Ohio Holistic Healthcare
570 North Leavitt Road
Amherst, OH 44001
(440) 340-1970 (phone)
(440) 370-3026 (fax)
www.ohioholistichealthcare.com
ATTENDING PHYSICIAN’S REPORT
TODAY’S DATE:_____________________________
PATIENT NAME:______________________________________________________________________________
D.O.B._____________________________________LAST FOUR OF SS#:***-**-___________________________
SEX: MALE FEMALE
ADDRESS:___________________________________________________________________________________
CITY:________________________STATE:______________________ZIP:________________________________
HOME PHONE:___________________________CELL PHONE:_________________________________________
PLACE OF EMPLOYMENT:______________________________________________________________________
JOB TITLE:___________________________________________________________________________________
IS PATIENT ABLE TO WORK? YES NO ON DISABILITY? YES NO
IS PATIENT ABLE TO PERFORM ADLs? YES NO
PRIMARY CARE PRACTITIONER:_________________________________________________________________
ADDRESS:____________________________________________________________________________________
CITY:______________________________STATE:_______________________ZIP:__________________________
PHONE:______________________________________FAX:____________________________________________
PRIMARY DIAGNOSIS FOR WHICH YOU ARE FOLLOWING THIS PATIENT AT THIS TIME OR IN THE RECENT PAST (LAST 6 MONTHS)?
IS THIS PATIENT STILL UNDER YOUR CARE? YES NO
***PLEASE SUBMIT SUPPORTING DOCUMENTATION IF AVAILABLE, SUCH AS LAB, BIOPSY, OR XRAY RESULTS***
- HIV
- AIDS
- AMYOTROPHIC LATERAL SCLEROSIS (ALS)
- CANCER
- CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE)
- EPILEPSY OR ANOTHER SEIZURE DISORDER
- FIBROMYALGIA
- GLAUCOMA
- HEPATITIS C
- MULTIPLE SCLEROSIS
- PAIN THAT IS CHRONIC AND SEVERE OR INTRACTABLE
- PARKINSON’S DISEASE
- POST-TRAUMATIC STRESS DISORDER
- SICKLE CELL ANEMIA
- SPINAL CORD DISEASE OR INJURY
- TOURETTE’S SYNDROME
- TRAUMATIC BRAIN INJURY (TBI)
- INFLAMMATORY BOWEL DISEASE
- CROHN’S DISEASE
- ULCERATIVE COLITIS
PHYSICIAN or PRACTITIONER COMPLETING STATEMENT (PRINTED): _____________________________________________________________________________________________
SPECIALTY (IF APPLICABLE): ___________________________________________________________________
ADDRESS:____________________________________________________________________________________
CITY:______________________________STATE:_______________________ZIP:__________________________
PHONE:______________________________________FAX:____________________________________________
_____________________________________________________________________________________________
(Physician Signature of Attestation)