Ohio Holistic Healthcare

570 North Leavitt Road

Amherst, OH 44001

            (440) 340-1970 (phone)

            (440) 370-3026 (fax)

www.ohioholistichealthcare.com

ohhc2018@gmail.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***

PHYSICIAN or PRACTITIONER COMPLETING STATEMENT (PRINTED): _____________________________________________________________________________________________

SPECIALTY (IF APPLICABLE): ___________________________________________________________________

ADDRESS:____________________________________________________________________________________

CITY:______________________________STATE:_______________________ZIP:__________________________

PHONE:______________________________________FAX:____________________________________________

_____________________________________________________________________________________________

(Physician Signature of Attestation)