Patient Intake Form
PLEASE ANSWER ALL QUESTIONS BELOW BEFORE SUBMITTING
Full Name *
Email *
Phone Number *
Birthdate *
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Physical Address *
City *
State *
Zip Code *
Height *
Weight *
What is your Blood Type And Dominant Hand *
Emergency Contact Person *
Emergency Contact Phone Number *
Emergency Contact Email
Current Doctor *
Have you worked with a holistic or functional practitioner before? *
What is your current profession? *
What is your previous profession(s)? *
What is your country of origin (genetically)? *
Where were you born? *
Where were you raised? *
What do you do for fun? *
When was your last vacation? *
Do you relax once a day? *
What do you do when you relax? *
What does your support system look like? *
Have you ever Smoked: Y / N If YES, then what and for how long? *
Do you have Children? *
If YES, then how many children do you have?
What are the Ages of each child?
Have they been Vaccinated? Which Ones?
Do your children have any health symptoms or conditions? (e.g. ADD or Allergies or Asthma)
Family Health History
Use this link to see an example of what types of information will be useful for the question below. https://249a90af-46cc-4d08-8d62-5074f27f11d4.filesusr.com/ugd/76edc2_f7c3d9bb4e134f67823b3e75fb4767ec.pdf
Give a complete chronological family health history. *
Any Other Relevant Family History? *
Reasons/Symptoms that motivated you to come in today: *
Have you experienced ANY of the following?​ *
Required
Any Other Concerns or Formal Diagnosis
What have you done in the past to work on these health conditions and have any been effective (please include both alternative & traditional modalities)? *
What obstacles, challenges, and struggles have you encountered in making changes to your lifestyle to improve your health? *
Have the Following Have Been Removed? *
Required
List Other Hospitalizations, Implants or Surgery (child births, C-section):
Do you wake up in the middle of the night to urinate? *
Have you ever had a Urinary Tract Infection? Y / N If YES, how often *
Is it painful to urinate? *
Have you ever had any motor vehicle or other accidents? *
Have you had any emotional upsets or traumas in your life “recently”? *
If Yes, can you please share what happened and the emotion it evokes?
Please list any known toxic exposures (chemicals, molds, etc.), and how long ago?
Have you received: Chemotherapy Y / N. If YES, then when? *
Have you received: Radiation Y / N. If YES, then when? *
If YES on either question, then what condition did you receive it for?
Do you take any medications or antacids or acid blockers? If yes, how long? *
DENTAL WORK
Have you had any dental work in the past 3 weeks (including cleanings)?
Clear selection
Do you have:
Clear selection
Have you ever had any mercury/gold fillings? *
Fillings were removed: Y / N If Yes, then when *
Do you have your wisdom teeth? *
Were your wisdom teeth removed? *
What kind of toothpaste do you use? *
Do you use a tongue cleaner? *
Do you floss? *
IN THE LAST 24 HOURS, HAVE YOU? *
Required
WATER
Do you drink tap water at home? *
Do you drink tap water from restaurants? *
Do you drink tap water at work? *
Do you shower in unpurified city water? *
Do you drink refrigerator filtered water? *
Do you drink well water? *
FEMALE ONLY QUESTIONS
Age of first menses ad length of a cycle?
What day of your cycle are you in and are they regular?
If cycles are irregular, then how irregular?
The number of live births?
The number of pregnancies and number of C-Sections?
Are you currently nursing your child?
Clear selection
Have you experienced ANY of the following:
MALE ONLY
Have you experienced ANY of the following:
Please Read and by clicking submit you acknowledge, understand and agree with the information below.
I understand that CRT Thermography is not a primary diagnostic device as deemed by the U.S. Food and Drug Administration and is not to exclude other methodologies of cancer detection. Its purpose is to add information to the physician or practitioner to aid in the integration of other tests and results in order to achieve treatment outcomes, and not intended as diagnostic of any disease or dysfunction in itself. I agree to not hold the Thermography Report Writing Services responsible for any decision I or my doctor make based on the results obtained. I am ultimately responsible for payment to the Thermography Center and accept that the Center does not bill insurance companies. Payment is due at the time of service. You will be given a receipt for your visit, which you can submit to your insurance company for reimbursement. If the insurance company does not pay for the services, The Thermography Center assumes no responsibility for reimbursement.
Please Read and by clicking submit you acknowledge, understand and agree with the information below.
I have requested and do hereby authorize The Thermography Center (“The Center”) or any qualified and certified agents, independent contractors, or trainees of the Computerized Regulation Thermography (Alfa Sight 9000) System to perform adjunctive diagnostic screening test with the Alfa Sight 9000 for the sole purpose of information only. I understand that The Center is not a medical facility and will not be treating me or diagnosing any medical condition. I understand that the test data or readings from this procedure will be classified and categorized by an independent party familiar with the Alfa Sight 9000 and the data will be forwarded to my chosen medical professional for interpretation and medical care intervention. Regulation Thermographyis an adjunctive NOT primary diagnostic tool. I am responsible for following up with medical care with my physician and should not rely on this procedure for the diagnosis or treatment of any medical condition. I further understand The Center operates as a separate business from Dr. Theodore J. Tuinstra.

I certify that I have consulted with a representative of The Center and have read all applicable literature given to me. I have read and fully understand all of the information presented in this Patient Consent and Release form for Diagnostic Screening. I accept the explanation of my responsibility for following up with a medical care professional of my choosing and understand that the diagnostic screening test data will not be mailed to me but directly to my medical professional I designate on my intake forms. I certify that I am eighteen (18) years of age or older, of sound mind, and I am fully capable of executing this Patient Consent and Release form for Diagnostic Screening myself.
Confirm Today's Date and that you are Agreeing to ALL Terms Above *
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Do you agree to all Terms Above? *This agreement of a yes is the same as a signature. *
Submit
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