESIGN Act).

Date: Click to Select a Date.

E-SIGN Your Name Here
Patient Signature

PATIENT NAME PRINTType your Name Here

RELATIONSHIP TO PATIENT Click or tap here to enter text.

Relative or Representative

LEGAL MINOR GUARDIAN PRINT NAME Type your Name Here

Legal Minor Guardian Signature

All Services of Living Springs Natural Health & Living Springs Health & Wellness are available to MEMBERS ONLY and Memberships MUST be renewed yearly!