AGAPE CLINIC WITH HEART
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Health History​
Intake Form

    Health History Intake



    MEDICAL
    Personal history of any of the following. Please answer Yes/No.  Include year of onset.

    SENSORY
    Please rate on a scale of 0 to 5 to symbolize how often you agree with the statement listed.
    ​‘0’ = Never Agree, ‘5’= Always Agree. You may also List DK= Don’t know, or NA= Not applicable. 

    HARDINESS
    Please rate on a scale of 0 to 5 to symbolize how often you agree with the statement listed.
    ​‘0’ = Never Agree, ‘5’= Always Agree. You may also List DK= Don’t know, or NA= Not applicable. 

    QUESTIONS OF THE CENTRAL NERVOUS SYSTEM
    Please answer Yes, No or Partially.
    For the issues listed below, please rate how often you are presently bothered by them. 
    On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
    SENSES
    Please list (and rate for each pertinent issue) if you have difficulty with any of the following senses:
    FEELINGS/EMOTIONS
    Please list On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
    ANXIETY
    Please list On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
    MEMORY
    Please list On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
    MOBILITY
    Please list On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
    PAIN
    Please list On a scale 0-5, ‘0’= Not at all, ‘5’= All the time.
SEND

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Phone: (707) 757-3117   |   Email: agapejmcivnp@gmail.com
 Santa Rosa, California 95405
Hours: Monday – Friday 10am-6pm.
​Appointments may be available outside of regular office hours for special circumstances and for additional fee.
Location: Approximately 1.5 miles east of the heart of downtown Santa Rosa. ​
© Agape Clinic with Heart, A Professional Nursing Corporation
  • Home
  • Services
    • Agape Clinic Services
    • LENS Treatment
    • PLS Treatment
  • Intake Form
  • About
  • Testimonials
  • Resources
  • Contact